Spanish Civil War (1936-39)
Barcelona Blood Transfusion Service
The Spanish Civil War (30-31), which ended in January 1939, almost 3 years before the United States entered World War II, proved conclusively, and for the first time in military history, the practicability of supplying wounded men in forward medical installations with stored blood secured from a civilian
population. Franco's armies, following the practice of the German Army ..., supplied blood at fully equipped medical centers in the rear. The Republic Army Medical Corps supplied it at advanced medical units in the field.
In the 2 1/2 years of its operation, from August 1936 through January 1939, the Barcelona Blood Transfusion Service collected more than 9,000 liters of blood in 20,000 bleedings, prepared more than 27,000 tubes of blood for forward use, maintained a list of 28,900 donors, and also prepared all necessary grouping sera.
Blood was kept under refrigeration, which was provided by electric ice-boxes
whenever current was available. It was supplied to classification stations in
heat-insulated wood or canvas boxes, with thick cord linings.
Transfusion data were recorded on special cards provided with all blood
containers. The records were so complete that it was possible to trace every
container to its point of origin in the collection center and to identify every
forward hospital in which blood had been given, the data including the name of
the person who had performed the transfusion. Blood was prescribed by surgeons
but administered by personnel of specially trained transfusion teams.
Donors were between 18 and 50 years of age. All blood was collected into a
closed system, under strictly aseptic precautions. Citrate and glucose were
added after collection, and bloods of the same group were mixed.
Clinical considerations. -- Only badly shocked casualties received blood at classification posts. Most transfusions were given in No. 1 hospitals, where very few seriously wounded patients did not receive them. Occasionally, if stored blood was not available or if the sector was particularly quiet, direct transfusions were given. The members of the hospital staff had previously been grouped and serologically tested against such emergencies.
Indications for blood and plasma administration were as follows:
1. Casualties with serious hemorrhage were given only blood, which was
injected as rapidly as possible, because cardiac function soon deteriorates when
systoles contract on a vacuum.
2. Casualties suffering from primary shock and hemorrhage were given both blood and plasma. If improvement followed the use of 2 pints of blood, a pint of plasma was given to "stabilize the improvement." Thereafter only plasma was used. If the response to the first transfusion was not satisfactory, a third pint of blood was given before plasma was used.
3. Casualties suffering only from shock were given 2 pints of plasma as
quickly as possible, followed, if there was no improvement, by a pint of blood,
also given quickly. If there was still no improvement, another pint of plasma
and another pint of blood were given over the course of an hour.4
The concept of blood replacement was that in "posthemorrhagic" shock,
at least 40 percent of the lost fluid must be restored promptly. There were,
however, no quick or reliable methods for estimating the amount of blood loss.
Generally speaking, 500 cc. of blood or blood derivatives was required for each
fall of 10 to 20 mm. Hg in the blood pressure. Failure of the transfusion to
raise the blood pressure was assumed to mean continued bleeding and indicated
the need for control of hemorrhage as well as additional transfusion.
Quick administration of blood and plasma was regarded as desirable and
without risk of cardiac embarrassment, since most casualties were young and
healthy. The rate of administration could be regulated from a slow drip up to
100 cc. per minute. Although most casualties received the first pint of blood
more quickly than the remainder, no instance of dilatation of the right heart
was recorded. As Whitby pointed out in 1945, failure to restore the blood
volume was a greater risk than overloading the circulation (32). In less urgent cases, speed of transfusion was not so important as administration of the necessary amounts of blood. The amounts given before and
after operation varied with individual needs. Trueta usually gave from 1,000
to 1,500 cc. per casualty. Patients with infected wounds required several
transfusions to restore the hemoglobin to normal values.
Madrid Blood Transfusion Institute
In September 1937, Saxton (33), a member of the British Ambulance Unit in Spain, reported on the Madrid Blood Transfusion Institute, organized by the Sanidad Militar of the Spanish Republic, which was then supplying about
400 liters of preserved blood per month and whose output was steadily increasing. The full-time personnel consisted of five physicians; five nurses; five members of the secretariat, including interpreters; and a domestic staff.
For practical reasons, only donors of groups II and IV (Moss) were utilized. The donors, all volunteers, were between 18 and 50 years of age. They were given cards that
permitted them to buy extra food and were sometimes also given small
quantities of rice, condensed milk, or other staples at the time of the
donation. They were liable to call not oftener than every 3 weeks, and they
usually gave 500 cc. at a time. Blood storage was limited to 3 weeks.
Saxton's suggestion that the Sanidad Militar organize a large-scale supply
of cadaver blood by the technique of Yudin ... does not seem to have been
4The persisting distinction between shock and hemorrhage should be noted. ...
14. Editorial, "Transfusion of Blood in Military and Civil Practice." LANCET 1: 773-774, 1 June 1918.
15. Moynihan, B.: "The Operation of Blood Transfusion." LANCET 1: 826, 8 June 1918 (Correspondence).
16. Fullerton, A., Dreyer, G., and Bazett, H. C.: "Observations on Direct
Transfusion of Blood, With a Description of a Simple Method." LANCET 1: 715-719,
12 May 1917.
17. Robertson, L. B.: "The Transfusion of Whole Blood. A Suggestion for Its
More Frequent Employment in War Surgery." BRIT. M. J. 2: 38-40, 8 July 1916.
18. Robertson, L. B., and Watson, C. G.: "Further Observations on the Results of Blood Transfusion in War Surgery. With Special Reference to the Results in Primary Haemorrhage." BRIT. M. J. 2: 679-682, 24 Nov. 1917.
19. Robertson, L. B.: "A Contribution on Blood Transfusion in War Surgery." LANCET 1:759-762, 1 June 1918.
20. Robertson, L. B., and Watson, C. G.: "Further Observations on the Results of Blood Transfusion in War Surgery; With Special Reference to the Results in Primary Hemorrhage." ANN. SURG. 67: 1-13, January 1918.
21. Robertson, O. H.: "Transfusion With Preserved Red Blood Cells." BRIT. M. J. 1:691-695, 22 June 1918.
22. Makins, G. H.: "Injuries to the Blood Vessels." In HISTORY OF THE GREAT WAR BASED ON OFFICIAL DOCUMENTS. Medical Services Surgery of the War. London: His Majesty's Stationery Office, 1922, vol. II, pp. 170-206.
23. Guiou, N. M.: "Blood Transfusion in a Field Ambulance." BRIT. M. J. 1: 695-696, 22 June 1918.
30. Trueta, J.: THE PRINCIPLES AND PRACTICE OF WAR SURGERY WITH REFERENCE TO THE BIOLOGICAL METHOD OF THE TREATMENT OF WAR WOUNDS AND FRACTURES. St. Louis: C. V. Mosby Co., 1943.
31. Jolly, Douglas W.: FIELD SURGERY IN TOTAL WAR. New York: Paul B. Hoeber, Inc.,1941.
32. Conference on Shock and Transfusion, 25 May 1945.
33. Saxton, R. S.: "The Madrid Blood Transfusion Institute." LANCET 2: 606-607, 4 Sept. 1937.
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.)