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Blood in War

World War I and the Spanish Civil War

The following is excerpted from BLOOD PROGRAM IN WORLD WAR II by Douglas Blair Kendrick (pgs. 5-7 and 11-12).

Chapter I: Historical Note

Blood Transfusion In World War I

The British Experience

World War I trenchesIn June of 1918, an editorial writer in the LANCET doubted that as recently as 4 years earlier any surgeon could have been found to perform "the operation" of transfusion in England (14). In the next issue, Sir Berkeley Moynihan (15) took exception to that statement: He and his associates in Leeds had been performing transfusion regularly for 10 years, first by the direct, and later by the indirect, technique.

The editorial writer's statement was, however, generally true. Blood transfusion was not practiced by the majority of surgeons in Great Britain before World War I, and its use in the last 2 years of the war was chiefly derived from the work which had been done on it in the United States.

Techniques. -- Direct transfusion, as might have been expected, proved a completely impractical method in military surgery. The elaborate preparation required in the Kimpton-Brown technique makes one wonder how it could have been employed at all in a busy casualty clearing station, but Fullerton and his associates (16), using improvised equipment, employed the method in 19 casualties at the Boulogne base in 1916. The 15 deaths were not too discouraging, since the blood was given only to patients whose condition was considered desperate. In 1917, U.S. Army medical officers introduced the standard Kimpton-Brown equipment into British hospitals, and numerous patients were treated by this technique in casualty clearing stations of the British Second Army.

In a series of reports between 1916 and 1918, Bruce Robertson (17-20), of the Canadian Army, explained the advantages of the syringe-cannula technique, which he had introduced into the British Second Army area. The method was far simpler than the Kimpton-Brown technique, but at that it was not simple, and it required a team of three persons to carry it out.

The use of preserved blood was introduced into a casualty clearing station in the British Third Army during the battle of Cambrai in November 1917 by Capt. (later Maj.) Oswald H. Robertson, MORC, USA (21, 22). His reasoning was that if blood had to be collected as casualties arrived, the number of transfusions given would necessarily be limited. The solution seemed to him to be the use of human red blood cells collected and stored in advance of the need.

World War I trenchesOnly group O (then termed group IV) blood was used. The 500 cc. taken from each donor was collected in the Rous-Turner glucose-citrate solution ... and stored in an icebox. After the blood had settled for 4 or 5 days, the cell suspension contained no more citrate than would be used in ordinary citrated transfusions. The majority of transfusions were given within 10 to 14 days after the blood had been collected, but in some instances they were given with 26-day-old blood. The length of time the blood was kept did not seem to influence the results. The blood arrived in good condition, with no evidence of hemolysis, after transportation by ambulance for 6 to 8 miles over rough roads, a demonstration later repeated by Capt. Kenneth Walker, who carried a bottle of preserved blood with him during a journey from Arras to London. The 22 transfusions with preserved blood reported by Robertson in June 1918 were carried out on 20 patients, of whom 9 died but all of whom, it was thought, would have died unless they had received blood.

In 1918, transfusions were carried out farther forward than casualty clearing stations, chiefly due to the efforts of Captain Walker, Capt. Norman M. Guiou (23) of the Canadian Army, and Major Holmes-á-Court of the Australian Army (22). The syringe technique, Guiou claimed, could "easily" be applied in advanced dressing stations and in the average regimental aid post. If casualties were given blood in these areas, he continued, they would be kept alive until they reached the casualty clearing station, where they could be treated surgically.

The official history of the British Medical Service in World War I concluded that whatever the merits of the various techniques of transfusion in civil life, there was no doubt of the superiority of the citrate method in wartime. It could be employed in circumstances in which other methods were impractical. It was simpler than other methods. It permitted the transportation of blood from donor to recipient without interrupting an operation and further congesting an already overcrowded operating tent. A skilled "transfuser," devoting himself entirely to the task of drawing and citrating blood, could supply a dozen patients in need of blood, leaving to anesthetists the "simple task" of administering the blood (22).

Donors. -- There was no difficulty in procuring blood donors. Up to the middle of 1918, the spirit of comradeship was sufficient to supply them. Later, a 3-week leave in England after the donation secured many offers from lightly wounded men. Dental patients and soldiers with minor injuries, sprains, and flat feet were also used as donors. Syphilitic and malarial subjects were rejected, as well as those with other infectious diseases, such as trench fever. A healthy donor, it was thought, could withstand the loss of 700-1,000 cc. of blood.

Blood grouping. -- Early in the war, the precaution of blood grouping before transfusion was frequently omitted because it was impractical. A number of reactions were attributed to this omission, and by June 1918, Bruce Robertson (19) had observed three cases of fatal hemoglobinuria in 100 transfusions. Later in the war, preliminary blood grouping became the rule, but, when there were no facilities for laboratory work, his suggestion of a test injection was generally used, particularly in emergencies. If no symptoms occurred within 1 or 2 minutes after the injection of 15 to 20 cc. of donor blood, it was thought safe to proceed with the transfusion. ...

From BLOOD PROGRAM IN WORLD WAR II (SUPPLEMENTED BY EXPERIENCES IN THE KOREAN WAR) by Douglas Blair Kendrick. Washington, D.C.: Office of the Surgeon General, Department of the Army, 1989. (Provided by the Office of Medical History, Office of the Surgeon General/US Army Medical Command.)

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