CHAPTER XVII
The Pacific Areas and the China-Burma-India Theater
THE NEW SOUTH WALES RED CROSS BLOOD TRANSFUSION SERVICE
Organization and Techniques
Since the first-and, for a time, the only-general supplyof whole blood for U.S. Forces fighting in the Southwest Pacific came from theRed Cross blood bank in New South Wales, Australia, it is appropriate to beginthis chapter on the Pacific areas with a brief note on its organization andtechniques (1,2).
The Australian blood service was instituted after a study ofmethods of blood storage, which resulted in:
1. The selection of the dihydric sodium citrate-glucosesolution recommended by the Medical Research Council of Great Britain.
2. The development of a heavily insulated wooden box suitablefor transporting blood by air.
The blood of two donors (430 cc. each) was collected into asingle 1,000-cc. Soluvac bottle containing 200 cc. of 3-percent dihydric sodiumcitrate solution and 40 cc. of 15-percent glucose solution. Only group O donorswere used. The technician who drew the blood prepared himself by an extremelyrigid aseptic technique and repeated the preparation before the second blood wascollected. Processing included grouping, crossmatching, the Kline test, andsterility tests.
As soon as the blood was drawn, it was placed in an electricicebox for 2 hours. It was then moved to the insulated box just mentioned. Thisbox held ten 1,000-cc. flasks, and the 56 pounds of ice which it contained wasenough to keep the blood between 40? and 46? F. (4.5? and 8? C.) for 48hours; if the box was not exposed to the sun, the blood remained chilled for aslong as 5 days. The ice was placed in the box at least 4 hours before theblood was to be dispatched, and, just before the blood was packed, it wasremoved, crushed into fine pieces, and replaced. Each box weighed 210 poundspacked and occupied 4.2 cu. ft. of space.
The expiration date of the blood was arbitrarily set at 10days from the date of collection. Blood considerably older was used inemergencies, with no report of ill effects, but the practice was not considereddesirable; it was fully realized that the older the blood, the more advanced thecellular destruction and the biochemical changes, and the greater the risk ofinfection. Con-
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tamination was never a factor, and no reactions attributableto O blood per se were recorded. In fact, thanks to the detailed preliminaryplanning, there were very few difficulties of any kind when the transfusionservice began active operation. Blood not used for transfusion was converted toserum (1), and the wastage factor was therefore kept very low.Rh-negative blood was supplied for Rh-negative casualties.
Distribution
The first box of blood for use by Australian troops was flownfrom Australia to New Guinea in December 1942. Thereafter, blood wascontinuously dispatched to forward battle areas. After August 1943, it was alsosupplied to civilian hospitals and to private physicians in the Sydneymetropolitan area.
When the lines of communication became too long for suppliesof blood to be flown directly to the battle areas, a relay station was set up inan advanced base (Finschhafen), where the blood was inspected, repacked, andthen shipped forward. This unit was also equipped to bleed service troops in thearea.
Up to 1 December 1944, about 7,000 liters of blood had beenflown from Sydney and Brisbane to combat operational areas.
PLANNING FOR LOCAL SUPPLIES OF BLOOD
The small supply of plasma available at Pearl Harbor (p. 338)was soon augmented by large quantities, and there were practically no shortagesof this item during the course of the war. Its portability, ease ofadministration, and the apparatus supplied with it made plasma an ideal agent inthe circumstances of Pacific fighting (figs. 127-131). Nonetheless, from thebeginning of the war, some medical officers in the Pacific recognized that therewas no substitute for whole blood. The transfusion service in this area had itsinception in this concept. In many instances in which plasma was used, it wasemployed because whole blood was not immediately available, and time could notbe lost finding a compatible donor, making the necessary tests, and drawing theblood.
First Proposals
The first proposal for a supply of whole blood procuredlocally in the Pacific came on 8 February 1943, when Col. Frederick H. Petters,MC, Surgeon, Base Section No. 3, Brisbane, Australia, asked the commandingofficers of the 105th and 42d General Hospitals their opinion of the feasibilityof establishing a blood bank with donations from nonmalarious troops in the area(3). Blood would be collected in 500-cc. amounts on a continuous dailybasis and shipped by plane to advanced bases. The supply of donors in the basewas exhausted. The number of troops who could give blood had been depleted byloss of weight and possible malarial infection, and those available were beingbled for a second time. It might be possible to identify a group of
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nonmalarious donors, test them serologically, draw andpackage their blood, and forward it by plane, by the system the Australians hadused so successfully.
Replies from Col. Maurice C. Pincoffs, MC, CommandingOfficer, 42d General Hospital (4), and Col. Raymond O. Dart, MC, CommandingOfficer, 105th General Hospital (5), stated that it would be perfectlyfeasible to ship blood to advanced bases by the plan proposed, but bothspecified that the entire procedure should be made the responsibility ofpersonnel trained in the handling of blood at the base and at advanced bases.Either jointly or singly, Colonel Pincoffs and Colonel Dart also made thefollowing points:
1. Some means of prompt communication shouldbe arranged between the officers in charge of blood at the base and at advancedbases, so that the collection of blood could fluctuate with the needs in theforward area.
2. Only group O and group A blood should beused, and collecting flasks should be provided in the ratio of 60:40.Eighty-five percent of recipients would thus receive homologous blood.
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FIGURE 128.-Administration of plasma towounded infantryman, Leyte,
Philippine Islands, October 1944.
3. Australian techniques should beinvestigated. If blood were collected in discarded 1,000-cc.intravenous flasks, the amounts from two donors could be combined and wouldprovide enough for a single exsanguinated casualty; it was assumed that plasmawould remain the intravenous fluid of choice, whole blood being given only incircumstances of extreme urgency. Specifications for marking the blood,maintenance of sterility, and other precautions were emphasized.
4. The blood should be refrigerated fromcollection to administration; in these circumstances, a dating period of 5 dayswould be considered safe.
5. Donors should be grouped, testedserologically, and examined physically before the blood was drawn, preferablybefore breakfast, to avoid foreign protein reactions.
Colonel Pincoffs did not believe that a system of volunteerdonors would stand up under heavy demands. He recommended that hospitals drawblood from their own detachments and that service troops, not including medicaltroops with detachments of active hospitals, should form donor pools. ColonelDart estimated that, if the cooperation of all enlisted personnel at a hospitalcould be secured, there would be available daily 10 times 500 cc. of blood. Ifofficers and patients were also used, daily availability would increase to 15times 500 cc. These figures would be maximum, however, if the need wereprolonged.1
1They proved to be overly optimistic.
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On 23 February 1943, Col. Julius M. Blank, MC, Surgeon, AdvancedBase, sent the following 1st indorsement to Brig. Gen. Guy B. Denit (6):
1. If whole blood were obtained from Australian sources andshipped to the advanced base (as was done 11 months later), it would benecessary to set up a small subbank in this base, with arrangements for preciserefrigeration at 38? F. (3.5? C.). Such facilities did not then exist.
2. Blood stored under these conditions would probably becomehemolyzed at a maximum of 10 days after bleeding. If it were used, benefitswould be reduced and the chances of reactions increased. At the end of thisperiod, however, it should be possible to remove the red blood cells and use theresidue-if the proper facilities were available.
3. The use of blood serum had given satisfactory results inmost patients sent to the base, and the use of whole blood could therefore belimited to those patients with a marked reduction in the cellular elements.
4. Authorities had set the level of transfusions below whichit was not considered practical to establish a blood bank at 1,000 to 1,200 perannum. At the 10th Evacuation
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Hospital, 50 transfusions had been given toapproximately 1,500 wounded in December 1942, and 44 had been given in January1943. These figures were interpreted to mean that the present supply of donorswas adequate and that, unless there was a sudden influx of casualties, bloodfrom the Australian bank was not needed.2
5. If such an influx occurred, it might beadvantageous to have an extra supply of blood on hand. It was thereforesuggested that adequate storage facilities be provided at the advanced base fora minimum of 25 liters of blood. If the supply were replenished every 10 days,the transfusion capacity per month would be 75 liters. Arrangements could alsobe made with the Australian blood bank to provide blood to be flown up asrequested by radiogram.
In comments on these proposals on 2 March 1943, Maj. (laterCol.) Wm. Barclay Parsons, MC (7), pointed out that the assumption thatthe donor supply was adequate seemed odd, since the paucity of donors had beenthe main reason for starting the discussion.
BLOOD SUPPLY FROM AUSTRALIA
On 3 August 1943, the Surgeon, Subbase D (Port Moresby), wasinformed by Colonel Petters (8) that thereafter blood would be suppliedregularly from
2It is curious, as well as typical of the lack of knowledge of the potentialities of blood at this time, that it was not realized that the small number of transfusions could be better explained both by lack of blood and by ignorance of its usefulness.
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the Australian Blood Bank Service, in amounts up to 200liters per week, within 24 to 36 hours after it had been requested by radiogram.Instructions were given for refrigeration of the blood on arrival; for itsshipment forward by air in insulated boxes, which would be supplied; and for a10-day dating period. It was requested that surgeons in forward areas beinformed of the availability of the blood, all of which would be group O.Instructions for the use of the Australian Soluvac giving set were attached.Great emphasis was placed upon the proper cleansing of the equipment immediatelyafter it had been used.
On 22 January 1944, the Australian Blood Distribution Centeroperating at Port Moresby, New Guinea (map 4), began to supply preserved bloodto U.S. troops located at bases within air reach. Delivery to them was by U.S.planes. When this operation began, the useful age of the blood was advanced from10 to 15 days, it having been found that hemolysis seldom occurred earlier.
By the original plan, 10 liters of blood were flown weekly toMilne Bay, Oro Bay, and Finschhafen in New Guinea. In July 1944, hospital ships
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departing from Finschhafen and Hollandia to forward bases at which there hadbeen recent activity were also stocked with blood.
From the initiation of this service until it was discontinued in February1945, U.S. bases in the Southwest Pacific received 2,310 liters of blood fromAustralia, about a quarter of their requirements, at a cost to the U.S. Army of$15 per liter (1).
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27TH GENERAL HOSPITAL BLOOD BANK
The plan to use the 19th Medical General Laboratory for ablood bank at Hollandia, to support the Leyte operation, could not be carriedout because this unit arrived in the area too late. The laboratory served as ablood bank, however, after the final Japanese surrender and the end of shipmentsof blood from the Zone of Interior in September 1945 (p. 629).
The bank at the 27th General Hospital (fig. 132) began tofunction on 9 September 1944, about 5 weeks before the landings on Leyte werescheduled (1). Instructions for its operation were given in the standingoperating procedures prepared by Maj. (later Lt. Col.) Mark M. Bracken, MC, whowas chief of the laboratory service, and in Technical Memorandum No. 13, Officeof the Chief Surgeon, Headquarters, USAFFE (U.S. Army Forces in the Far East),21 September 1944 (9).
The original plan, to pool the blood of eight donors in4,000-cc. flasks, had proved technically unworkable. There were no facilitiesfor creating a vacuum powerful enough to permit the collection of satisfactoryamounts of blood from each donor into bottles of this size. The substitute plan,to collect individual donations in 600-cc. Transfusovac bottles containingsodium citrate, was more satisfactory from the standpoint of sterility as wellas of efficiency. The final content of each flask was 500 cc. of blood; 70 cc.of citrate solution; and 5 cc. of 50-percent glucose solution, which wasadded before the flask was topped. The original plan of adding sodiumsulfathiazole
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to the blood was discontinued as unnecessary; the Instituteof Tropical Diseases at Sydney had shown that spirochetes and malarial parasitesdo not survive in blood stored under refrigeration for 5 days.
The dating period of the blood was set at 20 days. Plasmafrom blood not utilized by this time was to be used locally on burns and oncertain types of wounds, though in Major Bracken's experience, plasma thusprepared could be safely used intravenously.
The following modes of transportation were authorized forshipment of blood:
1. By plane, packed in crushed ice ininsulated boxes.
2. By boat, similarly packed until it could beplaced under refrigeration aboard. The boxes were to be returned to the bloodbank.
3. By boat, to which it would be delivered inThermos jugs. After the blood had been placed in refrigerators aboard, the jugswould be returned to the bank.
4. By boat, in portable reefers(refrigerators), in which it would be delivered to its destination. Blooddelivered in this manner kept for 5 days if the boxes were not exposed to directsunlight.
The bank at Hollandia (map 4) at once began to functionactively. During October, 697 liters of whole blood were distributed from it. Itproved to be a convenient supply base both for New Guinea bases and for combatareas forward.
On 20 December 1944, a supplementary depot began to operateon Biak Island (Base H), and a bank was projected for Leyte (Base K), as soon asthe military situation permitted.
STAFF VISIT TO PACIFIC AREAS BY ARMY AND NAVY
CONSULTANTS IN SHOCK AND TRANSFUSION
Objectives and Itinerary
In view of their close association in the plasma program, itwas logical that when Capt. Lloyd R. Newhouser, MC, USN, was ordered to thePacific in June 1944, similar orders should have been requested for Lt. Col.(later Col.) Douglas B. Kendrick, MC, his counterpart in the Army blood andplasma program. Captain Newhouser's orders placed no limit on his activities.Colonel Kendrick's orders directed him to accompany Captain Newhouser at alltimes.
Their combined survey, which began on 6 June and ended on 8August, had the following objectives:
1. Investigation of the need for, and availability of, wholeblood.
2. Investigation of available equipment and personnel forsupplying whole blood and setting up blood banks.
3. Coordination by the Army and the Navy of plans andequipment for supplying whole blood.
4. Investigation of the availability and use of plasma andserum albumin and the need for the products of plasma fractionation.
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5. Investigation of the supply and use of penicillin.
6. Collection of other miscellaneous medical information.
As specified in their official orders, Colonel Kendrick andCaptain Newhouser went from Washington to Honolulu, and then visited thefollowing locations (map 5) (10):
1. Central Pacific Area: Pearl Harbor, Hawaiian Islands;Kwajalein and Eniwetok, Marshall Islands; Saipan, Mariana Islands; JohnstonIsland.
2. South Pacific Area: Esp?ritu Santo, New Hebrides; Noum?a,New Caledonia (twice).
3. Southwest Pacific Area: Brisbane and Sydney, Australia(twice each); Dobodura, Oro Bay, Finschhafen and Hollandia in New Guinea; Biak,Owi, and the Woendi Islands in the Schouten Group; Manus and Los Negros Islandsin the Admiralty Group; Cape Gloucester, New Britain; and Milne Bay, New Guinea.
The policy in all of these places was the same: to holdconferences with Army and Navy medical officers with an interest in plasma andtransfusion; to visit Army and Navy hospitals, to get a cross section of theiractivities; and to determine the use of albumin and plasma and the use of, andneed for, whole blood. In all areas, Captain Newhouser and Colonel Kendrickfound a great need for a transfusion service, particularly in New Guinea, wherethe distances between the transfusion service in Australia and forward combatareas were becoming too long for efficient transportation of blood. There wasagreement in all areas by Army surgeons and Fleet surgeons that there was anincreasing need for whole blood, which, up to then, had been available only inlimited quantities. Augmentation of the supply had never been possible, nor hadit been possible to establish a blood bank, because of lack of trained personneland equipment.
It was immediately evident to Captain Newhouser and ColonelKendrick that, for a variety of reasons, it would not be practical to ship bloodfrom Sydney to any area beyond Finschhafen, but they thought it best to delayrecommendations for the location of a blood bank until their trip through NewGuinea was completed.
Recommendations for Blood Supply in the Southwest PacificArea
On 19 July 1944, at the request of General Denit (fig. 133)and with the concurrence of Captain Newhouser, Colonel Kendrick submitted toGeneral Denit a plan for a blood transfusion service in the SWPA (SouthwestPacific Area) with special reference to advanced bases, as follows (11):3
1. With high priorities and responsiblecouriers, it was practical to transport blood from Sydney to Finschhafen. Beyondthat point, a transfusion service must be established.
3The locally supervised programs recommended were all compromises, and none too desirable. It should be remembered, however, that when they were set up, there was no other choice; it was not until August 1944, when the tour of the Pacific areas was practically complete and Colonel Kendrick and Captain Newhouser were on their way back to the United States, that Maj. Gen. Norman T. Kirk reversed his ruling of November 1943 and agreed to the shipment of blood overseas to combat theaters.
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FIGURE 133.-Brig. Gen. Guy B.Denit, ChiefSurgeon, USASOS, SWPA, and USAFFE.
2. Two recommendations were made:
a. That a blood bank be set up at Hollandia,because of its proximity to future planned operations; the availability of anadequate service donor population (100 a day); and facilities already availablein the area. General Denit had also pointed out another advantage, that an Armylaboratory was shortly to be set up there.
b. That a blood bank to service both Army andNavy should be set up initially aboard LST 464 (landing ship, tank), whichshould remain in Humboldt Bay until the proposed Army laboratory came intooperation in this area (11, 12). When the ship eventually moved to a moreadvanced area, it was anticipated that it could continue to supply Army needs aswell as the needs of portable surgical hospital teams aboard all LST's in thearea. If the necessary transfusion equipment could be provided (which it wasunderstood the Army had immediately available), this ship had the space,facilities, and trained personnel to institute a transfusion serviceimmediately. Specifications for personnel, refrigeration, equipment, and sourcesof donors were stated in detail.
At General Denit's request, on 1 July 1944, a requisitionhad been sent by radio to the Zone of Interior asking for the immediate shipmentof 100 "apparatus, blood transfusion, indirect, field assemblies" toproduce blood for operations scheduled for the immediate future. A requisitionhad also been sent through regular supply channels for enough recipient bottles,recipient sets, and refrigerators to supply the need of the SWPA for the next 6months. General Denit intended to request trained personnel for the bank.
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Earlier, a radio request had been made for transfusionequipment for New Caledonia.
There was complete Navy agreement with all of these plans. Inall locations, in fact, Captain Newhouser and Colonel Kendrick had been greatlyimpressed by the way the two services worked together.
Recommendations for Blood Supply in the Central and SouthPacific Areas
When Captain Newhouser and Colonel Kendrick reported toHeadquarters, SPA (South Pacific Area), on 21 July 1944, they were informed byCapt. (later Rear Adm.) Frederick R. Hook, MC, USN, the Force Medical Officer,that hospital ships evacuating casualties from Saipan were in urgent need ofadditional blood. It was requested that sufficient equipment be made availableto operate a blood bank at Bougainville or Pearl Harbor, where donors could beprocured in adequate numbers and whence blood could be flown to the ports intowhich hospital ships could be ordered. After Captain Newhouser and ColonelKendrick had returned from a trip to Saipan on the hospital ship Samaritan, whichwas evacuating casualties from the Marianas, the Surgeon, SPA, on 22 July 1944,sent a radio request to the Office of The Surgeon General for 100 fieldtransfusion assemblies for use aboard hospital ships or in a blood bank atBougainville or any other location that might be decided upon for long storage ofblood. Meantime, part of the transfusion equipment which the Army had on hand atNoum?a, New Caledonia, was transferred to the Samaritan.
When the visiting officers returned to Pearl Harbor, Capt.Walter M. Anderson, MC, USN, Fleet Surgeon, and Brig. Gen. Edgar King, Surgeon,CPA (Central Pacific Area), requested advice as to the best location for a bloodbank to supply blood to advanced locations in the South Pacific Area.
Since the SPA and the CPA had been combined under the POA(Pacific Ocean Areas), it was thought that one bank at an advanced base couldcare for the emergency needs of the entire Pacific Ocean Areas. Pearl Harborcould provide an adequate donor population but was considered too far removedfrom the combat zone to supply blood for future operations west of the Marianas.Saipan or Guam, depending upon which had the larger military population, wouldbe a better choice. Blood collected on either island could be transported to thecombat zone by hospital ships or LST's until airstrips were secured. Later,Guam was selected as the distributing center for the airlift to the Pacific (p.614).
LST 464
Just before Colonel Kendrick recommended to General Denit theuse of LST 464, acting as hospital ship, as a blood bank for the invasion ofLeyte, Lt. Ernest E. Muirhead, MC, USNR, had prepared blood on it and carried itashore on another LST to supply troops going in at Noemfoor Island. Although
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his equipment was extremely limited and he had to use emptyintravenous solution bottles, his procedure had proved entirely feasible.Lieutenant Muirhead had had previous experience in the operation of blood banks,and it was recommended that he be put in charge of the bank proposed for LST 464(11, 12).
Detailed recommendations for operations on this ship coveredpersonnel, equipment, refrigeration, blood grouping, and donors. The closedsystem of collection, which was essential, would require the use of a sterile,self-sealing, vacuum-type, 1,000-cc. bottle, containing 500 cc. of Alsever'ssolution. This technique would make it possible to preserve the blood underrefrigeration at 43? to 46? F. (6? to 8? C.) for 18 to 21 days. Provisionwas also made for the use of individually packaged, expendable giving sets,ready for immediate use. Donor sets, consisting of 17-gage needles, latex rubbertubing, and stainless steel valves, would be cleaned and sterilized each timethey were used. The tubing must be replaced after 10 to 15 bleedings. The valvescould be used several thousand times.
Donors aboard ship would be obtained from Navy personnel.Only type O blood would be used. Serologic tests would be run, but it would beimpossible to rule out malaria-positive donors by blood smears. Suppressivetreatment with Atabrine (quinacrine hydrochloride), however, which wasuniversal, would prevent the transfer of the infection to the recipient, sincemost infections were caused by trophozoites. Refrigeration of the blood wouldalso have a lethal effect on the parasite.
These recommendations, including the appointment ofLieutenant Muirhead, were duly implemented on 23 July 1944, by orders fromHeadquarters, USASOS (U.S. Army, Services of Supply), SWPA. Steps were taken atonce to prepare the blood bank on board for the invasion of the Philippines(fig. 134).
DONORS
General Considerations
Hospitals in the Pacific which collected their own bloodfrequently had difficulty in securing donors. Detachment personnel could not bereused as promptly as in the Zone of Interior because experience had shown thatthey did not regenerate hemoglobin as rapidly as in more temperate climates. Itwas always undesirable to bleed troops shortly before they went into battle, andmuch more undesirable, for the reason just stated, in the Tropics.
When the Sixth U.S. Army was staging in Hollandia for theinvasion of Leyte, an attempt was made to maintain a list of 500 donors in theOffice of the Base Surgeon, but the project was not successful, partly becauseof the continued calls for large quantities of blood and partly because of therapid passage of prospective donors through the base. It was necessary to bleedlisted donors promptly if they were to be useful. When necessary, as many as 150donors could be bled in a day at the 27th General Hospital blood bank.
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The original plan of requiring two visits of donors (thefirst for confirmation of the blood group, the Kahn test, and the blood smear,and the second for bleeding if the first examination was satisfactory) provedcompletely impractical. A great many donors did not return because of transfers,leaves, and for other causes. When the plan was adopted of requiring only asingle visit, it proved equally impractical to hold donors until the tests werecompleted. The routine was therefore adopted of bleeding the donors at once anddiscarding blood that was serologically positive or that otherwise did not meetspecifications.
Calls for volunteers were made by notices in the dailybulletin, at headquarters, and by personal contacts by the officer in charge ofthe bank with various organizations from which donors might be secured. Thesewere the only practical plans. The postal service was entirely unreliable, andthe use of the telephone simply resulted in loss of time. Red Cross workers werevery helpful in securing donors from both Army and Navy personnel.
The response to a call for donors was sometimes enthusiastic.The number exceeded 500, for instance, when information, considered reliable,spread
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within the 32d Infantry Division, when it was staging atHollandia, that each donor would receive 2 ounces of whisky and a good meal. Thelimited facilities of the bank at the 27th General Hospital were all thatprevented mass participation. The donations proved well worthwhile: Thisdivision was the first to use whole blood on the battlefield, where itsusefulness far exceeded the most optimistic hopes for it. It is only fair to addthat there was always a prompt response to a real emergency (fig. 135).
The Malaria Problem
The malaria problem first assumed an areawide aspect in June1944, when preparations for the operation of a transfusion service were firstdiscussed. Upon inquiry, General Denit learned from the Surgeon, Base B (OroBay) that New Guinea hospitals were in the habit of using members of their owndetachments as donors (13). Even though negative smears for malaria wereobtained before bleeding, it was highly probable that a certain percentage ofthese donors had subclinical suppressive malaria, which would not be apparent ona single smear. Malaria had developed after transfusion in several casualtieswho had not previously had it and who had received blood from donors who hadbeen in New Guinea for some time. In one instance, the chills and associatedfever proved a serious complication of bleeding peptic ulcer. Since
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the problem was likely to increase as more troops remained inmalarious areas, two procedures were suggested:
1. The supply of pooled blood from Australia,which was now not being used in large quantities, might be increased. Althoughthis blood was supposed to be used within 10 days, it was preserved in glucoseand if it were properly refrigerated, the dating period could be extended to 15days.
2. On the suggestion of 1st Lt. (later Maj.)Frederick B. Bang, MC, of the Malaria Research Group, an intramuscular injectionof Atabrine might be given before transfusion. In an emergency, if blood had tobe used from a possibly malarious donor, it might be wise to increase the dosageof Atabrine as recommended for patients about to undergo surgery (14).
No positive malaria smears were reported at the bank at the27th General Hospital in its first 7 weeks of operation (and only one positiveserology). One reason was that donors who appeared cachectic and those with ahistory of malaria, jaundice, or any serious illness within the previous yearwere not accepted. There were no reports of malaria (or jaundice) after anytransfusion. It was realized, however, that since the bank was located in amalarious area, it would be impossible to exclude all malarious donors. It wasalso considered possible that, in a few instances, viable parasites had beentransmitted in the blood and that the transmittal had been masked by therequired daily use of Atabrine by all personnel in the area.
Other Tests
Up to the middle of 1945, the Rh factor was not considered ofimportance in the Pacific. In July 1945, 436 pints of Rh-negative blood weresent from the Zone of Interior in a total shipment of 4,465 pints of blood.
Up to this time, isohemagglutinins had also not been regardedas important. Crossmatching was performed when time permitted but was notconsidered essential, since the blood had been checked twice in the Zone ofInterior. Had the war continued, it would have been necessary for patients whohad had numerous transfusions to be crossmatched and have agglutination testsfor minor agglutinins.
Errors in the entries on the identification tags averagedabout 10 percent.
EQUIPMENT
The story of equipment for blood transfusion in the Pacificareas duplicated that in other theaters; that is, shortages and improvisationsuntil expendable receiving and giving sets became available, the latter when theairlift of blood from the Zone of Interior began in November 1944. Just beforethat happened, the scarcity of expendable sets was so great that those on handhad to be apportioned among POA and SWPA, according to the intensity of the areaneed.
Early in the whole blood program in the Pacific, there weresome complaints that it was difficult to pass stored blood through themetal-mesh filters
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in the giving sets. Up to this time, blood had been stored at36? to 40? F. (2? to 4.5? C.). The difficulty was almost entirely overcomewhen the storage temperature was raised to 40? to 45? F. (4.5? to 7? C.)because the gel which formed in the blood at the lower temperature did not format the higher temperature. One of the most important considerations of storagethen became the maintenance of the temperature above 39? and below 45? F. (4?and 7? C.).
In his first report from the Pacific, Colonel Kendrick statedthat the Medical Department in that area frequently had to construct its ownhospitals and was therefore greatly in need of building tools (10). Withoutappropriate facilities, blood could not be used. He suggested that hammers,saws, and even sawmills should be issued to hospital units as part of theirregular equipment. The suggestion about sawmills was not acted on favorably.
THE AIRLIFT OF BLOOD TO THE PACIFIC
Organization
Since the Army had set up, and was conducting, the airlift ofblood to the European theater, under the direction of Colonel Kendrick, it waslogical for the Navy to set up and conduct the similar service to the Pacificareas, under the direction of Captain Newhouser. In a conference between Brig.Gen. Fred W. Rankin and Captain Newhouser on 13 October 1944, while ColonelKendrick was on temporary duty in Europe, it was agreed that the Navy shouldestablish and operate the processing laboratory in San Francisco and shouldfurnish all the bottles, donor sets, and refrigerators for the program. The Armywould furnish all the equipment necessary to operate the laboratory. The SurgeonGeneral, Army, agreed to the coordinated program in the Pacific with theunderstanding that the allocation of blood to the two services would be basedentirely upon their requirements. The Navy would fly the blood from the westcoast to Guam, process it at the Navy blood laboratory there, and then deliverit to all areas in the Pacific as it was required.
The Army also furnished all personnel for the laboratory atthe Los Angeles bleeding center (blood grouping, serologic testing) and for thepackaging and shipment of blood to San Francisco. Requests for personnel forthese purposes were made by General Rankin in October 1944, and again inFebruary and March 1945, to the Personnel Division, Office of The SurgeonGeneral. Trained technicians were not requested, since the enlisted men requiredcould be trained by the staff of the Los Angeles and other centers supplyingblood for the airlift.
American Red Cross Participation
On 26 October 1944, after the feasibility of an airlift ofblood to the Pacific had been established, Vice Adm. Ross T. McIntire, MC, USN,Surgeon General, U.S. Navy, and Maj. Gen. Norman T. Kirk wrote jointly to Mr.Basil O'Connor, Chairman, American Red Cross, concerning the planned
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whole blood program for the Pacific (15). Neitherplasma nor serum albumin, it was pointed out, could compensate for the wholeblood lost by severe hemorrhage. Up to this time, blood had been obtained in thePacific from military personnel in combat areas. Since recent developments hadshown the feasibility of transporting blood to oversea theaters, the Red Crosswas being asked to furnish a minimum of 300 pints of O blood per day for thePacific from donor centers in San Francisco, Oakland, and Los Angeles, with theunderstanding that activities might be expanded if larger amounts of bloodproved necessary. It was requested that the service begin on or about 15November 1944 and that the collections be in addition to the blood then beingcollected for existing programs.
Mr. O'Connor replied on 3 November 1944 that the AmericanRed Cross would be glad to cooperate in the Pacific program and that steps werebeing taken to procure the blood, as requested, from the centers at SanFrancisco, Oakland, and Los Angeles(16).
The airlift to the Pacific began with the procurement ofblood from the three centers specified (17). As the need for bloodincreased, the Portland, Oreg., collection center was added to the program on 30January 1945 and the San Diego, Calif., center on 4 February. The Chicago centerbegan to produce blood for the Pacific on 13 April.
When the need for whole blood ended in Europe with the Germansurrender on 8 May 1945, the centers on the east coast, which had beencollecting whole blood as well as blood for plasma (New York, Philadelphia,Washington, Boston, and Brooklyn) were kept operational for procuring blood tobe flown to Oakland. The capacity of these centers, added to that of the centerson the west coast, brought the blood available for shipment to the Pacific to12,000 pints each week. As of 15 May, all blood collected in the eastern UnitedStates was being flown to the west coast, re-iced there, and then flown to Guam(map 6).
By the end of May, arrangements were completed to consolidatethe processing of all blood collected in Philadelphia, Boston, Washington, andNew York in one large laboratory at the blood donor center in New York. Theblood was collected in these cities, taken to New York by refrigerated motortruck, processed there, and then packed in Army expendable insulated boxes forthe flight to the west coast. This plan proved both safe and practical. WhenMaj. Leslie H. Tisdall, MC, inspected the Navy laboratory at Oakland (fig. 136)after these arrangements had been effectuated, he found that shipments arrivingfrom New York needed only a small amount of added ice before being flown toGuam.
Shipments were regulated according to requests from the navalofficer in charge of the distribution center on Guam. They varied widely, fromno donations at all on a few days to 12,000 pints during one week in May 1945.These irregularities caused some difficulties in the centers, since procurement
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MAP 6.-Flight plan, for distribution of bloodto Pacific from U.S. west coast.
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of donations had to be kept at as constant a level as possible.Donations in excess of whole blood requirements were shipped to the laboratoriesprocessing plasma.
Initial Difficulties
The inauguration of the airlift of blood to the Pacificterminated, for all practical purposes, the difficulties of replacement therapyin that area. The service evolved into an extremely efficient operation. As Lt.(later Lt. Cdr.) Herbert R. Brown, Jr., MC, USNR, stated in his report on thedepot for 6 March 1945, it had not been necessary to make a single major changein the original program and very few minor changes (18). The pilot run inSeptember 1944 had gone very smoothly, but there were multiple initialdifficulties, both in the Zone of Interior and overseas.
Zone of Interior-The first shipment of blood left SanFrancisco for Guam and Leyte (map 6) on schedule on 16 November 1944, in chargeof Lt. (later Lt. Cdr.) Henry S. Blake, MC, USN. Brig. Gen. Charles C. Hillmanand other Army and Navy personnel were extensively photographed as they assistedin placing the 10 boxes of blood (160 pints) on the plane. A naval medicalofficer, a naval public relations officer, and a photographer went on theflight, to send back stories and create more interest in the program. The
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blood reached Guam on 19 November and Leyte on 22 Novemberwithout complications.
Numerous complications, however, attended the departure ofthe first shipment and continued for several days afterward. They were describedby Maj. (later Lt. Col.) Frederic N. Schwartz, MAC, who had gone to Los Angeleson 13 November, to establish the Army part of the program, substantially asfollows (19):
The laboratory in which the blood was to beprocessed was not yet ready. All the necessary laboratory supplies had notarrived, including the indispensable centrifuge. Arrangements had not yet beenmade for air shipments to San Francisco. On the Navy side, there were alsoshortages, including insulated boxes, and, for a few days, the Oaklandlaboratory could handle only 40 bloods daily instead of the specified 100bloods.
The Army was able to meet the originalschedules by loans and improvisations. A centrifuge was flown in from FitzsimonsGeneral Hospital, Denver, Colo. Major Schwartz arranged with Hyland Laboratoriesfor the blood to be processed there until the Los Angeles center was ready. Thiswas not a particularly efficient arrangement, for it meant that the blood had tobe taken by the Red Cross Motor Corps from the collecting center, where itshould have been processed, to Hyland Laboratories for typing and serologictesting. It was fortunate, however, that the arrangement could be made. Theblood was taken to San Francisco by the Railway Express Agency, in Churchcontainers.
By 1 December 1944, most of these difficulties had beenironed out and daily shipments to the Pacific amounted to 250 pints, of which100 were supplied by the Army.
Overseas.-In correspondence with Col. (later Brig.Gen.) George R. Callender, MC (20), and Major Schwartz (21) inDecember 1944, Colonel Kendrick4 stated thatplanning in the United States for the Pacific airlift had been exceptionallywell done but the excellence had been confined to the United States:
1. No command in either the Central or theSouthwest Pacific had been advised officially of the whole blood program byeither Army or Navy sources. Colonel Kendrick made every effort to assure thesurgeons in the various Pacific commands that this was an official program,coordinated by the Army and the Navy, but lack of written authorizationsometimes made it difficult to secure cooperation.5He was told at one installation, where con-
4Colonel Kendrick, still serving asSpecial Representative to The Surgeon General on Blood and Plasma Transfusions,left the United States on 2l November1944, for temporary duty with the USAFPOA(U.S. Army Forces, Pacific Ocean Areas), of which Brig. Gen. John M. Willis wasSurgeon. Colonel Kendrick went to Guam and Leyte almost immediately and did notreturn to Hawaii until January 1945, after stopping en route for several days ofconferences on the blood program with Lieutenant Brown on Guam. By this time,the overall blood program was functioning smoothly in the Zone of Interior, theEuropean theater, and the Pacific; and Colonel Kendrick was relieved of hisresponsibilities for the program in the Office of The Surgeon General, where hewas replaced by Maj. John J. McGraw, Jr., MC (p. 402). Colonel Kendrick was alsorelieved of his responsibility in the Pacific, where no other consultant wasappointed during the remainder of the war.
At this time (January 1945), Colonel Kendrick was placed in command of the 10thField Hospital, which was designated to land on Okinawa on D+60, but on 14March, 5 days before the Tenth U.S. Army sailed for that target, the ArmySurgeon, Col. Frederic B. Westerfelt, MC, recognizing the peculiar requirementsof the management of shock and the handling and use of blood, assignedhim to his headquarters as consultant in these special fields. Colonel Kendrickwent ashore with the Tenth U.S. Army on Okinawa in early April and served asConsultant in Resuscitation, Whole Blood, and Shock for the next month. He thentook command of the 31st Field Hospital.
5This was an unfortunate contretemps. Letters had been written by theSurgeon General, Navy, advising all commanders in the Pacific that blood wouldbe shipped from the United States. The letters were to go airmail, but throughsome error, they were sent by regular mail. The commanders therefore did notreceive them until 2 to 4 weeks after the blood program had been set up in thePacific.
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fusion was rampant, that it was not necessaryfor a War Department representative to come out and tell them how to run theirtransfusion service. In an advanced area of the Sixth U.S. Army, his activitieswere restricted, and he was prohibited from interfering with present policies onthe ground that the officers in charge of the program were competent to handleit. By surreptitious methods, Colonel Kendrick provided thesurgical consultant, Sixth U.S. Army, with enough information for him to preparea circular letter on the new service.
2. The blood bank in Honolulu resented beingleft out of the program, even though its inclusion would have greatlycomplicated the transportation of blood. The additional supply, in fact, wouldnot have been worth the trouble necessary to secure it.
3. General Denit had not been notified of theprogram nor had any Army surgeon. Not having received any word on it from theOffice of The Surgeon General, Army, they concluded, quite logically, that theprogram was a Navy responsibility and had sent no information about it toforward hospitals.
4. The arrival of the first shipment of bloodin the Southwest Pacific in November 1944 had beenreported to the Army surgeon but not to the Fleet surgeon, and Colonel Kendrick,as Consultant on Blood and Transfusion to the Surgeon, POA, found himself in theodd position of selling a Navy program to the Navy.
5. Because of the lack of official notice ofthe blood program, it was "existing parasitically," by leaning heavilyon personnel and equipment from medical supply companies and otherorganizations, which could ill afford to spare either. It was Colonel Kendrick'sopinion that if the program had concerned anything but blood, it could not haveoperated.
6. Since no blood distribution teams had beenset up, the blood was frequently not being handled properly. Sent throughordinary supply channels, it was taking unnecessarily long in delivery. It wassometimes kept without refrigeration, and not even in insulated boxes. It wassometimes distributed without expendable giving sets. Eventually, during theLeyte campaign, Colonel Kendrick was able to have a distribution team set up inthe Philippines and to arrange for transportation, a supply of ice, and otheressentials.
7. It was regrettable that, because of someconfusion in his orders, which kept him in the Central Pacific for 10 days, hisplanned meeting with Lieutenant Blake did not occur. The exchange of experienceswould have been of great value.
In spite of these difficulties, cooperation had beenexcellent on the part of all concerned. The Naval Air Transport Service and theTransport Air Group, without written authority, gave Colonel Kendrick a No. 1priority for blood, and asked no questions about it. Since proof existed thatthe blood service could be operated with sacrifices on the part of other medicalunits, he saw no reason why, in view of its importance, it should be hamstrungby lack of its own adequately trained personnel, equipment, and transportation.Responsibility to the services and to the donors of the blood warranted theutilization of the best trained personnel and the most efficient equipmentpossible. If a commodity such as blood were lost, as the result of incompetenceon the part of makeshift personnel or inadequate refrigeration at relay points,the armed services would be put in a position of great culpability.
Colonel Kendrick, on the basis of his observations, made thefollowing recommendations (20, 21):
1. A circular letter or directive should beissued by the Army and the Navy, together or separately, authenticating theexistence of the transfusion service.
2. The transfusion teams recommended by theOffice of The Surgeon General in the T/O & E (Table of Organization andEquipment) sent to Army Service Forces on 15 December 1944 should be immediatelyapproved and activated.
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3. Two transfusion teams should be activated,equipped, and ordered to the Pacific, one to USASOS, SWPA, and the other toUSASOS, POA.
4. The transfusion service for the entire areashould be placed under a single control officer with a combined staff of Armyand Navy personnel. The present confusion caused by five or six differentofficers' being responsible for blood in different installations could nolonger be tolerated.
In one way or another, all of these recommendations exceptNo. 4 were implemented by the end of January 1945.
Personnel
When the service to the Pacific was once firmly established, theblood was consistently handled by specialized personnel, by what amounted to aspecial delivery service, which is the only efficient way to handle such avaluable commodity and, more important, the only safe way. At no stage along theway, from the collecting center in the Zone of Interior to the administration ofthe blood at the terminal point in the Pacific, was it touched by any buttrained, specialized personnel, on permanent assignment. The blood service inthe Pacific had its roots in the experiences gained in the Mediterranean andEuropean theaters, as well as in the Zone of Interior.
The initial handling of some of the first blood shipped fromGuam to Leyte furnished an excellent example of what could happen to this scarcecommodity once it left the care of personnel specially trained to handle it.These shipments had been correctly handled all the way from the Zone of Interiorto Leyte. When they reached Leyte, the bottles of blood were taken out of theinsulated containers in which they had traveled up to that time, thrown into thebacks of trucks, and transported for 4-5 hours over rough roads to the medicalinstallations which had requested them. The temperature, as it frequently was,was 100? F. in the shade, the humidity was extreme, and it was possible to havemud on one's shoes and dust in one's eyes at the same time. These shipmentswere entirely unusable, and if this sort of handling had not been promptlycorrected, the whole carefully worked out program would have been in a fair wayto being wrecked and to being highly dangerous besides.
Areas in which the use of whole blood was a new experience,as the area just described, did not immediately comprehend the importance ofrefrigeration and of other precautions in the handling of blood. The practicewas therefore instituted of sending a courier with the blood when the firstshipments went to areas new to the program.
Transfusion teams-On his return from his first trip tothe Pacific, in August 1944, Colonel Kendrick recommended to The Surgeon Generalthat a transfusion team be stationed at Saipan to handle blood drawn in the Zoneof Interior, as well as to bleed donors if it became necessary to supplement thesupply from this source. A second team should be stationed at some otherstrategic point, to be selected later, to function in the same fashion.
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The proposal was accepted, and cadres for the teams weretrained at the Army Medical Center and then placed on temporary duty at the RedCross blood donor centers while they waited assignment to the Pacific. On 17January 1945, arrangements were made with the Personnel Division, Office of TheSurgeon General, to send them to Fort Lewis, Wash., to move them on higherpriority than the theater requisition would allow.
Later in February 1945, Brig. Gen. John M. Willis, Surgeon,USAFPOA (U.S. Army Forces, Pacific Ocean Areas), was informed by Col. B. NolandCarter, MC, that such a low priority had been requested for these transfusionteams that there was little chance of dispatching them within the next 6 months.The request to nominate spaces for the officers and technicians of these teamson a theater troop basis had not been acted on by the POA, and it was thereforeimpossible to activate these units. Their training period had been extended by30 days, in the hope of straightening out the difficulties. If arrangements forthe dispatch of the teams could not be concluded within this period, there wouldbe nothing to do but scrap them. If General Willis agreed that time was afactor, the theater could request that the officers and men who had been trainedcould be shipped as casuals, to act as cadres for newly formed units to beactivated locally, but this, again, would require nomination of spaces on atheater troop basis.
These teams did not reach the Pacific during the war. When,however, the 317th General Hospital reached the POA, General Willis withdrew theblood transfusion personnel and sent them to the Marianas to form twotransfusion teams, one for the Marianas and the other for Okinawa, because bedid not wish to be entirely dependent on the mainland for the area blood supply.
Operational Factors
While the airlift of whole blood to Europe served as the pilotprogram, neither distances nor temperatures in that theater presented thehandicaps that accompanied the airlift of blood to the Pacific areas (22). Thedistance from the mainland and the high temperatures in combat areas introducedthree operational problems of extreme importance into the Pacific program: (1)transportation; (2) refrigeration; and (3) preservative solutions. All threefactors were closely related. A break in any one of them would have made thewhole program useless, and, if it had been persisted in, extremely dangerous.
Transportation-Some 7,400 miles of travel wereinvolved in flying blood from the laboratory at Oakland, Calif., to Leyte in thePhilippines (map 6). The actual flying time was about 48 hours, but withstopovers at various points and rechecking at the advanced base on Guam, mostblood was 4-5 days old when it reached Leyte.
The itinerary involved moving blood from the bleeding centersat San Francisco, Los Angeles and elsewhere to the naval laboratory at Oakland,where it was prepared for shipment (fig. 136) and whence it was flown to PearlHarbor, a matter of about 12 hours. At Pearl Harbor, there was a stopover
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ranging from 30 minutes to several hours, depending uponcircumstances, during which time the blood was re-iced by the Naval AirTransport Service, whose personnel had received special training in its care.The blood was flown from Pearl Harbor to Guam, with brief stopovers at JohnstonIsland and Kwajalein in the Marshall Islands.
The facility at Guam (figs. 137 and 138) received allshipments of blood from the Zone of Interior. The bloods were placed in therefrigerators there within 15 to 20 minutes after the plane had touched down andwere allowed to settle for at least 12 hours, to compensate for the agitationinduced by transit and movement. After the bottles had been inspected forhemolysis, clots, and possible contamination, they were placed in the re-icedinsulated boxes in which they had traveled from the Zone of Interior, and wereshipped by planes of the Transport Air Group, according to requirements andrequisitions, to:
1. Ulithi, 2? hours' transport distancefrom Guam. The planes landed at Falalop Island, where the shipments wereimmediately transferred to designated fleet units. The liaison at this base withfleet personnel was excellent, and for this reason, and because a senior medicalofficer was in charge of shipments, the blood was usually in reefers afloatwithin 6 to 10 hours after it had left Guam. Two inspections of this base byLieutenant Brown showed that all concerned with the handling of blood fullyappreciated the requirements and the possible dangers of the program.
2. Peleliu, 5 hours' transport distance fromGuam. Shipments were made by Transport Air Group planes to U.S. Naval BaseHospital No. 20 at this location as requested.
3. Tinian, 1 hour's flying time from Guam,to U.S. Naval Base Hospital No. 19.
4. Saipan, 1 hour's flying time from Guam.This island was a large Army outlet for hospitals and for further transfer tothe Philippine Islands. Col. Eliot G. Colby, MC, Surgeon, Headquarters, IslandCommand, arranged for Lieutenant Brown to visit all hospitals on the island andto make contact with Navy personnel in order to explain the blood program tothem. Also, the better to acquaint Army supply personnel on Saipan with theproblems of the transportation of whole blood, Colonel Colby sent a technicalsergeant to the base bank on Guam for instruction in the processing of blood forshipment to island bases and fleet units and for its care while it was instorage.
5. The Philippine Islands. From Saipan, bloodwas carried by Army Transport Command planes to Tacloban Airfield, Leyte, wherea medical supply depot received the shipments and saw to their refrigeration andre-icing before distribution. Re-icing was essential, for a trip of 30 to 50miles to forward area hospitals might require as much as 24 hours because of therough, difficult terrain to be traversed.
Smaller amounts of blood were shipped to various islands asnecessary and were cared for by Navy personnel who understood the requirementsfor refrigeration and storage.
Whole blood had a routine No. 2 priority in Army shipmentsand could employ a No. 1 priority when necessary. All shipments by Navy agentswere by No. 1 priority. In his 4 July 1945 report from Base K (Leyte), Capt.Henning H. Thorpe, MC, Blood Bank Facilities Officer, recommended that a similardirective memorandum be issued to Army units, to give official recognition tothe program of procurement and distribution of whole blood and in keeping withthe combined Army-Navy function of the program (23). This suggestion wasduly implemented.
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While it might have been better if whole blood had been givena universal No. 1 priority, no criticism of its handling by transport agencieswould be warranted. The cooperation of the Army and the Navy Air Forces wasalways superb, in all areas. They flew blood to combat units in medium bombersbefore transport planes could land on airstrips. In emergencies, they set upspecial flights to transport blood. There was not an instance in which blood wasneeded that it did not leave on the first aircraft available.
Refrigeration-In spite of the handicap of highenvironmental temperatures, transportation of blood to, and in, the Pacific wasfar more a matter of training personnel to observe the proper precautions thanof equipment.
The ice chest used by the blood bank in New South Wales (p.581) was a durable and efficient means of refrigeration. Its chief disadvantage,that it was not expendable and had to be returned to the point of origin, was areal
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disadvantage in an area in which shipping space by land and air was alwayslimited.
The chest developed by the Navy for the airlift of blood to the Pacific(figs. 139 and 140) was lighter than the Australian box and, more important, wasexpendable.
This chest, which had a hinged cover, measured 21 by 21 by 23 inches. It wasmade of ⅜-inch plywood and was completely lined with 3 inches ofFiberglas. A cardboard box that fitted into the outside box held two metalreceptacles, one on top of the other, each 7 inches high and 13⅓ inches in
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diameter, and each fitted with individual metal racks for eight bottles ofblood. In the center of the receptacles was a galvanized iron canister 5?inches in diameter and 14 inches high, with a detachable cover. It held 15pounds of ice. There was thus no direct contact between ice and bottles ofblood. The box occupied 5.9 cu. ft. of shipping space and, when it was packedwith ice and blood, weighed 87 pounds. Testing had been rigorous, but no damagehad been sustained by box or contents, even in parachute drops (fig. 141).
Bottles containing ACD (acid-citrate-dextrose) preservativesolution were taken directly from the refrigerator to the donor's side. Assoon as they were filled, they were placed in a refrigerator cooled to 40? to45? F. (4.5? to 7? C.) and left there for about 8 hours before they werepacked in the portable insulated box just described.
Under average environmental temperatures of 65? to 85? F.(18? to 28? C.), the temperature inside the box could be held to 42? to 45?F. (5.5? to 7? C.) for about 60 hours. When blood shipped from the west coastwas re-iced at Pearl Harbor, a half to three-quarters of the ice placed in thebox at Oakland was usually still present in the central compartment, and theinside temperature averaged 44? F. (6.5? C.). Lieutenant Blake'sobservations on a test shipment showed that temperatures within the chest weremaintained at 45.5? to 48? F. (7.5? to 9? C.). Boxes not re-iced at PearlHarbor but flown straight from Oakland to Guam had inside temperatures no higherthan 50? F. (10? C.).
When blood was shipped out from Guam, it was replaced in theexpendable Navy boxes in which it had been received. The central ice containerswere packed with as much ice as possible, and forward installations, withoutrefrigerating facilities, were instructed to re-ice the boxes every 24 hours;the importance of this precaution was emphasized to all units which receivedblood.
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FIGURE l39.-Icing center containers of Navyshipping cases on Guam.
Under combat conditions, refrigerators were frequently notavailable, but daily re-icing of the expendable boxes proved an entirelysatisfactory substitute.
In December 1944, requests were put in-and were filled-forthe immediate delivery of three 375-cu. ft. refrigerators to the center on Guam.It was anticipated-as proved true-that current calls for blood would begreatly increased to meet peak loads of combat casualties and that thousands ofpints of blood might sometimes have to be handled daily (18).
The standard field refrigerator was used for landtransportation of blood.
Preservative solutions-The glucose preservativesolutions employed by the Australian blood bank (p. 581) and by the Army bank atHollandia limited the usable life of blood to 15 days, though permitting its useup to 20 days if refrigeration had been adequate at all times and if markedhemolysis had not occurred (23).
Alsever's solution, as noted elsewhere, was used for theEuropean airlift as a matter of expediency, but its bulk made it undesirableclinically and highly undesirable for an airlift extending over many thousandsof miles. The trial runs for the Pacific airlift, begun in September 1944, weremade with ACD solution. Their complete success indicated that it would beentirely feasible to ship refrigerated whole blood to the Pacific in thismedium. Colonel Kendrick reported on it as follows from his observations inDecember 1944 (20):
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FIGURE 140.-Loading refrigerated Navyshipping containers with blood on Guam.
The ACD solution has stood all field tests ingood order. As you know, I viewed the use of this solution with a critical eyebecause of the lack of clinical experimental work. Hemolysis has been minimaleven with severe handling, heat, changes of temperature and terrible roadssometimes requiring 12 hours for delivery to a hospital. With properrefrigeration, ACD protects blood exceedingly well. A well recorded series oftransfusions (700) showed a reaction rate of 1.7 percent, none severe, mostlyurticarial. We have used a good many bottles after the expiration date, up to 30days, with good results. Due to the difficulty of controlling supply and demand,some blood passes the expiration date and we hesitate to discard it. We haveextended the expiration date to 24 days.
Colonel Kendrick also observed that a number of reactionscould be traced to the use of locally prepared sets and did not seem related tothe age of the blood.
Hemolysis and Dating Period
When Lieutenant Blake arrived on Guam on 19 November 1944,with 160 pints of blood from the Zone of Interior, it seemed wise to deferexamination
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of the bottles for hemolysis, clots, and other abnormalitiesuntil the blood had settled. Behind the blood was a long air trip, and ahead,over roads under construction, was the trip to Naval Base Hospital No. 18. Thepractice of delaying examination for 12 hours or more after the arrival of theblood immediately became routine.
It was soon evident, however, that bottles of blood thatwould show hemolysis at all would show it on their arrival on Guam, where theycould be detected on screening and could be removed from further shipment. Itwas not desirable to handle blood any more than necessary, but the World War IIexperience showed that the red cells, for the most part, toleratedtransportation without hemolysis. None appeared even when a full box, containing16 pints of blood, was dropped by parachute from a height of 800 feet. Anotherexperience was even more significant: Because of the sudden cancellation of aflight while the base bank facility was still located at U.S. Naval BaseHospital No. 18 on Guam, 160 pints of blood intended for an outgoing shipment,which had been
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transported 35 miles over poor roads under construction, hadto be returned to the reefers. When it was checked 12 hours later, beforereshipment, none of the bottles showed any hemolysis and all were consideredsafe for shipment to Leyte.
The dating period in the Pacific for blood preserved in ACDsolution was 21 days after it had been drawn. On numerous occasions, in extremeemergencies, it was used as late as 30 days. Much of it was in excellentcondition at this time, and if the war had continued, there seems little doubtthat the dating period would have been extended to 28 days, at least for bloodthat did not have to travel beyond Guam.
ADVANCE BASE BLOOD BANK FACILITY NO. 1
Location
The naval medical officer in charge of the advance base bloodbank facility on Guam, Lieutenant Brown, arrived at his post on 17 November1944. His assistant, Ens. (later Lt. jg) George E. Nicholson, HC, USN, arrivedon 21 November 1944 (18, 22, 24).
The day after Lieutenant Brown arrived, the blood bank wasset up temporarily at U.S. Naval Base Hospital No. 18, where a 675-cu. ft.refrigerator and an icemaking machine were available. As a temporaryarrangement, no fault could be found with this location, but it was evident fromthe arrival of the first shipment of blood from the Zone of Interior, whichLieutenant Blake brought in 48 hours after Lieutenant Brown had arrived on Guam,that it would not be satisfactory for blood that was to arrive by air and laterleave by air over several different military transport systems. The hospital wasabout 17 miles from Agana Airfield, and transportation would not only beinconvenient but would subject the blood to unnecessary trauma.
The logical location for the blood bank was at the airfield,but the move to it could not be made until 8 December, because the necessaryrefrigeration was not available. On this date, a 65-cu. ft. refrigerator wassecured on loan, and the bank was temporarily located in a large airfreightterminal. The temperature in the refrigerator was maintained at 40? to 45? F.(4.5? to 7? C.) with difficulty because of the heavy demands and the highhumidity, and, as a result, the unit had to be defrosted with inconvenientfrequency.
When the blood bank finally moved to its permanent facilitiesat Agana Airfield, the wisdom of the move was immediately apparent. The basecommunications center was nearby, as were the operational offices of theMilitary Transport Services. As a result, blood could be delivered with greatrapidity. On one occasion, when Lieutenant Brown was on Saipan, visiting thevarious units afloat and surveying their needs, he sent an operational prioritydispatch to Guam for 1,200 pints of blood, with the request that it arrivebefore dark, as the ships that needed it were sailing that night. The blooddepot at Guam received the message through the Port Surgeon's Office at 1300hours. Planes
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with blood aboard left at 1400 and 1500 hours. When theblood arrived at Saipan, at 1600 hours, it was loaded onto an Army reefertruck, taken to the dock area, placed on an LCM (landing craft, mechanized),and by 1900 hours was in the refrigerators of the ships that were leaving atmidnight.
As experience increased, the location of the blood bankbecame even more important. In March 1945, when the possible need for anotherblood depot came under discussion, Lieutenant Brown stated that, while thelocation of such a center would depend upon the tactical situation, it could notbe emphasized too strongly that the operational efficiency of a blooddistribution center depended upon its immediate connection with a large airbase,where emergency requests could be handled immediately. Hospital connections werenot necessary.
Notification of Needs
The blood depot on Guam supplied the urgent needs of thelatter part of the campaign on Leyte to the limit of transportation and storagefacilities. It also supplied other units of the Army and the Navy ashore andafloat within a radius of 1,100 miles. Hospitals in the Marianas dependedentirely on Guam for their large demands for blood. A moderate backlog of bloodwas maintained in all these hospitals, and cooperation concerning notificationof needs was excellent.
All hospitals were informed that a notification of at least10 days was required for any increase in operational demands, and a notificationof 4 to 5 days for emergency requests. Requests for blood were made from Guam tothe 12th Naval District in San Francisco, whence they were cleared to the blooddonor service. It took about 7 days for donor centers on the mainland to step uptheir collections to meet increased demands in the Pacific. It was thereforenecessary for hospital installations to anticipate their needs and notify thedistribution center on Guam, through channels, well in advance of the time theblood would be needed. All requests were on the basis of 1 pint of blood percasualty.
The amount of blood handled through Guam greatly increased asoperations were extended to Luzon, and then to Iwo Jima and Okinawa. Between 19November and 24 December 1944, 6,480 pints of whole blood were received and5,040 pints were distributed. In February 1945, 16,608 pints were received and16,563 distributed. On several days during the month, 1,000 pints daily werehandled, particularly during the final staging for the Iwo Jima operation. InApril, 25,760 pints were received and 30,177 pints, including the excess fromMarch, were distributed (24). Early in the month, it was necessary todistribute the accumulated blood and reduce the supply from the Zone ofInterior. Later in the month, the requests to the Zone of Interior had to beincreased because of increased demands from the Philippines and a considerableincrease in the Okinawa requirements.
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LEYTE
Planning
It was expected that, as the fighting in the SWPA increasedin intensity and advanced from New Guinea to the Philippine group, the Japanesewould begin to use field artillery of higher caliber, with greater frequency,and that bombing from the air would be heavier and more constant. Since woundsproduced by shell and bomb fragments cause shock, hemorrhage, and extensivetissue destruction, ample amounts of both plasma and blood would be necessary.Supplies of plasma furnished no problem; they were always ample, and they wereused intelligently.
The Leyte operation was the first in which combined Army andNavy blood banks were used and in which blood was supplied in the firststages of the operation. In general, the plan employed was that recommended toGeneral Denit by Colonel Kendrick, with Captain Newhouser's concurrence, on19 July 1944 (p. 591). It involved (map 4):
1. The transportation of blood from Sydney toFinschhafen.
2. The establishment of a blood bank at Hollandia.
3. The establishment of a blood bank aboard LST 464 which hadbeen converted into a hospital ship.
The recommended blood bank was set up aboard LST 464, withLieutenant Muirhead in charge. Its supplies were supplemented by the27th General Hospital, which began to function as a blood bank on 9September 1944. By 9 October 1944, plans for the initial supply of whole bloodfor the Leyte invasion and its maintenance had been agreed upon by representativesof the Sixth U.S. Army (fig. 142), the Medical Supply Section, USASOS, and theSeventh U.S. Fleet.
The blood supply was planned and reported in ETMD (EssentialTechnical Medical Data) as follows (25):
1. The task force would take 200 liters of blood ashore withit, for use on the beaches. Between D+5 and D+7, 400 additional units of bloodwould be shipped from Base G (Hollandia) on the 10 returning LST's, fordelivery by the Sixth U.S. Army medical supply depot on shore to Sixth U.S. Armymedical units.
2. Thereafter, blood would be shipped automatically by theBase G medical supply depot on LST's at the rate of approximately 200 unitsevery 5 days until D+20. These amounts would be varied only on radioinstructions from the Sixth U.S. Army to the medical supply depot on Base G. Onsuch instructions, the blood would be flown to Leyte via Biak, where 100 literswas kept as a pool. The first blood for the pool would be brought by an LSTwhich would leave Base G on D+6.
3. LST 464, converted to a hospital ship, would arrive on thebeach on D+4, with 100 liters of blood. This ship was equipped to collect andprocess blood, and it was expected that enough donors could be secured fromtroops on the beach to provide ample amounts for LST 464 and other LST'scaring for casualties. These LST's were located in the harbor at intervals of1,000 to 2,000 yards apart.
4. LST's arriving in the harbor on D+2 and D+21would eachbring 100 liters of blood.
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FIGURE 142.-Col. (later Brig. Gen.) WilliamA. Hagins, MC, Surgeon, Sixth U.S. Army.
Implementation of Planning
In general, the plans just described were implemented in theLeyte operation, which began on 20 October 1944. Plasma was used extensively,and the supply was adequate at all times. Its value in burns and in shockwithout hemorrhage was indisputable, but it was proved again that it was asupplement to, and in no sense a substitute for, whole blood in hemorrhage andthat its use might, indeed, give rise to a false sense of security.
On D-day, two 200-cu. ft. mobile reefers, each containing athousand 500-cc. units of blood, were put ashore on the beaches in which combatactivity was greatest. The blood was well used, but it was evident in retrospectthat even greater quantities should have been supplied. Multiple transfusions,for instance, often could not be given. Moreover, since whole blood had not beenavailable in previous combat except as it was obtained by on-the-spot donations,some organizations apparently remained ignorant of its ready availability inthis operation. Steps were taken to avoid this error in future operations.
Casualties brought to LST 464 received excellent shocktreatment and preoperative preparation. Blood was taken from each patient forhemoglobin,
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hematocrit, and protein estimations, and replacement therapywas based on the findings. This was the first time the combined facilities ofArmy-Navy blood banks were used in the initial stages of an operation, andcooperation was excellent.
LST 464, in addition to treating casualties, drew blood andacted as a blood bank for the 7th Amphibious Force. The great advantage in theuse of this particular LST was that she acted primarily as a hospital ship, notprimarily as a cargo ship and only secondarily as a hospital ship, after thecargo was unloaded. She was therefore able to remain on station in the harborand was available for medical service at all times.
LST 464 also received blood from the depot at Biak via theLST's returning to Leyte after taking casualties to Biak. Each convoyscheduled for Leyte, as already noted, received additional stores of blood totake back.
The landing at Leyte presented a problem in the care ofcasualties not encountered in any previous operation; namely, the bombingattacks on all ships in the harbor, including hospital ships, by Japanesesuicide planes. Large numbers of casualties continued to occur in the harbor for38 days and provided the strongest possible indications for the liberal use ofwhole blood. They had to be treated aboard ship. It proved impractical andinefficient to take them ashore for treatment because of poor communications,difficulties in beaching, inadequate facilities, poor roads, and lack oftransport. The risk of keeping hospital ships on station in the harbor was toogreat, in view of the indiscriminate bombing, and the problem would have beeninsoluble without the presence of LST 464 and other LST's.
Blood From the U.S. Airlift
In all, about 3,000 units of preserved whole blood were usedduring the first 30 days of the Leyte campaign, including blood from the 27thGeneral Hospital bank at Hollandia, from the relay depot at Biak, and from LST464. Arrangements had been made to have additional supplies of blood flown fromthe Australian blood bank at Sydney if it should be necessary to supplement theblood provided for at the beginning of any large operation.
Up to 22 November 1944, all of the blood used in the Leyteoperation was provided by the plans worked out by Colonel Kendrick in July 1944.On the twenty-second of this month, Lieutenant Blake, representing the Army, theNavy, and the American Red Cross, arrived on Leyte with 80 pints of whole groupO blood which had been flown from San Francisco via Guam. This was the firstblood to arrive from America and it represented a turning point in thetransfusion service in the Pacific. With greatly increased supplies available,greatly increased use of blood was possible, and plasma assumed its proper rolein replacement therapy as a supplement to whole blood, not as a substitute forit.
Between 19 November and 24 December 1944, 4,256 of the 6,480units of whole blood received on Guam went to Leyte (22).
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FIGURE 143.-Lt. Col. Frank Glenn, MC,Consultant in Surgery, Sixth U.S. Army.
LUZON
Planning
The Leyte operation, as already indicated, was the firstcombined Army-Navy whole blood project, and in retrospect, for a number ofreasons, it seems that it could probably have been handled more efficiently. Theoperation on Luzon was handled better, for two chief reasons:
1. Information concerning the blood supply was welldisseminated. Through the efficient cooperation of Maj. (later Lt. Col.) FrankGlenn, MC, Consultant in Surgery, Sixth U.S. Army (fig. 143), Colonel Kendrickwas able to present the blood program in detail to the senior medical officer,Navy; representatives of the Surgeon, Sixth U.S. Army; base and other surgeons;and a number of other medical officers with special interest in the use ofblood. At this meeting, he was able to demonstrate to these officers that theycould have all the blood they needed from the Zone of Interior and that it wouldbe delivered according to their requests if they merely made the requests.
2. Colonel Kendrick had encountered, during his stay on Leyte,a well-trained pathologist and fine medical officer, Captain Thorpe, who, withtotally inadequate resources, had done remarkably good work in supplying theSixth U.S. Army with blood. When he came into the Zone of Interior program, mostoperational difficulties were cleared away.
In the month Colonel Kendrick spent with the Sixth U.S. Army,he was able to work out a blood program for the invasion and to arrange for thedelivery
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of blood from Guam according to estimated needs from D-day onward, as follows (26):
1. A responsible officer, either MC or MAC, would bedesignated in the Sixth U.S. Army to be in charge of the blood bank. He would beadequately assisted by enlisted men and would have the sole responsibility forthe operation of the blood bank.
2. Equipment would consist of four 220-cu. ft. reefers with acapacity of 1,600 to 2,000 bottles of blood; one vehicle to take blood from thebeach to the airstrip to the distribution center; and an ice machine.
3. Beginning on 30 December 1944 (D-day on Lingayen Gulf,Luzon, was set for 9 January 1945), 300 to 400 pints ofblood would be requisitioned daily from the States. The four reefers to be usedcould accommodate 700 to 800 pints each, but for the M-1 (Luzon) operation, only400 to 500 pints would be stored in each. The reefers would be dispersed on LST's,so that they could be put ashore as soon as the military situation permitted. Onshore, one reefer would be placed behind each division, but as soon as thetactical situation permitted, all four would be brought together, to serve as acentral distribution facility. The officer in charge would be responsible forstocking the reefers at the mounting point of the invasion with bloodsufficiently fresh to arrive at the target area within the usable time limit.
4. The requirement of 1,600 pints of blood for the Sixth U.S.Army was based on the number of expected casualties and was in addition to thequantity requested for the Navy. The needs of both services for the first 4 daysof the operation were set at 3,500 pints. To meet these requirements:
2,400 pints would be shipped from the States.
500 pints would be shipped from the blood banks at the 27thGeneral Hospital in Hollandia and the 9th General Hospital, which then would beserving as a blood bank on Leyte.
600 pints would be collected locally by LST 464.
5. After the first 5 days of the operation, blood would besupplied from Leyte to the target by LST's or other ships leaving Leyte forLuzon. Blood would be flown in as soon as an airstrip was secured. The bloodbank officer would be responsible for developing the line of supply andreceiving the blood upon its arrival at the target.
6. If reefer space was limited, the racks containing the bloodcould be stored without the insulated boxes. The boxes, which contained thegiving sets, must be taken aboard the LST's, and the blood must be replaced inthem before landing, to keep it cool during its distribution.
A supply of ice to refrigerate the insulated boxes might notbe available early in the assault. If this happened, the blood must be delivereddirectly from the reefer to the using hospital. The ice machine, with a capacityof 800 to 1,000 pounds per day, must be placed ashore and made available to thedistribution team at the earliest practical time.
7. On 23 December 1944, the Navy estimated its requirements as1,200 pints of blood at the mounting area on 3 January 1945; 700 pints on 4January 1945; and 500 pints on 6, 9, 14, and 20 January. The LST 464 would bringin 1,200 pints for use on D-day and D+1, and would serve as a distributionpoint for other ships receiving casualties or acting as transports forcasualties.
This plan did not include the whole blood supply to convoys departing fromHollandia, Aitape, Noemfoor, and Sansapor, nor did it include the resupply ofblood for hospital ships bringing casualties to New Guinea bases. All blood forthese purposes would be supplied by the blood bank at Hollandia and the depot atBiak. If the ships departed from Hollandia, the blood would be placed aboardthem there. Blood would be flown from Hollandia to Aitape and to Noemfoor forthe convoys departing from those points. Blood for
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convoys leaving Sansapor would be flown from the depot at Biak. Convoys whichleft Leyte would carry blood from the Zone of Interior.
Implementation of Planning
The scope of the amphibious landings on Luzon was so vast thatit was impossible to set up a central distribution point, and the arrangementsjust outlined had to be substituted. The blood was placed aboard ship justbefore the convoys departed. All clearing companies, portable surgicalhospitals, field hospitals, evacuation hospitals, hospital ships, and cargo LST'swith medical officers aboard had fresh refrigerated whole blood with them whenthey left for the target.
At the beginning of the Luzon operation, equalization ofsupply and demand furnished something of a problem, which disappeared whenbetter liaison was established between the mainland and forward areas (27). Bythe end of January, blood was being received at Leyte that still had 17 days oflife. It was therefore possible to forward the blood by ship and have itreceived on Luzon with several days of life still left in it.
The first blood was flown into Luzon from Leyte 12 days afterthe invasion, by medium bombers, before transport planes could land (18). TheLuzon experience suggested that in future operations it might be wise to planthat ships and LST blood banks supply forces ashore for about 14 days; afterthat time, air transportation could be relied on.
When the system was finally established smoothly, it wasconsidered ideal (28). Blood shipped from Guam on requisition went toTacloban, on Leyte, where Captain Thorpe screened each shipment before it wasplaced under refrigeration. Blood for local distribution was stored in a 350-cu.ft. refrigerator at the 34th Medical Depot. Blood for Luzon was placed in astationary refrigerator, provided by the Quartermaster Refrigerator Co., whose4,300-cu. ft. capacity assured a minimum temperature change when the door wasopened. The temperature was maintained at 38? to 43? F. (3.5? to 6? C.).Three refrigerating units were used, so that, if one failed, the others couldoperate while repairs were being made.
Before the blood was placed in the refrigerator, each box wasopened, the blood was examined, and the amount of ice in the cylinder was noted.The expiration date of the blood was written on the outside of the box. Theblood was refrigerated with the lid of the box propped open, to allow thetemperatures inside and outside to equalize and thus to insure a stabletemperature while the icebox doors were opened and closed. Each box was re-icedbefore issue.
Supply was controlled by radiogram to the Island Command,Guam. The bank at Leyte operated on a 24-hour basis for distribution, andarrangements were made with the signal center that all messages concerning bloodwere reported immediately, by phone, to the bank. Shipments could thus be movedat once. Radio notification of the arrival of the blood, and the use of courierswhenever there might be any delay en route or at the receiving end, insured
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the arrival of the blood in good condition becauserefrigeration had been maintained and the boxes re-iced as necessary duringtransportation.
When necessary, emergency items were requested by radio ortelephone and were dropped over the frontlines, often within a matter ofminutes, from artillery liaison planes. Recovery was almost 100 percentsatisfactory, and even such delicate items as plasma and blood were received ingood condition (29).
Plasma was in ample supply and well used (figs. 127-131). Thefirst direct issue of blood in the Manila area was by the 15th Medical SupplyPlatoon (Aviation) on 11 March 1945. The initial supplies were obtained fromLeyte via Base M (San Fernando, La Union). Later shipments were made directlyfrom Leyte to the Nielson Airfield in Manila.
The average daily issue during March to units in the area was125 pints (30). During April, the daily issue ranged from 160 to 175pints, and, for the next 3 months, it averaged 175 pints. When casualties beganto drop as heavy fighting on Luzon ceased, any blood not utilized before theexpiration date was transferred to the Philippine Island Civil Affairs Unit, foruse in civilian hospitals. All blood supplied during this period originated inthe Zone of Interior.
IWO JIMA
The Iwo Jima operation, which lasted from 19 February to 16March 1945, was a Navy-Marine operation (18, 31).
OKINAWA
Planning
When Colonel Kendrick was appointed Consultant in Blood andShock to Col. Frederic B. Westerfelt, MC, Surgeon, Tenth U.S. Army, on 14 March1945, it was only 5 days before the Army sailed for the invasion of Okinawa.Little additional planning was possible at this time, but he was able to seethat the ships that went to Okinawa from Saipan were loaded with all the bloodlikely to be needed for the first stage of this operation, which was anArmy-Marine responsibility.
The plan for supplying blood for the Okinawa operation, whichwas incorporated in the III Amphibious Corps Administrative Plan No. 1-45, AnnexEasy, was in essence as follows:
1. The Distribution Center at Guam would stockAH's (hospital ships) with suitable quantities of whole blood and would alsostock LST 929, which had been designated for medical use by the Commander, JointExpeditionary Forces.
2. APH's (transports for wounded) and APA's(transports, attack) were scheduled to arrive at the target within the usablelimits of the blood carried on the other ships.
3. At the target, LST 929 and AH's would actas a local distribution center for APH's, APA's, PCE(R)'s (patrol craft,escort (rescue)), and LST's used for evacuating casualties. They would alsosupply blood for the medical units ashore.
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4. As soon as practical, a temporary whole blood distributioncenter would be established ashore and would take over the distributingfunctions of LST 929 and AH's which had been used for this purpose.
5. The distributing center on Guam would supply thedistributing center ashore with adequate quantities of blood by air or by fastsurface transportation. When hospitals were established, they would receivetheir blood by air.
6. Personnel, refrigerators, flake ice machines, and otherequipment would be supplied to the temporary distribution center and LST 929 byComServPac (Commander, Service Force, Pacific). Personnel and equipment would betaken ashore in assault shipping as soon as the landing force commander couldarrange their transportation.
Implementation of Planning
The plans worked out perfectly. The Fleet drew its whole bloodsupply in mid-March; some of it was due to expire late in March and theremainder at various dates in early April. In the event that resupply would havebeen necessary before regular channels of supply could be opened, 75 bottles ofblood were prepared to be dropped by parachute at some one of the Fleetrefueling stations. This did not prove necessary, though preliminary tests atAgana Bay had proved that this method of delivery was entirely practical and didnot harm the blood dropped.
Blood was brought into the target area by eight AH's, LSV-6 (landing ship,vehicle), and AGC-4 (amphibious force flagship), the U.S.S. Ancon. TheLST(H) 929 (landing ship, tank (casualty evacuation)), designated as thedistribution center afloat, arrived at the target on L-day. Because it was aslow ship, it brought in no blood, but it received blood at once from LSV-6 andthe U.S.S. Solace (AH). Additional AH's arriving at 2-3 day intervalsbrought in about 1,700 pints per ship. Any excess over the needs of thecasualties on the AH's was transferred to the LST(H) 929, which distributedblood to the seven other LST(H)'s and the numerous APA's which had arrived.
LST 929 continued to act as the distribution center afloat until L+15, whenthe blood distribution team set up by Colonel Kendrick was able to go ashore andbegin to function. Its arrival at the target had been delayed because the shipon which it had been transported was damaged by a suicide dive bomber and couldnot be unloaded at once. During this period, the XXIV Corps received all theblood it needed from LST(H) 929 which was lying off Beach Orange 2 in closeproximity to it. Blood was supplied to the III Amphibious Corps during the sameperiod by transfer of blood from LST(H) 929 to LST(H) 951, which wasconveniently located off Beach Yellow 2, near Corps headquarters. When the IIIAmphibious Corps advanced north on Okinawa, blood reached it from this LST(H),which went up daily to evacuate casualties.
By L+20, about 12,900 pints of blood had reached the target by surfacecarrier. Approximately 3,200 pints were retained aboard AH's, LST(H)'s, andAPA's for their own use.
The first blood, 200 pints, received by air, arrived on Okinawa on L+17. Thedistributing center ashore (fig. 144) was set up at Yon-tan Airstrip, where
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it operated with two 150-cu. ft. refrigerators, equipped withgenerators. Daily shipments from Guam (200 pints) were received from Guam afterL+18.
The original plans called for the provision of 6,000 pints ofwhole blood for the target on Love Day and the delivery of another 3,000 pintsby hospital ship during the first week of the campaign. The course of eventsmade clear the importance of the control of blood by trained personnel ifwastage was to be avoided: The casualties in the first days of the Okinawaoperation were unexpectedly low. As a result, only 3,000 pints of blood wereneeded, and the resupplies planned for this period were not needed at all. Asmall amount of blood was lost, but most of the 3,500 pints involved were saved.Several of the ships to sail with blood from Ulithi were not dispatched becausethey were not needed. A medical officer sent to Honolulu to investigate localneeds found that most of the blood on which the dating limit was due to expirecould be utilized there.
The initial slow pace of the campaign made it possible forColonel Kendrick, accompanied by Col. George G. Finney, MC, Consultant inSurgery, Tenth U.S. Army, Lt. Col. (later Col.) Harold A. Sofield, MC, and Col.Walter B. Martin, MC, to make daily trips ashore for indoctrination purposes.The circumstances were peculiarly propitious: The Japanese had retreated southas the landings were made, and it was a week before real resistance wasencountered. During this interval, it was therefore possible for these officersto visit every field and evacuation hospital ashore, whether Army or Navy, andto pass on to the hospital staffs all the available information about the useand handling of whole blood, including the information Colonel Kendrick hadsecured in the Mediterranean and European theaters about its correct use inbattle casualties. The discussions covered careful triage at the field hospitallevel after adequate resuscitation (figs. 145, 146, and 147), the physicalarrange-
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FIGURE l45.-Administration of plasma toofficer wounded by Japanese sniper, Okinawa, April 1945.
ments of a shock ward (p. 707), the employment of shockteams, and the establishment and observance of a routine of surgical management.When the hard fighting started, the medical officers responsible for the care ofbattle casualties were well trained in resuscitation procedures and in the useof whole blood.
The daily distribution of blood ashore varied from 5 casesoriginally to 59 cases. As soon as needs began to increase, the center at Guamwas requested to ship 1,000 pints immediately, to provide for a backlog in caseof bad weather. As the operation progressed, it was necessary to increase therequisitions to 750 pints per day. Between L+39 and L+42, 2,336 pints were used.
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FIGURE 146.-Administration of plasma tosoldier wounded on Okinawa, 7th Division, May 1945.
Shock Teams
Because large numbers of casualties were anticipated in theIwo Jima and Okinawa operations, shock teams were used in numerous hospitals.The team attached to the 148th General Hospital was organized on 26 February1945, on Saipan. It consisted of five medical officers, two nurses, and fourenlisted men, so assigned that the team was on duty around the clock. Two of theenlisted men were trained to perform venipunctures.
The shock center was located in a small quonset hut.Refrigerated blood was stored conveniently near it, in a large reefer. Equipmentwas generally sufficient, but motorized transportation would have saved timebecause of the extent of ground occupied by the hospital.
All casualties were treated by a regular shock routine, whichincluded immediate determinations of hemoglobin and of the hematocrit and plasmaprotein values by the copper sulfate technique, which was generally used in thePacific as soon as it became available. These results were entered on amimeographed form that bore the patient's name, serial number, and wardassignment and that was checked in the shock center before it went to the ward.If the hematocrit level indicated the need for blood, the center notified theward officer and provided the proper amount. If, however, a casualty seemedclinically in need of blood, the ward officer, without waiting for thelaboratory results, phoned the information to the shock center, which providedthe transfusion.
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In order to save time and avoid unnecessary repetition of venipunctures, eachward officer gave the shock center each morning a consolidated requisition forthe estimated blood and other intravenous fluid needs of all his patients forthe next 24 hours.
During the Iwo Jima and Okinawa campaigns, between 24 February and 13 August1945, the shock team at the 148th General Hospital handled 3,767 patients, whoreceived 4,748 pints of whole blood. The 164 reactions averaged 4.3 per patientand 3.0 per transfusion. Of the 5,412 pints of blood received, 664 had to bediscarded because of excessive lipoid content, clotting, overdating, andtechnical difficulties of administration.
The smooth functioning of this well-organized shock team played an importantrole in the low mortality rates achieved in both the Iwo Jima and the Okinawacampaigns.
Critique
In his report to General Willis on the blood program for the Okinawacampaign, Colonel Kendrick made the following comments:
1. Overall planning was practical and effective. Shipment ofblood by surface carriers provided adequate supplies for the initial phase ofthe operation. Reefers and an ice-manufacturing machine on LST(H) 929 enabledthis ship to act as a distribution center for units afloat and ashore.
2. The LST(H) 929 arrived at the target area without its ownsupply of blood because its slow speed would have made the blood outdated beforeits arrival. It had to draw its
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supplies from other ships before it could begin to function asa distribution center, and this delay, which made the LST(H) 929 dependent onother ships, was responsible for some delay ashore.
3. APH's and APA's were stocked with varying quantities ofblood at the assembly point, and certain other ships were also well stocked. Allof these ships could have drawn blood, as they needed it, from LST(H) 929, andit would be advisable to use this plan in future operations.
4. The plan called for AH's as well as LST(H) 929 to act asdistributing centers for other ships. The AH's carried sufficient blood forthis purpose, but no personnel had been designated to act as distribution teamsor to keep adequate records of issues of blood. Local distribution could beaccomplished with less confusion if some designated LST acted as the otherfloating distribution center and was made responsible for issues of blood andrecords of receipts and distribution. If the shoreline in a future operationshould be long, another LST could be designated as a subdistribution ship, tosupply half of the beachhead, but not to supply other ships. Because of thispossible necessity, two LST's should be provided with reefers and icemachines. At Okinawa, LST 951 supplied the III Amphibious Corps and served as asupplementary distribution center.
5. The blood distribution team was delayed in going ashorebecause the U.S.S. Achinar, on which it traveled, sustained bombingdamage. Since the team was not brought in on the LST(H) 929, it provided nosupport for the distribution activities on that ship. Hereafter, team andequipment should be transported on the LST which is to serve as a distributioncenter, or on one of the LST's which accompanies it, so that the team canmaintain complete control of blood distribution afloat and ashore, part of theteam remaining afloat on the LST until the distribution center ashore isfunctional.
6. Considerable confusion was caused in medical installationsashore by lack of knowledge as to where blood could be obtained. In futureoperations, instructions should be given by each corps to its medicalinstallations concerning the location of the distribution center afloat. Theofficer in charge of the blood distribution team should notify each shore partof the location of the floating center and the availability of blood from it.
7. The LST(H) 929 did not have facilities for delivery ofblood to the beach when signaled by the shore party.
8. The equipment brought ashore by the distribution team wasnot completely adequate. The ice machine could not be used because accessoryparts were lacking. There was no provision for water for manufacturing ice andfor removing latent heat. Water tanks, piping, a water trailer, a water pump,and other supplies could be obtained from Island Command and NCB's (Navyconstruction battalions) before the center ashore could make its own ice. In themeantime, it had to obtain its ice from LST(H) 929. An ice machine withaccessory cooling system should be available for immediate use in futureoperations.
Another 2?-ton 6-by-6 truck to transport a third 150-cu. ft.reefer and a 250-gallon water trailer should be made part of the equipment ofdistribution teams.
9. While a distribution team proved entirely capable offunctioning as a blood supply point under the supervision of a hospital corpsofficer, it was considered imperative that a medical officer be responsible forthe proper care and use of blood. He could be in charge of the team or attachedto the medical section of the Landing Force Commander's headquarters. Thesecond arrangement would be more desirable, for it would give the officer morelatitude in advising on the proper use of whole blood.
Colonel Kendrick made recommendations to cover these various points and alsorecommended:
1. That the personnel of all medical installations assigned toan amphibious task force be instructed before departure in the principles andpractices relating to the treatment of shock and the proper use of whole blood.
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2. That each field hospital supporting amphibious operationshave attached to it four shock teams, each consisting of a medical officer, anurse, and two enlisted men. It would thus be possible for two teams to be onduty each 12 hours.
TERMINATION OF AIRLIFT
As the campaigns in the Southwest Pacific decreased in intensity and thenwere concluded, the quantity of whole blood needed and used decreasedcorrespondingly. The blood bank at Hollandia and the depot at Biak were closedat the end of 1944, since planning for the invasion of Japan was predicated onprocurement of the major supply of blood from the Zone of Interior (p. 639).
The abrupt end of the Pacific war on 14 August 1945 caused an equally abruptchange in the transfusion service. On 5 September 1945, the commanding generalsof all base areas and commands were notified by Colonel Dart, Deputy ChiefSurgeon, U.S. Army Forces, Western Pacific, that shipments of whole blood fromthe Zone of Interior would be discontinued on or about 15 September and thatthereafter blood must be obtained from local sources (32). A blood bankhad been established at the 19th Medical General Laboratory in Manila to supplyblood for hospitals in the Philippine Islands and would begin to function on 15September.6 Instructions were given for theprocurement of blood from this source. The dating period for properlyrefrigerated blood was set at 30 days. If a hospital needed only small amountsof blood, it should collect it from local donors. Attention was called to thetechnical instructions on the storage and administration of blood contained inCircular Letter No. 38, Office of the Chief Surgeon, USAFPAC (U.S. Army Forces,Pacific), dated 20 August 1945 (33).
The plan worked out very well. After shipments from the Zone of Interiorceased, the blood bank at the 19th Medical General Laboratory in Manila tookcare of the initial needs of the army of occupation and supplied the needs ofall U.S. hospitals in the Philippines as long as they were in operation. Theabsence of opposition in Japan and adjoining territories soon relieved the bloodbank of the necessity of supplying blood for the armies of occupation.
STATISTICAL DATA
An accurate statistical analysis of the whole blood program in the Pacific isalmost impossible because of the circumstances under which many, perhaps themajority, of transfusions were given. The figures to be cited should thereforebe viewed as representing trends correctly but not accepted as precise data.
Supplies From the Zone of Interior
Final figures from the American Red Cross show the following shipments ofwhole blood, group O, to the Pacific (17):
6Although the delayed arrival of the 19th Medical General Laboratory made it impossible to use it for blood bank purposes, as had been planned, it served as a blood bank in Manila both before and after the Japanese surrender.
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| 1944 |
|
November 16 | 1,667 |
December | 8,265 |
| 1945 |
|
January | 10,575 |
February | 20,576 |
March | 29,215 |
April | 24,842 |
May | 41,558 |
June | 22,505 |
July | 8,029 |
August | 11,604 |
September 15 | 2,719 |
| 181,555 |
The wide variations in the monthly amounts, which reflect the varyingintensity of fighting, made for difficulties in maintaining collection schedulesin the Zone of Interior. The remarkable accuracy of the estimates, however, isevident in the April 1945 report of the distributing center on Guam (24):In that month, it was necessary, for the first time, to distribute excesssupplies of blood to general and other hospitals in the bases, instead ofsending it forward to combat zones.
Oversea Supply and Distribution
The following general data, which are incomplete and inaccurate because ofthe circumstances (p. 455), are available for the supply and distribution ofblood in the Pacific:
4,260 units (2,130 liters) to U.S. Army bases in New Guineaand the Philippine Islands by the Australian Red Cross Blood Transfusion Servicebetween January 1944 and February 1945 (p. 586).
2,597 units to U.S. bases in New Guinea, the surroundingislands, and the Philippine Islands by the whole blood bank at the 27th GeneralHospital, Hollandia, New Guinea, between September and December 1944.
88,728 units to U.S. bases in the Philippines by the blooddistribution center, Leyte, Philippine Islands, between December 1944 andSeptember 1945. All of this blood was received from the Zone of Interior viaGuam (23, 34).
2,145 units to U.S. bases in the Philippine Islands by theblood bank at the 19th Medical General Laboratory, Manila, in September andOctober 1945, when these tabulations were concluded.
As the result of planned indoctrination combined with the availability ofpreserved whole blood, the use of blood in all forward installations in theSouthwest Pacific increased steadily (35). There were few medicalofficers who did not eventually realize that lost whole blood can be replacedonly by whole blood. The value of massive transfusions was also universallyappreciated, and it was not uncommon to encounter patients in rear hospitals whohad received from 5,000 to 7,000 cc. within a few hours after wounding. Theblood supply was originally on the basis of 1 pint of blood per casualty butfrequently much more blood was used. In one series of 6,807 casualties treatedsurgically, 10,242 units of blood were used, and by the end of the war a ratioof 1.5:1 was the rule.
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While accurate total figures are not available, certain comparativestatistics are significant:
The first report for U.S. Naval Whole Blood Distribution Center No. 1 onGuam, from 19 November to 24 December 1944 (22), showed that 6,480 pintswere received from the mainland, of which 5,041 pints had been distributed,4,256 pints to Leyte, 288 pints to hospital ships and Fleet units, 48 pints tothe 3d Marine Division, 128 pints to the 168th General Hospital, 40 pints forcivil emergencies on Guam, 191 pints to three naval base hospitals, and 14 pintsto the U.S. Naval Air Base Dispensary. In addition, 76 pints had been discardedfor causes not connected with outdating.
The April report from the Guam distribution center (24) showed 5,663pints of whole blood on hand on 1 April and 25,760 pints received during themonth from the United States. Of this amount, 12,568 pints were distributed tothe Philippine Islands and 15,916 to the Okinawa operation. By 30 April 1945, atotal of 18,316 pints of blood had been distributed for the Okinawa operation,of which 5,120 pints had been shipped by air. The remainder of the blood flownto Guam, mostly in small amounts, went to hospitals in the Marianas and on Guam,and to hospital ships and Fleet units. Included in the April distribution wasthe blood (535 pints) that went to hospitals in the Hawaiian Islands whencasualties in the first stage of the Okinawa operation proved fewer than hadbeen anticipated (p. 624).
From L-6 to L+43, approximately 25,444 pints of blood were supplied for theOkinawa operation, 12,900 by surface carrier and the remainder by air (31). Duringthis period, there were 23,681 casualties, including killed in action,wounded in action, missing in action, and nonbattle casualties. The ratio of 1pint of blood per casualty admitted to field hospitals, which had beenestablished in the Mediterranean and European theaters, was thus exceeded in theOkinawa operation, one reason being the kamikaze suicide bombings.
Between 1 April and 21 June 1945, approximately 40,000 units of blood werereceived by the various hospitals and other medical installations operating onOkinawa.
Losses
Considering the circumstances in the Pacific, it is remarkable that thelosses of blood were so small. They were chiefly due to hemolysis, breakage,failures of refrigeration, and outdating.
Hemolysis.-Early in the operation of the airlift, it was wellestablished that bottles of blood which would become hemolyzed would be in thatstate on their arrival at Guam, where they could be screened and discarded asnecessary (p. 607). It was also found, in the Pacific and elsewhere, that bloodcould undergo considerable movement without hemolysis.
In the total shipments, excessive hemolysis before the outdating period wasreached occurred in less than 5 percent of the flasks. The single seriouscomplaint in respect to this change came from the 2d Field Hospital, which, onone occasion, found 80 percent of its stock hemolyzed. While the precise
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cause was never determined, the most plausible explanationwas a break in refrigeration technique.
Breakage.-Breakage was remarkably infrequent.Lieutenant Brown reported no instance of breakage in the blood received at Guambetween 25 December 1944 and 31 March 1945, and Captain Thorpe made the samestatement in his 4 July 1945 report from the Leyte bank.
Failure of refrigeration-The chief losses fromrefrigeration failures were in forward hospitals and, for the most part, inhospitals in which the control of blood was not the responsibility of a singlemedical officer with training in this field. Faulty refrigeration, withtemperature fluctuations and storage at too high temperatures, was the chiefcause of loss of blood by hemolysis. Base units reported only small lossesbecause of incorrect refrigeration. This would be expected, for they had goodrefrigerators and experienced mechanics to maintain them.
Outdating-The blood that combat medical unitscarried with them to the target always was loaded at the latest possible date,so that the expiration date would not be exceeded before a new supply could beflown in; this was not possible until airstrips were secured. Invasion forceswent ashore with supplies of blood adequate for all estimated casualties. Mostof the losses-many unrecorded-probably occurred at such times. There was noalternative, however, to the provision of blood on the basis of possible needs.Resupply was on the basis of actual needs; automatic resupply would haveoccasioned far heavier losses than those that occurred.
The bank at Leyte was at first supplied with blood with only10 days of life remaining in it, the fresher blood being given to Fleet combatteams. As supply and demand equalized, the bank at Leyte was supplied withfresher blood. It was kept stocked at all times with 3-4 days' supply, toprovide for emergency requests and to guard against failure of supplies becauseof bad flying weather. Not much blood was lost by outdating, and, according toCaptain Thorpe, there was never a time during the operation of this bank thatblood was not available for issue.
The dating period for all banked blood in the Pacific,including the blood collected locally, was set at 21 days. There was somediscussion in the spring of 1945 about extending the shelf life to 28 days, butno formal action was taken.
The report of the center on Guam for June 1945 showed totallosses due to aging in 1945 as 3.6 percent, 2.9 percent for the first quarterand 4.3 percent for the second. During this period there were only threeoccasions when supply and demand were not well balanced; in January, inpreparation for the Luzon invasion; in April, in preparation for the Okinawainvasion; and in June, when there was an unexpectedly rapid cutback ofrequirements in the POA and SWPA. On all of these occasions, more blood wasordered than was needed for the combat forces, but most of it was used inhospitals to the rear.
The total losses from aging were probably somewhat higherthan these figures suggest because they take incomplete account of losses inhospitals,
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particularly the forward hospitals which required only smallamounts of blood at irregular intervals but which had to carry a stock largeenough for possible emergencies (36).
The use of blood beyond the 21-day limit set was not recommended, but thedating period was occasionally exceeded when the choice lay between outdatedblood or no blood at all. Lives were undoubtedly saved as a result. At one time,when the 7th Portable Surgical Hospital received a heavy influx of casualties,it used a considerable amount of outdated blood with no reactions (37). Twocasualties, each of whom received more than 4,000 cc. in a 36-hour period,showed no ill effects, though all of the blood used was outdated from 14 to 20days (37).
CLINICAL CONSIDERATIONS
Indoctrination
When Colonel Kendrick reached Hawaii on 25 November 1944, he went on to Guam,and then, after discussions there with Lieutenant Brown, he continued on toLeyte, to discuss all aspects of the supply and use of whole blood with medicalofficers in General Denit's office and with the Surgeon, Sixth U.S. Army. Atthis time, there were no personnel in the POA who had the overall responsibilityof supervising the reception, storage, and distribution of blood or who had theauthority to undertake these tasks.
Also, as might have been expected in the circumstances, there was no generalrecognition of the importance of the liberal use of whole blood in battlecasualties. One of Colonel Kendrick's important tasks, and it was not aparticularly easy one, was the indoctrination of medical officers concerningthis modality. He had to convince officers of the Sixth U.S. Army, which hadbeen functioning effectively for several years without adequate supplies ofwhole blood, that the new blood program had a great deal to offer them. Many ofthem frankly told him that they had got along very well without it and him. Healso had to convince medical officers in an army that had never had enough ofanything that they could have all the blood they needed and wanted simply byasking for it. His observations in the Mediterranean and European theaters stoodhim in good stead, for he could bear personal testimony to the feasibility andadvantages of the plan he was advocating.
The acceptance of the blood program and the liberal use of whole blood thatfollowed (fig. 148) can be attributed chiefly to the vision and support of theConsultant in Surgery, Sixth U.S. Army, Major Glenn. Without his understandingof the problem, and without the high esteem in which he was held by medicalpersonnel in the Sixth U.S. Army, it would have been far more difficult than itwas to support this Army with the blood which it required.
As has been pointed out already, the arrival of the first shipment of bloodfrom the United States changed the whole face of the management of shock andhemorrhage in the Pacific. Up to that time, the ratio of pints of blood tocasualties had been about 1:10. The ratio changed to 1:1, and later to 1.5:1.
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When whole blood was immediately available as far forward asclearing companies and portable surgical hospitals, it became the practice touse plasma only when blood was not at hand, which was seldom, or to supplementtransfusion, but never as a substitute for it. By March of 1945, it was routinefor invasion forces to carry blood ashore with them, and it was not uncommon, onreading a casualty's Emergency Medical Tag in a rear hospital, to find that hehad received 1 or more pints of bank blood at a clearing company (34).Some casualties received as much as 6 pints in an hour.
Numerous reports from individual surgeons and hospitalstestified to the value of whole blood. The Surgeon, Palawan Task Force, saidthat the buffered whole blood brought in with medical units on D-day in theLuzon operation proved invaluable: "The value of whole blood over plasmafor battle casualties is unquestioned." A surgeon at the 27th PortableSurgical Hospital said that the mortality rate from abdominal wounds dropped 20percent when transfusions, penicillin, and oxygen therapy became available. Areport from the 80th General Hospital stated that the superiority of wholeblood over plasma was most striking in casualties with shattered pelvis andassociated abdominal injuries, who required 3,000 to 4,000 cc. of blood in thefirst 24 hours after wounding. The surgeons of the 119th Station Hospital foundplasma of little value in casualties received for definitive and convalescentcare. "Blood is what is needed."
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The comments of the Surgeon, Sixth U.S. Army, were particularly enthusiastic. The use of plasma in the restoration of blood volume in hemorrhage and shock needed no comment on its merits, he wrote, but if hemorrhage had occurred, only whole blood could meet the situation. Blood had been used extensively as far forward as battalion aid stations. Given over a 24-hour period, 5,000 cc. could completely change the appearance and outlook of a critically wounded casualty. The use of whole blood in the Luzon campaign had played a very significant part in reducing the mortality from serious wounds and had also proved that massive transfusions early, followed by slower transfusions, were much more efficacious than plasma. Finally, fewer reactions were occurring with banked blood than had occurred with fresh blood collected locally.
Numerous case reports were also cited that showed both the value of whole blood and the success of the indoctrination in its use. One casualty, for instance, with a ruptured arteriovenous aneurysm in the thigh, received 5 pints of blood immediately and another 5 pints over the next 12 hours. By former methods of collecting and administering blood, he could not possibly have been saved. With banked blood immediately available, he was brought out of shock, hemorrhage was controlled, reparative surgery was done, and both life and limb were preserved.
The Luzon Experience
The Luzon experience is typical of all later experiences with whole blood. Inthis campaign, for the first time, blood was administered to all patients withsevere and moderately severe wounds or with evidence of impending shock,regardless of their status on admission. Those with no signs of shock received 2pints of blood. Those in moderate shock received from 4 to 6 pints, run inrapidly by gravity. Those in shock from severe hemorrhage sometimes received asmuch as 10 pints in 90 minutes. One patient received 17 pints in 9 hours. Inseverely shocked patients, blood was often forced through cannulas into severalveins at once by multiple syringes or by pressure gravity techniques. Afterobservation of the results of these practices, it required little effort toconvince Sixth U.S. Army medical officers at headquarters or in the field of thevalue of the whole blood program.
Whole blood was used in chest wounds with the usual precautions againstoverhydration. It was given liberally in wounds of the abdomen and of theextremities. Its postoperative use was found to be an effective way to preventwound disruption. Casualties coming from forward hospitals often suffered fromhypoproteinemia, and the liberal use of blood and plasma, supplemented by earlyhigh-protein feedings, helped to prevent this complication.
Blood was also used as necessary on the medical service. Several patientswith aplastic anemia received 20 pints or more before evacuation.
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Techniques of Administration
Data concerning the practices used in the administration of whole blood inPacific hospitals were reported in the ETMD for March and April 1945 (35). Thecontainer was inverted and agitated gently until the cells had returned to astate of uniform suspension in the plasma. The blood was given either cold as itwas taken from the refrigerator or after it had stood at room temperature for ashort time; it was never warmed to body temperature. When it was given rapidly,it was preferable that it be at environmental temperature. When it was givenover a 30- to 90-minute period, the temperature seemed unimportant.
The time required to administer a unit of blood was widely variable. Whenpressure was exerted by use of the bulb on a Baumanometer or by some othermeans, a pint could be given in 5 to 10 minutes. A transfusion could be givenrapidly under minimal pressure if a cannula was tied into the long saphenousvein. The intrasternal route was occasionally used. When a casualty was insevere shock, two transfusions could be run into different veins at a rapidrate. As soon as bleeding was controlled and the blood pressure returned to asatisfactory level, the rate of administration was decreased, and the blood wasgiven just rapidly enough to keep the pressure near that level.
Difficulties originally experienced with filtration of the blood soon disappeared with improvements in the filter. There were some complaints because it was not possible, with the sets used, to see the blood dripping through a glass adapter, but the objection was not considered significant when a filter was used which did not clog.
PLASMA
The story of plasma in the Pacific is much the same as its story in other theaters. Before whole blood was available, many casualties who clearly needed whole blood were given plasma; some received as much as 10 to 14 bottles over a period of a few hours. Once whole blood became available and its correct use was comprehended, plasma was used on the proper indications.
In his report to The Surgeon General on his survey of blood requirements and supplies in the Pacific in July 1944, Colonel Kendrick stated that he and Captain Newhouser had found adequate supplies of plasma in all areas (10). Some of the packages were 2? years old, but plasma, distilled water, and intravenous equipment were still intact and uncontaminated, and there was no apparent deterioration of the rubber tubing or stopper. The few reactions reported after plasma transfusions were apparently urticarial. Medical officers were enthusiastic about the change to the 500-cc. package.
On land, plasma was reconstituted in battalion aid stations, carried forward, and administered as splints were applied before the casualty was moved. In thick jungle country such as on Biak, where it often took 8 hours to move a
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casualty 4 miles by litter, the use of plasma before and during evacuation was often lifesaving.
The use of plasma both afloat and ashore was greatly extended by training Army and Navy corpsmen to prepare and administer it. Aboard ship, naval medical officers depended upon these well-trained men to administer most of the plasma given. The ability of enlisted men to master the intravenous technique was sometimes underestimated. They learned readily, and some technicians, who had not been trained, administered plasma for the first time under fire simply by following the instructions on the container.
The following instances illustrate the importance of giving enlisted personnel such training:
A seriously wounded man lay in a depression in the direct line of fire of anactive Japanese machinegun. To leave him without treatment would have risked hisgoing into irreversible shock. To move him would have meant certain casualtiesfor the litter squad. A staff sergeant, who was later awarded the Silver Starmedal for bravery, crawled out to him, dressed his wounds, splinted a fracture,and then administered three units of plasma to him by lying by his side andelevating the bottle of plasma with one hand(38).
Five men in a command post about an hour's litter carry from a battalionaid station were seriously wounded by a short 81-mm. mortar. An enlistedtechnician on the spot prepared five units of plasma, suspended the bottles byforked sticks in the ground, and had the last infusion flowing before the firstwas complete.
Many lives were saved because enlisted technicians with supplies of plasmawere assigned to companies carrying out flanking attacks in the jungle andoperating apart from the battalion.
OTHER REPLACEMENT AGENTS
Serum albumin was available in the Pacific but Captain Newhouser and ColonelKendrick found that it was not widely used, either ashore or on ships, forseveral reasons: Many medical officers had never heard of it; the circumstancesdid not favor rapid dissemination of information. No extensive educationalprogram had been carried out concerning it, and plasma, which had been thesubject of careful indoctrination, was universally available and had provedextremely satisfactory. The necessity for using additional fluid with albuminwas a distinct disadvantage, for dehydration was a real entity in troopsfighting in the Pacific areas.
Many hours were spent on hospital ships and in other Army and Navyinstallations instructing medical officers on the availability and use of serumalbumin. It was also pointed out that it need not be stored in refrigerators,in which it was being kept in all the storehouses visited.
Almost nothing was known in the Pacific about immune globulin, fibrinogen,thrombin, and fibrin foam.
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All intravenous preparations and equipment examined werefound in good condition, although some of the tubing had been exposed totemperatures from 85? to 110? F. for 18 months.
CONCLUSIONS
Once the program to supply blood to the Pacific from themainland had been instituted, there was never a shortage of blood in theseareas. At times, when the weather was bad and supplies on hand did not exceed24-hour requirements, some concern was felt, but, as in the European theater,the blood never failed to arrive when and where it was needed. Had OperationOLYMPIC (p. 639) been carried out and the estimated 500,000 to 600,000casualties come to pass, there is little doubt that sufficient blood would havebeen provided for all their needs. In one operation out of four, said the May1945 report of the distribution center at Guam (36), in reference to theearly stages of the Okinawa operation, "we had too much too early but innone, including the other phases of the Okinawa operation, to date did we everhave too little too late." That statement continued true until the end ofthe war.
The experience of the airlift of blood to the Pacific and thehandling and use of blood there proved a number of points:
1. That it is perfectly practical to collect blood in theZone of Interior and deliver it safely to a theater far removed from the pointof origin. It was not unusual for blood to be collected in the United States,sometimes in cities as far inland as Chicago, and to be used in places as remotefrom the point of collection as Okinawa within 6 days after it had beencollected.
2. That a theater transfusion officer, with his staff,attached to the office of a theater surgeon and given the proper authority andresources, can keep a combat force adequately supplied with blood. This is true,however, only if the resources made available to this officer include the staff,personnel, and equipment necessary to collect, process, and deliver whole bloodto all medical installations in the theater.
3. That in dealing with a commodity such as blood, which hasonly a brief life and which is easily contaminated and rendered not only uselessbut dangerous, handling and distribution must be the responsibility of medicalofficers and other personnel trained in this particular specialty. For thereasons just stated, blood cannot be handled efficiently or safely throughconventional supply channels.
4. That collection of blood from base troops is necessary to insure adequate supplies of fresh whole blood in the event that transportation from the Zone of Interior is impossible because of adverse weather. Local collections are also useful in buffering the wide fluctuations in the amounts required from the Zone of Interior. It was very difficult for the Red Cross to regulate its schedule so as to bleed no donors one day and 2,000 the next, and then to drop from 2,000 to almost none again on very short notice.
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5. That the delivery of blood over great distances and itsdistribution to widely dispersed medical units on separate land massesrequire coordination and timing of a high degree. The experience on Okinawaproved that in island operations, in which blood must be carried ashore withlanding forces, it is essential that a trained medical officer, with experiencein the handling of blood be given the responsibility for prior planning, fordistribution, and for resupply, and also be given the resources necessary todischarge his duties. All the blood used at Okinawa came, via Guam, from theUnited States, 8,000 miles away. With the dating period set at 21 days, itrequired careful timing to guarantee adequate quantities of blood with minimumwastage from outdating. That the project was accomplished so successfully wasdue to (1) a highly efficient blood supply system extending from the Zone ofInterior to Okinawa and (2) to the assignment of a trained transfusion officerwho was responsible for planning, supply, and distribution, and for the properclinical use of the blood once it had reached the target.
As these conclusions indicate, perhaps the most essentialfactor in the efficient operation of a transfusion service is the assignment tothe office of the theater surgeon of a trained transfusion officer, whoseresponsibility is overall supervision of the transfusion teams and liaisonbetween hospitals, teams, and the source of blood in the Zone of Interior.
OPERATION OLYMPIC
Just before the end of the campaign on Okinawa, at thesuggestion of Col. I. Ridgeway Trimble, MC, Consultant in Surgery, SWPA, GeneralDenit invited Colonel Kendrick to Manila to plan the blood program for theinvasion of Japan (Operation OLYMPIC). It was interesting that even at this latedate, certain medical personnel in the SWPA, while fully recognizing the urgentneed for whole blood, doubted that all that was regarded as necessary for theinvasion of Japan could possibly be supplied.
The essentials of the plan developed for Operation OLYMPICwere as follows (39):
1. Whole blood would be flown under refrigeration by anArmy-Navy airlift from the Zone of Interior to Guam. All requisitions wouldclear through this center.
2. Accessory distribution units would be set up in Manila andon Leyte and Okinawa, each to be operated by a well-trained and well-equippeddistribution team.
3. Initial supplies of blood would be provided by the Manilacenter. The center at Okinawa would be responsible for resupply by surfacecarrier, air, or both means.
4. The blood supply at the target would be provided initiallyby LST(H)'s designated as blood distribution centers afloat. As soon aspossible, blood distribution teams would be put ashore at each of the targetareas.
Detailed descriptions were given of personnel, equipment,function of the centers, and other matters.
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Blood would be provided for Operation OLYMPIC as follows:
1. A consultant or other responsible medical officer would beattached to USAFPAC as officer-in-charge of the transfusion service.
2. The two Army transfusion teams on duty in Saipan would berequested from the Commanding General, POA. One team would be assigned toManila, to serve as a distribution team and, when necessary, as a bloodcollecting team. The other would serve in Okinawa as a collecting team and wouldbe prepared to furnish distribution personnel to go forward to the target areaon call if one of the teams at that point should be incapacitated.
3. Three Navy distribution teams would be attached to theSixth U.S. Army, one to go in with each assault force. These teams would betransported to the target on the LST(H)'s designated as blood distributionpoints afloat and would function on them until they went ashore. The centerashore would be centrally located, to supply both installations ashore and shipsafloat.
4. One LST(H) would serve as a blood distribution center ateach target. It should be provided with adequate reefer space for the necessaryamounts of blood and should also be provided with an ice machine. If thebeachhead were wide, each LST(H) might need to be supported by other LST(H)'sserving as subsidiary blood distribution points, but all blood should beobtained from the designated whole blood distribution center afloat.
5. Delivery of blood to individual hospitals would be a unitfunction. If the LST(H) serving as the distribution center afloat were on thebeach, the supply of blood to shore units would be simplified. If it wereoffshore, transportation of the blood should be by LCVP's (landing craft,vehicle, personnel) at the direction of the distribution team aboard the LST(H).Arrangements should be made for flash signals for notification of the need ofblood on the beach.
Blood requirements for the invading Army and Marine troopswere estimated at 1.5 pints per casualty and on the assumption that 80 percentof all casualties arriving in forward hospitals would require blood. For thefirst 15 days of the invasion, 7,780 casualties would require 11,670 pints ofblood. The respective cumulative figures for the first 30 days would be 18,060casualties and 27,090 pints; for the first 60 days, 44,725 casualties and67,087 pints; and for the first 120 days, 99,948 casualties and 149,922 pints.
To insure adequate supplies, enough blood should be carriedashore initially for a 5-day period; this plan would require 6,000 pints ofblood, 2,000 pints to be loaded with each assault force. After the first 5days, resupply would depend upon placing distribution centers as close to thetarget as possible, the availability of surface and air transportation, andmaintenance of an adequate flow of blood from Guam to the distribution centersat the target. Because of the short haul, it would be most desirable toutilize the distribution center at Okinawa for the resupply of blood untilairstrips were available. This center should be familiar with the total bloodrequirements for Operation OLYMPIC, and requests from the target area should beaddressed to it.
The officer in charge of the transfusion service shouldwork out a table showing the amount of blood required, the dates it mustarrive, and the points at which it should be delivered from Guam. LieutenantBrown at Guam should have this information at least 12 days before the bloodwould be needed at the loading points. This interval would allow the centers onthe
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mainland to step up their program to meet requirements. Itwould take from 4 to 6 days to accumulate the 6,000 pints of blood needed forthe first stage of the operation.
Critique
The plan just outlined was presented to General Denit insufficient time for it to be approved in his office and sent to the Office ofThe Surgeon General, so that Maj. John J. McGraw, Jr., MC, then servingas his special representative on blood and plasma transfusions, could commenton it in the light of his experience in the Mediterranean theater.
Major McGraw found the plan excellent and noted that therewere 11 centers in the United States capable of supplying whole blood at therate of 2,300 or more units per day 6 days a week (40). He considered the plan for a consultant at Headquarters, USAFPAC, charged with the overallresponsibility for the transfusion service, to be an essential part of theprogram. He also emphasized again that blood distribution must not be afunction of Medical Supply but the responsibility of blood distribution teamswhich were trained to handle it.
Major McGraw also made the following comments:
1. Blood should not be used after 21 days. At that time,high-titered group O bloods must be considered dangerous for A, B, andAB recipients.
2. The teams assigned to operate the two distributioncenters were probably not large enough for the collection, processing, anddelivery of significant amounts of blood. It was suggested that they be replacedby the type 2 blood transfusion teams (listed NB under T/O&E 8-500),which consisted of 5 officers (2 MC, 3 SnC) and 26 enlisted men.
3. The Navy distribution teams attached to assault forcesshould be replaced as soon as possible by Army teams, so that all personneldealing with blood would be under the control of the consultant on transfusionat Headquarters, USAFPAC.
4. The plan of making each hospital responsible for pickingup its own blood, by the ambulances bringing patients to hospitals, wasconsidered a hit-or-miss proposition. It was recommended instead thatdistribution teams make regular rounds to all hospitals, delivering blood asneeded and picking up blood nearing its expiration date for delivery to moreactive units.
These comments were made on 4 August 1945, just 10 daysbefore the cessation of active fighting, which made unnecessary any furtheraction on the blood program for the invasion of Japan. They were also, ColonelKendrick noted later, made by an officer whose experience with the supply ofwhole blood, although very extensive, did not include the ship-to-shoreoperations required in the Pacific areas. Colonel Kendrick considered havinghospital ambulances carry their own blood supply almost the heart of theprogram in this sort of warfare in its initial stages.
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CHINA-BURMA-INDIA THEATER
National Blood Programs
The first blood bank in India was organized in Calcutta, atthe School of Tropical Research, in 1925 (41). When the war broke out in1939, a transfusion service was set up here for the Indian Army, and anothercenter was opened in Lahore. When Japan entered the war and Burma was occupied,the blood program was expanded into most of the major Indian cities, to provideblood for both civilian and military use. All of these centers operated underGovernment control, but each used techniques to fit the local situation. Whenthey were opened, a Government-sponsored educational program was launched, toovercome the superstitious fears of the polyglot Indian people about givingblood.
Blood was processed into serum in several large cities, and alimited amount of dried plasma was produced in Calcutta. The expansion of theprogram was hampered by lack of equipment and by long delays in procuring it.
China had no organized blood or plasma program. In 1943, theAmerican Bureau for Medical Aid to China undertook the training of technicalpersonnel in a special donor center in Chinatown in New York. The idea was thatthis group would be sent to China, as a pilot group to train other technicalpersonnel, who would establish additional centers to bleed donors supplied frommilitary sources. The plan had a limited success.
Blood and Plasma Supplies
When U.S. troops reached India, a basic supply of driedplasma was forwarded to them by air. Maintenance was on the basis of 100 unitsper month for each 10,000 troop strength. Supplies of plasma were practicallyalways adequate, and it served the same useful purpose that it did in othertheaters. Unfortunately, it frequently had to be used when blood would have beenmore desirable.
The blood bank set up at the 20th General Hospital atMargherita, Assam, in May 1943, also served the 14th and 73d EvacuationHospitals and all their substations which were accessible by motor transport (42).Wet plasma was also provided, and some serum (figs. 149 and 150). The bloodwas collected under aseptic precautions by a semiclosed method. It was citratedwhen it was to be used for whole blood or plasma but not when it was intendedfor serum. The blood had a shelf life of 10 days. At the end of this time, theplasma was withdrawn and the cells were discarded. No centrifuge was available,so when plasma or serum was to be processed, separation took from 3 to 5 days.The citrated blood, wet plasma, and serum were stored in electric refrigeratorsof 6-cu. ft. capacity.
When blood first became available, combat injuries were not numerous, and its chief use was for patients with malaria and dysentery, who often were
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in a serious state of shock, and for civilian-type traumaticinjuries. When combat casualties were treated, the indications for transfusionwere the same as in other theaters (fig. 151).
Malaria in Donors
The blood of every donor, whether American or Chinese, wasexamined for malaria, and a Kahn test was also performed. If either reactionwere positive, the donation was used for plasma, which was kept in therefrigerator for 14 days before it was used. Information disseminated by theIndian Medical Directorate at New Delhi was to the effect that neither thestorage of blood at low temperatures nor the addition of quinine nor Mepacrine (quinacrinehydrochloride) in vitro made malaria-infected blood safe for transfusion (43).If whole blood had to be secured in malarious areas, donors should beselected who had no history of frank attacks, who had had no recent symptoms,whose spleens were not enlarged, and whose thick films were negative.
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Since potential infection had to be assumed in a malariousarea during the malaria season, it was recommended in these instructions thatthe donor, when time allowed, should be given Mepacrine and that the recipientshould also be given it for several days after the transfusion, until hiscondition had improved sufficiently for a frank attack of malaria to betolerated.
If the recipient developed malaria, or if it were foundthat malarious blood had been accidentally given, the diagnosis should beconfirmed by examination of thick and thin smears, and the standard course oftreatment carried out. After giving blood, donors with latent or suppressedmalaria frequently had attacks, especially if they were walking wounded.Standard suppressive treatment should be given in malarial areas; otherwise,no treatment should be given unless an attack of malaria ensued.
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Supplies for Chinese
One of the chief reasons for the establishment of theblood bank at the 20th General Hospital was to provide blood and plasma forChinese patients. Only small amounts of plasma and serum were available to them from Chinese sources (fig. 152).Arrangements were made with the Directorof the All India Institute of Hygiene and Public Health in Calcutta tolyophilize pooled plasma and serum from Chinese donors, with the idea ofbuilding up a reserve for use in forward installations. A small blood bank wasmaintained at the 20th General Hospital, with limited amounts of wet plasma andserum, but the project did not succeed as it had hoped that it would,and the arrangements made in Calcutta were not utilized because Chinesedonations barely met the day-by-day local requirements.
At the 20th General Hospital, it was found that blood wasneeded in about 30 percent of U.S. patients who required replacement therapy and in about75 percent of the Chinese patients. The chief reason for the discrepancy was the high incidence ofhypoproteinemia and severe anemia in the Chinese, as the result of injurysuperimposed on disease. Seriousanemia was frequently secondary to prolonged malnutrition, severe and recurrentdysenteries, and
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severe, recurrent malaria. Traumatic rupture of the liver and spleen was alsodisproportionately frequent in the Chinese soldiers. Enlargement of these organswas frequent in them, and susceptibility to trauma correspondingly great.
References
1. Bracken, Lt. Col. Mark M., MC, n.d., subject: The Use of Whole Blood andBlood Plasma in the Pacific Operational Area During World War II.
2. Report, Maj. R. J. Walsh, Secretary, New South Wales, Red CrossTransfusion Committee, n.d., subject: New South Wales Red Cross BloodTransfusion Service at the Conclusion of the War (1945).
3. Memorandum, Col. F. H. Petters, MC, to Commanding Officers, 105th GeneralHospital and 42d General Hospital, 8 Feb. 1943, subject: Blood Bank.
4. 1st Indorsement (Memorandum No. 3) from Col. Maurice C. Pincoffs, MC, 12Feb. 1943.
5. Memorandum, Col. Raymond O. Dart, MC, to the Surgeon, Headquarters, U.S.Army, Services of Supply, Base Section No. 3, 15 Feb. 1943, subject: Shipment ofWhole Blood to Advanced Areas.
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6. 1st Indorsement (Memorandum No. 3), Col. J. M. Blank, MC, 23 Feb. 1943.
7. Memorandum, Maj. Wm. Barclay Parsons, MC, to Col. F. H. Petters, MC, 2Mar. 1943, subject: Comments on Letter from Colonel Blank.
8. Memorandum, Col. F. H. Petters, MC, to Surgeon, Subbase D, 3 Aug. 1943,subject: Blood Bank.
9. Technical Memorandum No. 13, Office of the Chief Surgeon, Headquarters,USAFFE, 21 Sept. 1944, subject: Blood Bank.
10. Memorandum, Lt. Col. Douglas B. Kendrick, MC, for The Surgeon General,30 Oct. 1944, subject: Report of Trip to South Pacific Area, SouthwestPacific Area, Central Pacific Area. Time: June 6th to August 8, 1944.
11. Memorandum, Lt. Col. Douglas B. Kendrick, MC, to Brig. Gen. Guy B.Denit, 19 July 1944, subject: Plan for Blood Transfusion Service in SWPA WithSpecial Reference to Advanced Bases.
12. Memorandum, Lt. Col. Douglas B. Kendrick, MC, to Brig. Gen. Guy B. Denit(attention: Col. A. M. Libasci, MC), 19 July 1944, subject: Supply Problems inthe Advanced Bases SWPA.
13. Memorandum, Lt. Col. Bruce P. Webster, MC, to Chief Surgeon, USASOS, 26June 1944, subject: Informal Report on the Use of Army Personnel as Blood Donorsin Malarious Areas.
14. Technical Memorandum No. 6, Office of the Chief Surgeon, Headquarters,USAFFE, 12 May 1944, subject: Treatment of Malaria.
15. Letters, Vice Adm. Ross T. McIntire, MC, USN, and Maj. Gen. Norman T. Kirkto Mr. Basil O'Connor, 26 Oct. 1944.
16. Letters, Mr. Basil O'Connor to Maj. Gen. Norman T. Kirk and Vice Adm.Ross T. McIntire, 3 Nov. 1944.
17. Robinson, G. C.: American Red Cross Blood Donor Service During World WarII. Its Organization and Operation. Washington: The American Red Cross, 1 July1946.
18. Report, Officer-in-Charge, U.S. Naval Whole Blood Distribution Center No.1, to Chief of the Bureau of Medicine and Surgery, Navy Department, Washington,D.C., 6 Mar. 1945, subject: Operation of the U.S. Naval Whole Blood DistributionCenter No. 1.
19. Letter, Maj. F. N. Schwartz, MAC, to Col. B. N. Carter, MC, 14 Nov. 1944.
20. Letter, Lt. Col. Douglas B. Kendrick, MC, to Col. George R.Callender,MC, 28 Dec. 1944, subject: Blood Supply to Pacific.
21. Memorandum, Lt. Col. Douglas B. Kendrick, MC, to Maj. F. N. Schwartz, MAC,28 Dec. 1944, subject: Blood Supply to Pacific.
22. Report, Lt. Herbert R. Brown, Jr., MC, USNR, and Ens. George E.Nicholson, HC, USN, subject: Operation of Advance Base Blood Bank Facility No. 1From the Period of 19 November 1944 Through 24 December 1944.
23. Report, Capt. Henning H. Thorpe, MC, to Chief Surgeon, U.S. Army Forces,Western Pacific, 4 July 1945, subject: Second Quarterly Report for History,Whole Blood Distribution, Office of the Surgeon, Base K.
24. Brown, Lt. Herbert R., Jr., MC, USNR: Operation of U.S. Naval Whole BloodDistribution Center No. 1 for Period of 1 April 1945 to 30 April 1945.
25. ETMD, USAFFE, for November 1944.
26. Kendrick, Lt. Col. Douglas B., MC, n.d., subject: Plan for the Use ofWhole Blood in the M-l Operation.
27. ETMD, POA, for March 1945.
28. ETMD, USAFPAC, for July 1945.
29. History of 32d Infantry Division, SWPA, 1944.
30. ETMD, USAFPAC, for November 1945.
31. Memorandum, Lt. Col. Douglas B. Kendrick, MC, to Surgeon, Tenth U.S.Army, 14 May 1945, subject: Report of Transfusion Services for the OkinawaOperation.
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32. Letter, Col. Raymond O. Dart, MC, to Commanding Generals, Philippine BaseSection, Luzon Area Command, Bases M, X, K, R and S, 5 Sept. 1945, subject: WholeBlood Distribution to Hospitals in the Philippine Islands.
33. Circular Letter No. 38, Office of the Chief Surgeon, GeneralHeadquarters, USAFPAC, 20 Aug. 1945, subject: Whole Blood.
34. Report, Capt. Henning H. Thorpe, MC, to Chief Surgeon, AdvancedHeadquarters, U.S. Army Services of Supply (attention: Central Medical RecordsOffice), 4 Apr. 1945, subject: Initial Quarterly Report for History of BloodBank Facilities.
35. ETMD, USAFFE, for March-April 1945.
36. Report, Lt. Herbert R. Brown, Jr., MC, USNR, n.d., subject: Operation ofU.S. Naval Whole Blood Distribution Center No. 1 for the Period of 1 May to 31May 1945.
37. Quarterly History, Medical Activities of 7th Portable Surgical Hospitalfor 1945-1, 1 Apr. 1945.
38. History of 116th Medical Battalion, SWPA, summary 14 Dec. 1942 to 5 Oct.1943.
39. Memorandum, Lt. Col. Douglas B. Kendrick, MC, to Brig Gen. Guy B.Denit, 21 July 1945, subject: Proposed Plan for the Supply of Whole Blood for theOlympic Operation.
40. Memorandum, Maj. John J. McGraw, Jr., MC, to Col. B. N. Carter, MC (forCol. I. Ridgeway Trimble, MC), 4 Aug. 1945, subject: Comment on Proposed Planfor Supply of Whole Blood for Olympic Operation.
41. Memorandum, Col. Elias E. Cooley, MC, to The Adjutant General, WarDepartment, Washington, D.C. (attention: The Surgeon General, U.S. Army),through Commanding General, U.S. Army Forces, China-Burma-India, 17 Jan. 1944,subject: Essential Technical Medical Data from Overseas Forces.
42. ETMD, Headquarters, U.S. Army Forces, CBI, December 1943.
43. Medical Directorate, India, Technical Instructions No. 11, GeneralHeadquarters, India, 10 Dec. 1943, subject: Precautions to be Observed WhenGiving Whole Blood Transfusion in a Malarious Area.
