Blood Basics > Blood in War
World War II Blood Programs
The following is excerpted from BLOOD PROGRAM IN WORLD WAR II by Douglas Blair Kendrick (pgs. 13-16, 21-22, and 24).
Chapter I: Historical Note
Blood for Britain
Origin of Program
The project in New York City hospitals which came to be known as Blood for Britain (34, 35) originated in June 1940, when Dr. Alexis Carrel, who had recently returned from France, made known the great need there for plasma for the treatment of shock in battle casualties. The idea of shipping plasma to France and England was suggested to the president of the Blood Transfusion Association of New York, and a meeting to discuss the possibility was called for 12 June 1940. It was attended by the trustees of the association; its Board of Medical Control; Dr. Carrel; experts in the field representing the Army, the Navy, NRC (National Research Council), and Rockefeller Institute; and representatives of a number of large pharmaceutical and biological firms.
It was the sense of the meeting that, even though the use of plasma was still in an experimental stage, enough knowledge was available to justify an effort at quantity production. The cooperation of the New York chapter of the American Red Cross was secured as soon as it was pointed out to its officials that the experience to be gained from this project would be of great assistance in the National Defense Program, one phase of which was the supply of plasma for the Armed Forces. ...
The program became operational on 15 August 1940, at the Presbyterian Hospital in New York, and terminated on 17 January 1941. All the plasma collected went to Great Britain, France having fallen shortly after the 12 June meeting. The program, which represented the first effort in the United States to collect large amounts of blood from voluntary civilian donors for military use, had great popular appeal, and during its existence, 14,556 donations were made.
Technique of Collection and Shipment
Liquid plasma was selected for processing rather than dried plasma, partly because the time element was vital and partly because of the expense of installing drying equipment, whose performance at this time was still inadequate and far from satisfactory.
Originally, the system by which the blood was collected was not completely closed. Later, it was realized that a completely closed system was imperative.
The plasma was separated by either sedimentation or centrifugation. To reduce viscosity, it was diluted with equal amounts of sterile physiologic salt solution; the solution, under 13 inches of water vacuum, was in the Baxter bottle (Plasmavac) in which it was finally dispensed. Merthiolate was added in quantity sufficient to guarantee dilution of 1:10,000 in the final plasma-saline mixture.
The finished product was shipped in 1,000-cc. bottles, six to a carton. Larger packages were not practical because the shipments were made by Clipper planes -- this was long before the existence of a transatlantic airlift.
Laboratory Tests and Losses from Contamination
Exacting bacteriologic and toxicity controls were required before any lot of plasma was dispensed. These tests were carried out not only in the laboratories of the participating hospitals but also in a central laboratory, under the direction of Dr. Frank L. Meleney. When the material reached England, samples from each carton were also checked bacteriologically before they were released for use. The latter precaution was instituted when it was found that certain pools of plasma that were free from bacteria when examined within 3 to 7 days after collection and processing were later found to be contaminated. Up to 1 November 1940, 1,950 liters of plasma were sent abroad as sterile after examination in Dr. Meleney's laboratory and 30 liters had been discarded because of contamination. The delayed contamination just described was discovered soon after this analysis had been made, and more rigid bacteriologic controls were at once set up. The total figures show that of 6,151 liters of plasma produced, 361 liters were found contaminated at the various hospitals and 160 liters were found contaminated in the central laboratory, the combined loss from contamination (exclusive of the amounts found contaminated in England) being 8.5 percent. The total loss from all causes was 581 liters, 9.4 percent; 151 bloods were rejected because of serologic evidence of syphilis (1.03 percent).
Analysis of Operation
The original opinion that the collection of blood and the separation of plasma would be "as simple as mixing a cocktail" promptly proved fallacious. The mass production of liquid plasma and its shipment abroad were very different from the production of small quantities for immediate local use. There were long debates on the size and shape of the collecting bottles, the stopper, the collection of blood by vacuum versus suction versus simple venous pressure, and the technique of removal of supernatant plasma. There were also discussions about the criteria for donors. Eventually, the age range was set at 21 to 60 years inclusive, the systolic blood pressure at 110 mm. Hg, and the hemoglobin level at 80 percent. Fasting was considered desirable, but the requirement proved impractical.
To set up criteria for production, to develop standard techniques, and to insure the safety of the final product involved far more difficulties than could be solved by volunteer part-time workers, and Dr. Charles R. Drew, later Assistant Professor of Surgery, Howard University, was appointed full-time medical supervisor of the project shortly after it was initiated.
The New York experience with liquid plasma led to the later decision that dried plasma would best solve the problem of so-called blood substitutes for the Armed Forces because of its greater stability; the simplicity of its packing, storage, and transportation; and reduced losses from breakage.
The Blood for Britain project was a most valuable introduction to the later development of the American Red Cross Blood Donor Service. ... The experience of the New York chapter served as a pattern for the organization and operation of the blood donor service which was to supply plasma for the Armed Forces and blood for oversea shipment. This chapter was ready to begin operations as soon as the Surgeons General of the Army and the Navy requested the American Red Cross to be responsible for the blood donor program.
There were many mistakes made in the operation of the blood and plasma program during the United States participation in World War II, but far more would have been made without the trial-and-error experience of the Blood for Britain project. The chief lesson learned was that blood and plasma, if they are to remain uncontaminated and safe for use, must be handled in a completely closed system. ...
The British Blood Program In World War II
The Association of Voluntary Blood Donors founded in Great Britain in 1922 later became the British Red Cross Transfusion Service, the first organization of its kind in the world and the forerunner of a number of similar associations in Great Britain and elsewhere (37). Blood banks were in operation in various hospitals in that country for at least 6 years before the outbreak of World War II.
In the months after the Munich crisis in 1938, recent advances in transfusion techniques, especially the use of stored blood on the field in the Spanish Civil War, were under constant discussion in Great Britain (32, 37, 38). The Medical Research Council, on behalf of the Ministry of Health, established four blood depots in the outer suburbs of London. Arrangements were also made to establish an Army Transfusion Service, which would enroll all available donors in the South-Western Countries and which would also supply civilian needs in that area. ...
The British blood program was a remarkably successful operation for ... two reasons ...: (1) that it was carefully planned before hostilities began, and (2) that it was based on the concept that blood is a perishable fluid, as potentially dangerous as it is potentially useful, and therefore to be handled in special channels by specially trained personnel. The daily, almost hourly, care that trained British officers and men gave to the blood they handled reduced accidents to a minimum. The British also regarded it as essential that their armies be self-contained as regards blood. The success of the attempt in World War II, first made by the British in the Western Desert, to bring surgeons forward to casualties, was due in large part to the successful operation of the Army Transfusion Service.
A similar separate service was recommended by the Subcommittee on Blood Substitutes, NRC, for the U.S. Armed Forces early in U.S. participation in the war. ... Such a service was later set up in Italy, and time, expense, and lives would have been spared if it had been put into operation when it was proposed.
Functions of the Army Transfusion Service
The chief function of the British Army Transfusion Service was to supply blood and other fluids, including crystalloid solutions, with equipment for their use, to the entire British Army overseas and in the United Kingdom, and also to supply civilian needs in the areas of the United Kingdom in which it operated. Liquid plasma was used in temperate climates and was safely exported as far as India; it was kept cool but not under refrigeration.
Dried human grouping serum was prepared by the Army Transfusion Service. It was selected because it did not require refrigeration. It was colored with acriflavine for group A and with methylene blue for group B. ...
The Soviet Union Blood Program In World War II
While not a great deal is known about replacement therapy in the Soviet Union during World War II, all reports indicate that blood was the chief replacement fluid (41-43). This might be expected because of the large civilian population; its proximity to the frontlines; the cold climate, which eliminated many of the difficulties of preservation and storage; and, perhaps, the lack of facilities for processing blood to plasma or serum. ...
The nationwide transfusion service that existed in the Soviet Union before the war was organized in Moscow in 1926, by Lt. Col. Andre Arkadievich Bagdasarov. This officer later directed transfusions under fire during the border warfare with the Japanese in 1939 and during the war with Finland in 1940-41.
The Central Institute for Blood Transfusion in Moscow was at the head of several subordinate institutes and about 1,500 blood donor centers. When Russia entered World War II, this organization became, in effect, a system of factories for collecting and preserving blood and delivering it to the front as it was needed.
About 2,000 persons a day gave blood in Moscow, about the same number who donated at the two blood centers in New York. All possible methods of "sanitary" propaganda were used to attract donors. About 95 percent of the donors were women, as compared with 50 percent in the United States. Donations ranged from 225 to 450 cc. A second donation was permitted in 4 to 6 weeks, but only if the blood picture had returned to normal. With these precautions, some donors had given blood for periods of 12 to 15 years with no ill effects.
A standard four-cornered container was used to collect and administer blood. The bottles were transported, preferably by plane, in specially constructed isothermic boxes, suitable for use in both warm and cold weather. Blood was also put up in 200-cc. ampules which could be carried by medical corpsmen and used well forward.
The Russians used type O blood for most battlefield transfusions and also used large amounts of type-specific, unpooled plasma. The institute worked out a method which permitted the preservation of blood for 3 or 4 weeks without loss of its biologic properties and also devised a technique for drying plasma that insured its solubility without turbidity or precipitation.
Transfusions were given at all points up to the regimental medical aid station (battalion aid station) but were most widely used at the medical sanitary battalion service level (collecting station). The most important indication was hemorrhage with shock, especially in wounds of the abdomen and extremities. The combined experience of the institute and the army was that only large transfusions, from 1,000 to 1,500 cc., given rapidly, were effective in shock. ...
Other Sources of Blood
Cadaveric blood. -- In 1928, Shamov reported the experimental use of cadaveric blood and demonstrated the absence of toxicity (48, 49). At this time, Yudin was in charge of the entire surgical and accident department of the Sklifosovsky Institute, the central hospital for emergency surgery in Moscow, in which from 8,000 to 10,000 patients were treated every year. The admissions also included many patients who died promptly from acute cardiac disease or severe trauma. In other words, the patients who needed transfusion and the bodies from which, in the light of Shamov's demonstration, the necessary blood could be secured, were both at hand.
reported his first seven transfusions with cadaveric blood at the Fourth Congress of Ukranian Surgeons at Kharkov in September 1930. The work was investigated by two commissions, one legal and the other military, both of which recognized its scientific foundation, and he was given a special permit to collect blood from fresh cadavers before autopsy.
With the discovery that cadaveric blood could be stored safely, time was provided for both serologic tests and bacteriologic examinations. In November 1932, Yudin reported to the Société Nationale de Chirurgie in Paris on 100 transfusions with cadaveric blood kept for 3 weeks, and in one instance 4 weeks. In 1937, he reported in the Lancet that he had performed a thousand transfusions by this method, chiefly for internal hemorrhage and traumatic shock and in operations for gastrointestinal disease, particularly cancer.
In Yudin's first 200 transfusions, all performed with citrated blood, there were 40 reactions, all moderate. In the next 800 transfusions, all performed with noncitrated blood, the incidence of reactions fell to 5 percent. The five fatal cases in the series were explained in three instances by technical errors, including the transfusion of incompatible blood. The fourth death was due to embolism and the remaining death to anaerobic infection.
Cadaveric blood was apparently never used widely, even in Russia. It was not mentioned to Dr. George K. Strode (42) of the Rockefeller Foundation, who visited the Central Blood Transfusion Institute of Moscow in October 1941, and no statement in the literature suggests that it was used during the war. It is doubtful that transfusions with blood secured from cadavers could ever have been employed in any country in the world except Russia, for the idea, in spite of its logic, is revolting.
32. Conference on Shock and Transfusion, 25 May 1945.
34. REPORT OF THE BLOOD TRANSFUSION ASSOCIATION CONCERNING THE PROJECT FOR SUPPLYING BLOOD PLASMA TO ENGLAND, WHICH HAS BEEN CARRIED ON JOINTLY WITH THE AMERICAN RED CROSS FROM AUGUST, 1940, TO JANUARY, 1941. Narrative Account of Work and Medical Report. New York: Blood Transfusion Association, 31 Jan. 1941.
35. Stetten, D.: "The Blood Plasma for Great Britain Project." BULL. NEW YORK ACAD. MED. 17: 27-38, January 1941.
37. Proger, L. W.: "Development of the Emergency Blood Transfusion Scheme." BRIT. M. J. 2: 252-253, 29 Aug. 1942.
38. Whitby, L. E. H.: "The British Army Blood Transfusion Service." J.A.M.A. 124:421-424, 12 Feb. 1944.
41. Phalen, J. A.: THE BLOOD PLASMA PROGRAM. Division of Medical Sciences, NRC, Washington: Office of Medical Information, 25 July 1944.
42. Strode, G. K.: BLOOD TRANSFUSION AND DONORSHIP IN THE U.S.S.R. New York: Rockefeller Foundation, 14 Nov. 1941.
43. BLOOD PROCUREMENT PROGRAMS IN OTHER COUNTRIES. Distribution 74427, American Red Cross Blood Donor Service.
48. Yudin, S. S.: "Transfusion of Stored Cadaver Blood. Practical Considerations: The First One Thousand Cases." LANCET 2: 361-366, 14 Aug. 1937.
49. "Minutes, meeting of Subcommittee on Blood Substitutes, Division of Medical Sciences," NRC, 24 Feb. 1943.
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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