U.S. Army Medical Department, Office of Medical History
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In World War I, between 8 and 11 of each 100 wounded men who reached forward hospitals alive died in them. In World War II, the number was reduced to 4.5 per hundred. In the Korean War, it was further reduced to 2.6 per hundred. The explanation is simple, that the mortality rate in combat wounds is inversely proportional to the availability of prompt and adequate resuscitation, in the routine of which whole blood and plasma play major roles.

The lessons learned in World War II furnished convincing evidence of the soundness of that concept-but they had to be learned in the course of the war. When the Korean War began, the concept of the essentiality of whole blood in the management of shock was firmly established in the minds of both clinical and administrative personnel and had been accepted by statisticians. The fly in the ointment was that administrative personnel had not yet learned that whole blood is best handled out of supply channels, as a separate supporting service.

In 1939, at the outbreak of the Second World War, the United States found itself with no organized blood bank system, and, indeed, with no plans for supplying whole blood or so-called blood substitutes to wounded casualties. By 1941, when this country was precipitated into that war, the plasma program was beginning to evolve, but the whole blood program was not yet even in the planning stage. Both programs developed by a series of expedients, almost on a trial-and-error basis. The end result was brilliantly successful, but the success was achieved at the cost of delay, inefficiency, and far greater expense than should have been incurred. Moreover, there was only a small capitalization on the tremendous research potentialities afforded by the collection of millions of units of blood and its clinical use in war casualties, partly as whole blood and partly in the form of plasma and serum albumin.

It is distressing to relate that when the Korean War broke out in June 1950, less than 10 years after the United States had entered World War II and just 5 years after World War II had ended, planning for a blood bank system had been instituted, but so shortly before the beginning of hostilities that, as in World War II, planning and implementation again were carried out on a basis of expediency.

It is doubly distressing to recollect that this situation was entirely unnecessary: At the end of World War II, well-founded, detailed recommendations for a transfusion service had been prepared and submitted through channels to the proper authorities. Time, manpower, effort, money, and lives could all have been spared in Korea if these recommendations had been utilized as a basis for postwar planning. As it was, the newly developed plans were not ready for implementation when the Korean combat began.

The essentials of a blood program for oversea theaters may be described as material. In addition to donors, they include equipment, refrigeration, preservatives, and an airlift. Basic to the program, however, is the acceptance of the concept of the need for whole blood for combat casualties. It was failure to recognize this need, and to face and overcome the associated logistic problems promptly, that was the real reason for the delay in supplying whole blood to oversea theaters in World War II.

When World War II began, the concept of shock was still vague, and, in the light of World War II experiences and investigations, it was found to be in error in many of its aspects. Transfusion was still a dramatic and heroic procedure, resorted to more often than not only when the situation was critical or desperate. Direct techniques were just beginning to give way to indirect techniques. Reactions, due chiefly to the presence of pyrogens, were still alarmingly frequent. Plasma was still in the experimental stage. The fractionation of plasma proteins had not yet become a practical reality, and the clinical use of byproducts of that process was not yet even imagined.

Many of the problems of shock still remain to be solved, but a great deal was learned about them in World War II, not only by clinical observation but also by the careful studies carried out on them in theaters of operations, particularly in the Mediterranean theater, by the Board for the Study of the Severely Wounded. Though much remains to be clarified, there is now full realization that the fundamental cause of shock in the wounded man is diminution of the amount of circulating blood. Logically, therefore, the objective of all therapy is the restoration of the diminished blood volume to its approximately normal status, so that the wounded soldier may withstand the measures-which are often heroic-necessary to care for his wounds.

In spite of the attention paid to plasma in the early months of World War II, there were many whose eyes, from the beginning, were fixed upon whole blood. It is interesting and significant that it was a biochemist, not a clinician, who, some years after the war, vigorously called attention to this fact. Dr. Edwin J. Cohn, in recounting the history of the World War II National Research Council Subcommittee on Blood Substitutes to the similar committee which took its place in 1949, stated that he "* * * wanted the group to realize that at a very early point in the history of the earlier Subcommittee, Dr. DeGowin had started writing and talking about the necessity of using whole blood instead of blood fractions, and for the need to start immediately to develop a service to supply blood to the Armed Forces."

The subcommittee, Dr. Cohn continued, had repeatedly recommended the use of whole blood for combat casualties, but no specific action was taken on these recommendations until reports from the North African theater indicated the need for blood. Then, concerted efforts were made to supply it, but there were delays while logistic problems, which had not yet been evaluated, were solved. At first, many authorities outside of the Subcommittee on Blood Substitutes considered it impractical to extend the dating period beyond 8 days, let alone to fly blood overseas. It took persistence, faith in the concept and in the possibility of its implementation, and a great deal of hard work to set up the plan, but, by November 1943, the same airlift was available that was-belatedly-put into effect in August 1944. One can only regret the lost months and, as a corollary, the lost lives, that resulted from the delay.

In retrospect, it is difficult to understand why the United States was so slow in setting up a whole blood program in World War II. We could have learned some lessons from World War I. O. H. Robertson, for instance, and Ohler both stated unequivocally from their experience in it that, when blood is lost, it must be replaced by blood. We could also have learned from the very successful program in effect in the Spanish Civil War.

Above all, we could have learned from the British, who, to quote Brigadier Sir Lionel E. H. Whitby, RAMC, entered the war with a "firm policy," decided upon 6 months earlier, that there would be a completely distinct and separate transfusion service in their Army because the transportation of potentially dangerous biologic fluids over long distances would require close personal supervision and could not be trusted to the usual supply routes emanating from a base medical supply store. The British policy was remarkably successful. It was carefully planned before hostilities began. It was based on the concept that blood is a perishable substance, as potentially dangerous as it is potentially useful, and therefore is to be handled only in special channels and only by specially trained personnel. We followed that plan only partially in World War II, and not much more effectively in Korea, and, in both wars, we paid the penalty for our folly.

In the face of these facts, one can only wonder why the United States did not have a special transfusion service planned before we entered World War II; why the recommendation of the Subcommittee on Blood Substitutes, National Research Council, for such a service was not adopted during the war; why it was not until 4 years after the war ended that such a special service was established; and why we had been engaged in World War II for almost 3 years before the proposal, made many months before, was adopted and blood was flown overseas to the European theater and to the Pacific areas.

Once the oversea airlift was instituted, it was clearly demonstrated that blood can be collected thousands of miles from its point of use; can be safely transported over those miles; and can be used with safety and benefit if there is proper planning, proper handling, proper timing, and adequate airlift, trained administration, and careful coordination. The successful use of whole blood reached a high point on Okinawa in World War II. Planning-in which, naturally, there were some mistakes-was detailed and timely. Blood was provided in ample quantities. There were 40,000 casualties, and their treatment involved the use of approximately 40,000 pints of whole blood, 1:1. All the blood used on Okinawa was flown from the United States, a distance of 8,000 miles. With the dating period set at 21 days, it required careful timing to insure provision of adequate quantities of whole blood with a minimum amount of wastage from outdating. There were two reasons why the operation was successful: First, the blood supply from the United States to Okinawa via Guam was highly efficient. Second, the commanding general, with the full concurrence of the surgeon of the task force, assigned to a trained transfusion officer full responsibility for the supply, distribution, and correct use of all the whole blood brought onto the island.

Although whole blood is usually the fluid of choice in the resuscitation of wounded casualties, it would be fatuous not to grant that there are military situations-and there probably will be civilian situations-in which it cannot be provided and, as a matter of expediency, fluid of a longer shelf life must be used. Plasma met this requirement admirably in World War II. It was useful in the field, forward of hospitals; in the initial phases of landing operations, in which it was difficult logistically to supply a perishable item like whole blood, which always requires special care; and aboard ship, where, however, the Navy found serum albumin equally useful, because the procurement of water, which usually had to be administered with this agent, was no problem.

During World War II, an abundance of plasma was available to the Armed Forces of the United States, so much that an extensive clinical trial was possible, unhampered by considerations of supply or cost. The purity and excellence of the product supplied, and the disposable, sterile, pyrogen-free dispensing sets and distilled water supplies with it, permitted the administration of large quantities without fear of reaction. How many casualties plasma kept alive until they reached installations in which whole blood could be administered and surgery performed is not a fact that can be reduced to statistics, but it is safe to say that it was in the hundreds of thousands.

Plasma was used most effectively when its indications and limitations were clearly realized. In addition to its use for resuscitative purposes, it was the agent of choice in crushing injuries, in burns, in injuries from blunt instruments, and in other injuries in which there was no great loss of blood. It was built up beyond its capabilities early in World War II; it was often used to excess and unwisely, though that criticism must be tempered by the fact that very often, in the early days of the war, the choice was plasma or nothing. In the Mediterranean and the Pacific, in those days, medical units and hospitals went in with little or no provision for the collection and administration of blood, chiefly because there was lack of logistic support in the Zone of Interior to make the necessary equipment available.

When it became evident that plasma was carrying the virus of hepatitis, its use in the Korean War had to be discontinued, but that unfortunate development has nothing to do with its essential value. When this problem has been solved-and there is no doubt that it will be solved eventually-plasma can resume its proper and valuable place as an agent of resuscitation to be used to supplement whole blood.

No matter what form future conflicts may take, casualties will result, and there is no conceivable kind of wound which will not require blood, plasma, or both. It is quite possible that more blood and plasma will be needed in a future conflict than have been needed in the past, because future wars will involve civilians as well as troops, and will involve them in far greater numbers than were affected in the countries that bore the brunt of the air raids in World War II.

Since the need for blood will arise whenever combat commences and whatever form it may take, it is imperative, before it commences, to maintain supplies and equipment, to train personnel, and to plan adequately for the provision of whole blood for any forces that may be placed in the field and for civilians who may be part of the conflict at home. Although research done on the long-term storage of blood by freezing with glycerol indicates that this technique offers a realistic and practical approach to the problem, whole blood, at least as yet, is not a commodity that can be generally stored on a long-term basis. Nor can it be collected as the need for it arises unless there has been prior planning for its procurement.

There was no such provision when World War II broke out, and it was not until late in the war that the correct equipment for collecting it and using it was made available in oversea theaters. That situation was only partially rectified when the Korean War broke out. Neither contingency must be permitted to happen again.

War has very little left of glamour, but if, in World War II, there was anything dramatic and glamorous, it was the miracles wrought by the use of whole blood. Since this is so, readers may wonder, and perhaps complain, that this book contains a great many prosaic, repetitious, monotonous details. It does indeed, and their inclusion has been deliberate. It is extremely important-in fact, it is imperative-to recognize that behind the drama of transfusion in World War II lay an elaborate mechanism of procurement, storage, delivery, and many other mundane details. It was only by the strictest attention to such matters that blood was able to achieve its miracles, and, equally important, was prevented from becoming a deadly agent. It must never be forgotten that without proper care, blood can be lethal.

Many agencies were involved in this gigantic enterprise, including:

The Department of Surgical Physiology, Army Medical School, and the similar division of the Naval Medical School.

The Office of The Surgeon General, U.S. Army.

The Medical Departments of both the Army and the Navy.

The American Red Cross.

The Division of Medical Sciences, National Research Council, with its various committees, permanent and ad hoc, particularly the ill-named Subcommittee on Blood Substitutes. The actions of this subcommittee occupy considerable space in this book, as they should, for it was the advice of its membership that guided the Army and the Navy Medical Departments in many aspects of the blood-plasma program. This subcommittee anticipated events by an early recommendation that whole blood be supplied for combat casualties and by an early recommendation for an airlift of blood to the European theater. It is a great pity that these recommendations were not accepted when they were made. Considering the fact that its petition was never granted that it be permitted to visit combat zones and determine personally what the circumstances and needs were, it is remarkable that this subcommittee was able to accomplish what it did.

The National Institute of Health.

The Army Medical Procurement Agency.

The biologic processing plants that participated in the program and pioneered in new and untried fields.

And, finally, the millions of U.S. citizens who donated their blood.

As to the individuals who participated in the program, it is difficult to single out any for mention without omitting others who should be included. Four exceptions, however, might be made:

Dr. G. Canby Robinson, who directed the American Red Cross Blood Donor Service.

Maj. Earl S. Taylor, MC, who served as Technical Director of the Service.

Dr. Walter B. Cannon, who, at the first meeting of the Committee on Transfusions, National Research Council, suggested that some "outstanding biochemist" be brought into the program.

Dr. Edwin J. Cohn, who was brought into the program in response to that suggestion, and in whose Department of Biochemistry at the Harvard Medical School the fractionation of blood plasma was successfully accomplished and the serum albumin program was translated into reality.

Surgeon Vice Admiral Sir Edward Greeson, RN, wrote in the preface to one of the volumes of the history of the Royal Naval Medical Service in World War II that no one has ever written "the" history of anything. The best that can be accomplished is "a" history. He made that statement in advance, he frankly admitted, to take care of the adverse criticisms he knew the volumes he was editing would receive.

This volume, which is concerned with the blood-plasma program in World War II and in the Korean War, is intended as "a" history of that program. It is a chronicle built upon personal knowledge of what happened and upon a mass of material almost exasperating in its voluminousness and equally exasperating in its lack of many essential details. A great deal of the story is necessarily-and quite properly-built upon personal knowledge of what happened, what actions were taken, and why and in what circumstances they were taken.

World War II was the first war in which the United States was engaged in which blood was used with any frequency, and the first in which plasma and serum albumin were used at all. The attempt has therefore been made to record the whole story, and, in particular, to omit no errors and no failures. A major failure was the attempt-which seemed so near success-to use bovine albumin instead of human blood. So many problems would have been solved if only the attempt had succeeded. It may be that one day the project will be revived and the difficulty solved. No more practical man ever lived than the late Dr. Cohn, and he believed that this might happen, though it was he who, against the desire of some clinicians, insisted upon an immediate stop to clinical testing when it became evident that the bovine albumin developed in his laboratory was not a safe agent.

The preparation of this book according to the principles just laid down has presented certain major difficulties. World War II was a global war, and the blood and plasma program was an essentially global program. On the surface, as has been suggested for many of this series of volumes, it seems perfectly simple to present what might be termed "a linear chronologic account," with the events in all theaters presented synchronously as they occurred. Actually, this would be an impossible task, and, granting the possibility of its accomplishment, it could result only in confusion.

After considerable experiment, it was decided that the most logical mode of presentation would be first by subjects and then by theaters. By this plan, the book falls into the following divisions:

1. A historical note, for which no apology is offered, if only because the chronicle makes clear how far we still had to go in World War II, as well as-to our discredit-what had been accomplished in the Spanish Civil War and by the British before the United States entered the war.

2. Two background chapters, dealing with shock and with the evolution of the whole-blood concept.

3. The provision of blood for blood transfusions and for conversion into plasma. This group of chapters deals with administrative considerations; the American Red Cross, which was the collecting agency; the donors who provided the blood; the equipment used to collect and administer it; transportation and refrigeration; and the laboratory studies necessary before blood could be used safely and accurately.

4. A group of chapters dealing with plasma, serum albumin (bovine and human), byproducts, so-called blood substitutes, and other intravenous agents.

5. Separate chapters dealing with the Mediterranean and European Theaters of Operations and the Pacific areas.

6. A final clinical section dealing with reactions and with principles of replacement therapy.

7. A chapter on the blood and plasma program in the Korean War, which is included, contrary to the usual practice in this historical series, because this war furnished an opportunity to study the application of the lessons learned in World War II, some of which, unfortunately, had to be learned over again.

No matter what the plan of presentation, a certain amount of repetition would be inevitable in this volume. The plan adopted perhaps calls for an undue amount, though some of it is deliberate and necessary. As much repetition as possible, however, has been eliminated by the copious use of cross-references.

One other item might be mentioned in conclusion: the number of veterans of World War II and Korea who have given blood since those wars in gratitude for the blood they themselves had received in them. One man, a recent newspaper story related, had just given his sixty-fifth pint; he lost a leg on Guam but, thanks to the blood he received, he did not lose his life. No one appreciated the value of whole blood more than GI Joe, and not the least of its benefits was its effect upon his morale.

Brigadier General, MC, USA.