Blood Basics > 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
In 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.
Only 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. ...
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 acted upon.
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.)
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