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Chapter XVII

Contents

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 supply of whole blood for U.S. Forces fighting in the Southwest Pacific came from the Red Cross blood bank in New South Wales, Australia, it is appropriate to begin this chapter on the Pacific areas with a brief note on its organization and techniques (1,2).

The Australian blood service was instituted after a study of methods of blood storage, which resulted in:

1. The selection of the dihydric sodium citrate-glucose solution recommended by the Medical Research Council of Great Britain.

2. The development of a heavily insulated wooden box suitable for transporting blood by air.

The blood of two donors (430 cc. each) was collected into a single 1,000-cc. Soluvac bottle containing 200 cc. of 3-percent dihydric sodium citrate solution and 40 cc. of 15-percent glucose solution. Only group O donors were used. The technician who drew the blood prepared himself by an extremely rigid aseptic technique and repeated the preparation before the second blood was collected. Processing included grouping, crossmatching, the Kline test, and sterility tests.

As soon as the blood was drawn, it was placed in an electric icebox for 2 hours. It was then moved to the insulated box just mentioned. This box held ten 1,000-cc. flasks, and the 56 pounds of ice which it contained was enough to keep the blood between 40° and 46° F. (4.5° and 8° C.) for 48 hours; if the box was not exposed to the sun, the blood remained chilled for as long as 5 days. The ice was placed in the box at least 4 hours before the blood was to be dispatched, and, just before the blood was packed, it was removed, crushed into fine pieces, and replaced. Each box weighed 210 pounds packed and occupied 4.2 cu. ft. of space.

The expiration date of the blood was arbitrarily set at 10 days from the date of collection. Blood considerably older was used in emergencies, with no report of ill effects, but the practice was not considered desirable; it was fully realized that the older the blood, the more advanced the cellular destruction and the biochemical changes, and the greater the risk of infection. Con-


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tamination was never a factor, and no reactions attributable to O blood per se were recorded. In fact, thanks to the detailed preliminary planning, there were very few difficulties of any kind when the transfusion service began active operation. Blood not used for transfusion was converted to serum (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 flown from Australia to New Guinea in December 1942. Thereafter, blood was continuously dispatched to forward battle areas. After August 1943, it was also supplied to civilian hospitals and to private physicians in the Sydney metropolitan area.

When the lines of communication became too long for supplies of blood to be flown directly to the battle areas, a relay station was set up in an advanced base (Finschhafen), where the blood was inspected, repacked, and then shipped forward. This unit was also equipped to bleed service troops in the area.

Up to 1 December 1944, about 7,000 liters of blood had been flown 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 shortages of this item during the course of the war. Its portability, ease of administration, and the apparatus supplied with it made plasma an ideal agent in the circumstances of Pacific fighting (figs. 127-131). Nonetheless, from the beginning of the war, some medical officers in the Pacific recognized that there was no substitute for whole blood. The transfusion service in this area had its inception in this concept. In many instances in which plasma was used, it was employed because whole blood was not immediately available, and time could not be lost finding a compatible donor, making the necessary tests, and drawing the blood.

First Proposals

The first proposal for a supply of whole blood procured locally in the Pacific came on 8 February 1943, when Col. Frederick H. Petters, MC, Surgeon, Base Section No. 3, Brisbane, Australia, asked the commanding officers of the 105th and 42d General Hospitals their opinion of the feasibility of establishing a blood bank with donations from nonmalarious troops in the area (3). Blood would be collected in 500-cc. amounts on a continuous daily basis and shipped by plane to advanced bases. The supply of donors in the base was exhausted. The number of troops who could give blood had been depleted by loss of weight and possible malarial infection, and those available were being bled for a second time. It might be possible to identify a group of


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FIGURE l27.-Preparation of plasma for administration to incoming casualties,
43d Division Hospital, Rendova, July 1943.

nonmalarious donors, test them serologically, draw and package their blood, and forward it by plane, by the system the Australians had used so successfully.

Replies from Col. Maurice C. Pincoffs, MC, Commanding Officer, 42d General Hospital (4), and Col. Raymond O. Dart, MC, Commanding Officer, 105th General Hospital (5), stated that it would be perfectly feasible to ship blood to advanced bases by the plan proposed, but both specified that the entire procedure should be made the responsibility of personnel trained in the handling of blood at the base and at advanced bases. Either jointly or singly, Colonel Pincoffs and Colonel Dart also made the following points:

1. Some means of prompt communication should be arranged between the officers in charge of blood at the base and at advanced bases, so that the collection of blood could fluctuate with the needs in the forward area.

2. Only group O and group A blood should be used, 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 to wounded infantryman, Leyte,
Philippine Islands, October 1944.

3. Australian techniques should be investigated. If blood were collected in discarded 1,000-cc. intravenous flasks, the amounts from two donors could be combined and would provide enough for a single exsanguinated casualty; it was assumed that plasma would remain the intravenous fluid of choice, whole blood being given only in circumstances of extreme urgency. Specifications for marking the blood, maintenance of sterility, and other precautions were emphasized.

4. The blood should be refrigerated from collection to administration; in these circumstances, a dating period of 5 days would be considered safe.

5. Donors should be grouped, tested serologically, and examined physically before the blood was drawn, preferably before breakfast, to avoid foreign protein reactions.

Colonel Pincoffs did not believe that a system of volunteer donors would stand up under heavy demands. He recommended that hospitals draw blood from their own detachments and that service troops, not including medical troops with detachments of active hospitals, should form donor pools. Colonel Dart estimated that, if the cooperation of all enlisted personnel at a hospital could be secured, there would be available daily 10 times 500 cc. of blood. If officers and patients were also used, daily availability would increase to 15 times 500 cc. These figures would be maximum, however, if the need were prolonged.1

1They proved to be overly optimistic.


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FIGURE l29.-Administration of plasma to wounded Filipino with severe, almost fatal, wound from saber cut by Japanese officer, Manila, Philippine Islands, February 1945.

On 23 February 1943, Col. Julius M. Blank, MC, Surgeon, Advanced Base, sent the following 1st indorsement to Brig. Gen. Guy B. Denit (6):

1. If whole blood were obtained from Australian sources and shipped to the advanced base (as was done 11 months later), it would be necessary to set up a small subbank in this base, with arrangements for precise refrigeration at 38° F. (3.5° C.). Such facilities did not then exist.

2. Blood stored under these conditions would probably become hemolyzed at a maximum of 10 days after bleeding. If it were used, benefits would be reduced and the chances of reactions increased. At the end of this period, however, it should be possible to remove the red blood cells and use the residue-if the proper facilities were available.

3. The use of blood serum had given satisfactory results in most patients sent to the base, and the use of whole blood could therefore be limited to those patients with a marked reduction in the cellular elements.

4. Authorities had set the level of transfusions below which it was not considered practical to establish a blood bank at 1,000 to 1,200 per annum. At the 10th Evacuation


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FIGURE 130.-Administration of plasma to wounded U.S. soldier in courtyard of Walled City, Manila, Philippine Islands, February 1945.

Hospital, 50 transfusions had been given to approximately 1,500 wounded in December 1942, and 44 had been given in January 1943. These figures were interpreted to mean that the present supply of donors was adequate and that, unless there was a sudden influx of casualties, blood from the Australian bank was not needed.2

5. If such an influx occurred, it might be advantageous to have an extra supply of blood on hand. It was therefore suggested that adequate storage facilities be provided at the advanced base for a 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 also be made with the Australian blood bank to provide blood to be flown up as requested by radiogram.

In comments on these proposals on 2 March 1943, Maj. (later Col.) Wm. Barclay Parsons, MC (7), pointed out that the assumption that the donor supply was adequate seemed odd, since the paucity of donors had been the main reason for starting the discussion.

BLOOD SUPPLY FROM AUSTRALIA

On 3 August 1943, the Surgeon, Subbase D (Port Moresby), was informed by Colonel Petters (8) that thereafter blood would be supplied regularly 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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FIGURE l3l.-Administration of plasma to wounded U.S. soldier directly behind frontlines near San Nicholas, Luzon, Philippine Islands, March 1945. Filipinos carried the wounded from the front to ambulances in the rear. Note large bottle (500 cc.) of plasma.

the Australian Blood Bank Service, in amounts up to 200 liters 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 its shipment forward by air in insulated boxes, which would be supplied; and for a 10-day dating period. It was requested that surgeons in forward areas be informed 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 immediately after it had been used.

On 22 January 1944, the Australian Blood Distribution Center operating at Port Moresby, New Guinea (map 4), began to supply preserved blood to 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 from 10 to 15 days, it having been found that hemolysis seldom occurred earlier.

By the original plan, 10 liters of blood were flown weekly to Milne Bay, Oro Bay, and Finschhafen in New Guinea. In July 1944, hospital ships


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MAP 4.-Distribution of blood from Australian blood bank to Pacific areas and of locally collected blood from Hollandia.

departing from Finschhafen and Hollandia to forward bases at which there had been recent activity were also stocked with blood.

From the initiation of this service until it was discontinued in February 1945, U.S. bases in the Southwest Pacific received 2,310 liters of blood from Australia, 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 a blood bank at Hollandia, to support the Leyte operation, could not be carried out because this unit arrived in the area too late. The laboratory served as a blood bank, however, after the final Japanese surrender and the end of shipments of blood from the Zone of Interior in September 1945 (p. 629).

FIGURE l32.-Dispensary housing blood bank at 27th General Hospital, Hollandia, New Guinea, January 1945. Laboratory is in background. Donors are waiting to be called. White containers on ground behind dispensary were used for shipping refrigerated whole blood from the bank.

The bank at the 27th General Hospital (fig. 132) began to function on 9 September 1944, about 5 weeks before the landings on Leyte were scheduled (1). Instructions for its operation were given in the standing operating procedures prepared by Maj. (later Lt. Col.) Mark M. Bracken, MC, who was chief of the laboratory service, and in Technical Memorandum No. 13, Office of 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 in 4,000-cc. flasks, had proved technically unworkable. There were no facilities for creating a vacuum powerful enough to permit the collection of satisfactory amounts of blood from each donor into bottles of this size. The substitute plan, to collect individual donations in 600-cc. Transfusovac bottles containing sodium citrate, was more satisfactory from the standpoint of sterility as well as 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 was added before the flask was topped. The original plan of adding sodium sulfathiazole


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to the blood was discontinued as unnecessary; the Institute of Tropical Diseases at Sydney had shown that spirochetes and malarial parasites do not survive in blood stored under refrigeration for 5 days.

The dating period of the blood was set at 20 days. Plasma from blood not utilized by this time was to be used locally on burns and on certain types of wounds, though in Major Bracken's experience, plasma thus prepared could be safely used intravenously.

The following modes of transportation were authorized for shipment of blood:

1. By plane, packed in crushed ice in insulated boxes.

2. By boat, similarly packed until it could be placed under refrigeration aboard. The boxes were to be returned to the blood bank.

3. By boat, to which it would be delivered in Thermos jugs. After the blood had been placed in refrigerators aboard, the jugs would be returned to the bank.

4. By boat, in portable reefers (refrigerators), in which it would be delivered to its destination. Blood delivered in this manner kept for 5 days if the boxes were not exposed to direct sunlight.

The bank at Hollandia (map 4) at once began to function actively. During October, 697 liters of whole blood were distributed from it. It proved to be a convenient supply base both for New Guinea bases and for combat areas forward.

On 20 December 1944, a supplementary depot began to operate on Biak Island (Base H), and a bank was projected for Leyte (Base K), as soon as the 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, it was logical that when Capt. Lloyd R. Newhouser, MC, USN, was ordered to the Pacific in June 1944, similar orders should have been requested for Lt. Col. (later Col.) Douglas B. Kendrick, MC, his counterpart in the Army blood and plasma program. Captain Newhouser's orders placed no limit on his activities. Colonel Kendrick's orders directed him to accompany Captain Newhouser at all times.

Their combined survey, which began on 6 June and ended on 8 August, had the following objectives:

1. Investigation of the need for, and availability of, whole blood.

2. Investigation of available equipment and personnel for supplying whole blood and setting up blood banks.

3. Coordination by the Army and the Navy of plans and equipment for supplying whole blood.

4. Investigation of the availability and use of plasma and serum 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 and Captain Newhouser went from Washington to Honolulu, and then visited the following locations (map 5) (10):

1. Central Pacific Area: Pearl Harbor, Hawaiian Islands; Kwajalein and Eniwetok, Marshall Islands; Saipan, Mariana Islands; Johnston Island.

2. South Pacific Area: Espíritu Santo, New Hebrides; Nouméa, 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 Islands in the Admiralty Group; Cape Gloucester, New Britain; and Milne Bay, New Guinea.

The policy in all of these places was the same: to hold conferences with Army and Navy medical officers with an interest in plasma and transfusion; to visit Army and Navy hospitals, to get a cross section of their activities; and to determine the use of albumin and plasma and the use of, and need for, whole blood. In all areas, Captain Newhouser and Colonel Kendrick found a great need for a transfusion service, particularly in New Guinea, where the distances between the transfusion service in Australia and forward combat areas were becoming too long for efficient transportation of blood. There was agreement in all areas by Army surgeons and Fleet surgeons that there was an increasing need for whole blood, which, up to then, had been available only in limited quantities. Augmentation of the supply had never been possible, nor had it been possible to establish a blood bank, because of lack of trained personnel and equipment.

It was immediately evident to Captain Newhouser and Colonel Kendrick that, for a variety of reasons, it would not be practical to ship blood from Sydney to any area beyond Finschhafen, but they thought it best to delay recommendations for the location of a blood bank until their trip through New Guinea was completed.

Recommendations for Blood Supply in the Southwest Pacific Area

On 19 July 1944, at the request of General Denit (fig. 133) and with the concurrence of Captain Newhouser, Colonel Kendrick submitted to General Denit a plan for a blood transfusion service in the SWPA (Southwest Pacific Area) with special reference to advanced bases, as follows (11):3

1. With high priorities and responsible couriers, it was practical to transport blood from Sydney to Finschhafen. Beyond that 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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MAP 5.-Itinerary of official representatives of the Surgeons General of the Army and the Navy on blood and plasma during visit to Central, South, and Southwest Pacific Areas, June-August, 1944.


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FIGURE 133.-Brig. Gen. Guy B. Denit, Chief Surgeon, 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 an adequate service donor population (100 a day); and facilities already available in the area. General Denit had also pointed out another advantage, that an Army laboratory was shortly to be set up there.

b. That a blood bank to service both Army and Navy should be set up initially aboard LST 464 (landing ship, tank), which should remain in Humboldt Bay until the proposed Army laboratory came into operation in this area (11, 12). When the ship eventually moved to a more advanced area, it was anticipated that it could continue to supply Army needs as well as the needs of portable surgical hospital teams aboard all LST's in the area. If the necessary transfusion equipment could be provided (which it was understood the Army had immediately available), this ship had the space, facilities, and trained personnel to institute a transfusion service immediately. Specifications for personnel, refrigeration, equipment, and sources of donors were stated in detail.

At General Denit's request, on 1 July 1944, a requisition had been sent by radio to the Zone of Interior asking for the immediate shipment of 100 "apparatus, blood transfusion, indirect, field assemblies" to produce blood for operations scheduled for the immediate future. A requisition had 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 6 months. General Denit intended to request trained personnel for the bank.


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Earlier, a radio request had been made for transfusion equipment for New Caledonia.

There was complete Navy agreement with all of these plans. In all locations, in fact, Captain Newhouser and Colonel Kendrick had been greatly impressed by the way the two services worked together.

Recommendations for Blood Supply in the Central and South Pacific Areas

When Captain Newhouser and Colonel Kendrick reported to Headquarters, SPA (South Pacific Area), on 21 July 1944, they were informed by Capt. (later Rear Adm.) Frederick R. Hook, MC, USN, the Force Medical Officer, that hospital ships evacuating casualties from Saipan were in urgent need of additional blood. It was requested that sufficient equipment be made available to operate a blood bank at Bougainville or Pearl Harbor, where donors could be procured in adequate numbers and whence blood could be flown to the ports into which hospital ships could be ordered. After Captain Newhouser and Colonel Kendrick had returned from a trip to Saipan on the hospital ship Samaritan, which was 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 field transfusion assemblies for use aboard hospital ships or in a blood bank at Bougainville or any other location that might be decided upon for long storage of blood. Meantime, part of the transfusion equipment which the Army had on hand at Nouméa, 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 blood bank 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 could care for the emergency needs of the entire Pacific Ocean Areas. Pearl Harbor could provide an adequate donor population but was considered too far removed from the combat zone to supply blood for future operations west of the Marianas. Saipan or Guam, depending upon which had the larger military population, would be a better choice. Blood collected on either island could be transported to the combat 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 the use of LST 464, acting as hospital ship, as a blood bank for the invasion of Leyte, Lt. Ernest E. Muirhead, MC, USNR, had prepared blood on it and carried it ashore 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 empty intravenous 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 covered personnel, equipment, refrigeration, blood grouping, and donors. The closed system 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's solution. This technique would make it possible to preserve the blood under refrigeration at 43° to 46° F. (6° to 8° C.) for 18 to 21 days. Provision was also made for the use of individually packaged, expendable giving sets, ready for immediate use. Donor sets, consisting of 17-gage needles, latex rubber tubing, and stainless steel valves, would be cleaned and sterilized each time they were used. The tubing must be replaced after 10 to 15 bleedings. The valves could 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 be impossible to rule out malaria-positive donors by blood smears. Suppressive treatment with Atabrine (quinacrine hydrochloride), however, which was universal, would prevent the transfer of the infection to the recipient, since most infections were caused by trophozoites. Refrigeration of the blood would also have a lethal effect on the parasite.

These recommendations, including the appointment of Lieutenant Muirhead, were duly implemented on 23 July 1944, by orders from Headquarters, USASOS (U.S. Army, Services of Supply), SWPA. Steps were taken at once 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 blood frequently had difficulty in securing donors. Detachment personnel could not be reused as promptly as in the Zone of Interior because experience had shown that they did not regenerate hemoglobin as rapidly as in more temperate climates. It was always undesirable to bleed troops shortly before they went into battle, and much more undesirable, for the reason just stated, in the Tropics.

When the Sixth U.S. Army was staging in Hollandia for the invasion of Leyte, an attempt was made to maintain a list of 500 donors in the Office of the Base Surgeon, but the project was not successful, partly because of the continued calls for large quantities of blood and partly because of the rapid passage of prospective donors through the base. It was necessary to bleed listed donors promptly if they were to be useful. When necessary, as many as 150 donors could be bled in a day at the 27th General Hospital blood bank.


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FIGURE 134.-Transfusion of whole blood at Burauen, Leyte, October 1944.
Blood for this campaign was collected on LST 464.

The original plan of requiring two visits of donors (the first for confirmation of the blood group, the Kahn test, and the blood smear, and the second for bleeding if the first examination was satisfactory) proved completely impractical. A great many donors did not return because of transfers, leaves, and for other causes. When the plan was adopted of requiring only a single visit, it proved equally impractical to hold donors until the tests were completed. The routine was therefore adopted of bleeding the donors at once and discarding blood that was serologically positive or that otherwise did not meet specifications.

Calls for volunteers were made by notices in the daily bulletin, at headquarters, and by personal contacts by the officer in charge of the bank with various organizations from which donors might be secured. These were the only practical plans. The postal service was entirely unreliable, and the use of the telephone simply resulted in loss of time. Red Cross workers were very 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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FIGURE 135.-Response of donors to emergency call after air raid, 8th Medical Laboratory, Biak Island, Netherland East Indies, March 1945.

within the 32d Infantry Division, when it was staging at Hollandia, that each donor would receive 2 ounces of whisky and a good meal. The limited facilities of the bank at the 27th General Hospital were all that prevented mass participation. The donations proved well worthwhile: This division was the first to use whole blood on the battlefield, where its usefulness far exceeded the most optimistic hopes for it. It is only fair to add that there was always a prompt response to a real emergency (fig. 135).

The Malaria Problem

The malaria problem first assumed an areawide aspect in June 1944, when preparations for the operation of a transfusion service were first discussed. Upon inquiry, General Denit learned from the Surgeon, Base B (Oro Bay) that New Guinea hospitals were in the habit of using members of their own detachments as donors (13). Even though negative smears for malaria were obtained before bleeding, it was highly probable that a certain percentage of these donors had subclinical suppressive malaria, which would not be apparent on a single smear. Malaria had developed after transfusion in several casualties who had not previously had it and who had received blood from donors who had been in New Guinea for some time. In one instance, the chills and associated fever proved a serious complication of bleeding peptic ulcer. Since


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the problem was likely to increase as more troops remained in malarious 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. Although this blood was supposed to be used within 10 days, it was preserved in glucose and if it were properly refrigerated, the dating period could be extended to 15 days.

2. On the suggestion of 1st Lt. (later Maj.) Frederick B. Bang, MC, of the Malaria Research Group, an intramuscular injection of Atabrine might be given before transfusion. In an emergency, if blood had to be used from a possibly malarious donor, it might be wise to increase the dosage of Atabrine as recommended for patients about to undergo surgery (14).

No positive malaria smears were reported at the bank at the 27th General Hospital in its first 7 weeks of operation (and only one positive serology). One reason was that donors who appeared cachectic and those with a history of malaria, jaundice, or any serious illness within the previous year were not accepted. There were no reports of malaria (or jaundice) after any transfusion. It was realized, however, that since the bank was located in a malarious area, it would be impossible to exclude all malarious donors. It was also considered possible that, in a few instances, viable parasites had been transmitted in the blood and that the transmittal had been masked by the required daily use of Atabrine by all personnel in the area.

Other Tests

Up to the middle of 1945, the Rh factor was not considered of importance in the Pacific. In July 1945, 436 pints of Rh-negative blood were sent from the Zone of Interior in a total shipment of 4,465 pints of blood.

Up to this time, isohemagglutinins had also not been regarded as important. Crossmatching was performed when time permitted but was not considered essential, since the blood had been checked twice in the Zone of Interior. Had the war continued, it would have been necessary for patients who had had numerous transfusions to be crossmatched and have agglutination tests for minor agglutinins.

Errors in the entries on the identification tags averaged about 10 percent.

EQUIPMENT

The story of equipment for blood transfusion in the Pacific areas duplicated that in other theaters; that is, shortages and improvisations until expendable receiving and giving sets became available, the latter when the airlift of blood from the Zone of Interior began in November 1944. Just before that happened, the scarcity of expendable sets was so great that those on hand had to be apportioned among POA and SWPA, according to the intensity of the area need.

Early in the whole blood program in the Pacific, there were some complaints that it was difficult to pass stored blood through the metal-mesh filters


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in the giving sets. Up to this time, blood had been stored at 36° to 40° F. (2° to 4.5° C.). The difficulty was almost entirely overcome when 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 form at the higher temperature. One of the most important considerations of storage then 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 stated that the Medical Department in that area frequently had to construct its own hospitals and was therefore greatly in need of building tools (10). Without appropriate facilities, blood could not be used. He suggested that hammers, saws, and even sawmills should be issued to hospital units as part of their regular 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 of blood to the European theater, under the direction of Colonel Kendrick, it was logical for the Navy to set up and conduct the similar service to the Pacific areas, under the direction of Captain Newhouser. In a conference between Brig. Gen. Fred W. Rankin and Captain Newhouser on 13 October 1944, while Colonel Kendrick was on temporary duty in Europe, it was agreed that the Navy should establish and operate the processing laboratory in San Francisco and should furnish all the bottles, donor sets, and refrigerators for the program. The Army would furnish all the equipment necessary to operate the laboratory. The Surgeon General, Army, agreed to the coordinated program in the Pacific with the understanding that the allocation of blood to the two services would be based entirely upon their requirements. The Navy would fly the blood from the west coast to Guam, process it at the Navy blood laboratory there, and then deliver it to all areas in the Pacific as it was required.

The Army also furnished all personnel for the laboratory at the Los Angeles bleeding center (blood grouping, serologic testing) and for the packaging and shipment of blood to San Francisco. Requests for personnel for these purposes were made by General Rankin in October 1944, and again in February and March 1945, to the Personnel Division, Office of The Surgeon General. Trained technicians were not requested, since the enlisted men required could be trained by the staff of the Los Angeles and other centers supplying blood for the airlift.

American Red Cross Participation

On 26 October 1944, after the feasibility of an airlift of blood 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). Neither plasma nor serum albumin, it was pointed out, could compensate for the whole blood lost by severe hemorrhage. Up to this time, blood had been obtained in the Pacific from military personnel in combat areas. Since recent developments had shown the feasibility of transporting blood to oversea theaters, the Red Cross was being asked to furnish a minimum of 300 pints of O blood per day for the Pacific from donor centers in San Francisco, Oakland, and Los Angeles, with the understanding that activities might be expanded if larger amounts of blood proved necessary. It was requested that the service begin on or about 15 November 1944 and that the collections be in addition to the blood then being collected for existing programs.

Mr. O'Connor replied on 3 November 1944 that the American Red Cross would be glad to cooperate in the Pacific program and that steps were being taken to procure the blood, as requested, from the centers at San Francisco, Oakland, and Los Angeles(16).

The airlift to the Pacific began with the procurement of blood from the three centers specified (17). As the need for blood increased, the Portland, Oreg., collection center was added to the program on 30 January 1945 and the San Diego, Calif., center on 4 February. The Chicago center began to produce blood for the Pacific on 13 April.

When the need for whole blood ended in Europe with the German surrender on 8 May 1945, the centers on the east coast, which had been collecting whole blood as well as blood for plasma (New York, Philadelphia, Washington, Boston, and Brooklyn) were kept operational for procuring blood to be flown to Oakland. The capacity of these centers, added to that of the centers on the west coast, brought the blood available for shipment to the Pacific to 12,000 pints each week. As of 15 May, all blood collected in the eastern United States 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 consolidate the processing of all blood collected in Philadelphia, Boston, Washington, and New York in one large laboratory at the blood donor center in New York. The blood was collected in these cities, taken to New York by refrigerated motor truck, processed there, and then packed in Army expendable insulated boxes for the flight to the west coast. This plan proved both safe and practical. When Maj. Leslie H. Tisdall, MC, inspected the Navy laboratory at Oakland (fig. 136) after these arrangements had been effectuated, he found that shipments arriving from New York needed only a small amount of added ice before being flown to Guam.

Shipments were regulated according to requests from the naval officer in charge of the distribution center on Guam. They varied widely, from no 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 blood to Pacific from U.S. west coast.


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FIGURE 136.-Navy processing laboratory for blood for Pacific, Oakland, Calif. Note Church chest in left foreground.

of donations had to be kept at as constant a level as possible. Donations in excess of whole blood requirements were shipped to the laboratories processing plasma.

Initial Difficulties

The inauguration of the airlift of blood to the Pacific terminated, for all practical purposes, the difficulties of replacement therapy in 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 the depot for 6 March 1945, it had not been necessary to make a single major change in the original program and very few minor changes (18). The pilot run in September 1944 had gone very smoothly, but there were multiple initial difficulties, both in the Zone of Interior and overseas.

Zone of Interior-The first shipment of blood left San Francisco for Guam and Leyte (map 6) on schedule on 16 November 1944, in charge of Lt. (later Lt. Cdr.) Henry S. Blake, MC, USN. Brig. Gen. Charles C. Hillman and other Army and Navy personnel were extensively photographed as they assisted in placing the 10 boxes of blood (160 pints) on the plane. A naval medical officer, a naval public relations officer, and a photographer went on the flight, 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 November without complications.

Numerous complications, however, attended the departure of the first shipment and continued for several days afterward. They were described by Maj. (later Lt. Col.) Frederic N. Schwartz, MAC, who had gone to Los Angeles on 13 November, to establish the Army part of the program, substantially as follows (19):

The laboratory in which the blood was to be processed was not yet ready. All the necessary laboratory supplies had not arrived, including the indispensable centrifuge. Arrangements had not yet been made for air shipments to San Francisco. On the Navy side, there were also shortages, including insulated boxes, and, for a few days, the Oakland laboratory could handle only 40 bloods daily instead of the specified 100 bloods.

The Army was able to meet the original schedules by loans and improvisations. A centrifuge was flown in from Fitzsimons General Hospital, Denver, Colo. Major Schwartz arranged with Hyland Laboratories for the blood to be processed there until the Los Angeles center was ready. This was not a particularly efficient arrangement, for it meant that the blood had to be taken by the Red Cross Motor Corps from the collecting center, where it should have been processed, to Hyland Laboratories for typing and serologic testing. It was fortunate, however, that the arrangement could be made. The blood was taken to San Francisco by the Railway Express Agency, in Church containers.

By 1 December 1944, most of these difficulties had been ironed out and daily shipments to the Pacific amounted to 250 pints, of which 100 were supplied by the Army.

Overseas.-In correspondence with Col. (later Brig. Gen.) George R. Callender, MC (20), and Major Schwartz (21) in December 1944, Colonel Kendrick4 stated that planning in the United States for the Pacific airlift had been exceptionally well done but the excellence had been confined to the United States:

1. No command in either the Central or the Southwest Pacific had been advised officially of the whole blood program by either Army or Navy sources. Colonel Kendrick made every effort to assure the surgeons in the various Pacific commands that this was an official program, coordinated by the Army and the Navy, but lack of written authorization sometimes made it difficult to secure cooperation.5 He was told at one installation, where con-

4Colonel Kendrick, still serving as Special 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 was Surgeon. Colonel Kendrick went to Guam and Leyte almost immediately and did not return to Hawaii until January 1945, after stopping en route for several days of conferences on the blood program with Lieutenant Brown on Guam. By this time, the overall blood program was functioning smoothly in the Zone of Interior, the European theater, and the Pacific; and Colonel Kendrick was relieved of his responsibilities for the program in the Office of The Surgeon General, where he was replaced by Maj. John J. McGraw, Jr., MC (p. 402). Colonel Kendrick was also relieved of his responsibility in the Pacific, where no other consultant was appointed during the remainder of the war.
At this time (January 1945), Colonel Kendrick was placed in command of the 10th Field Hospital, which was designated to land on Okinawa on D+60, but on 14 March, 5 days before the Tenth U.S. Army sailed for that target, the Army Surgeon, Col. Frederic B. Westerfelt, MC, recognizing the peculiar requirements of the management of shock and the handling and use of blood, assigned him to his headquarters as consultant in these special fields. Colonel Kendrick went ashore with the Tenth U.S. Army on Okinawa in early April and served as Consultant in Resuscitation, Whole Blood, and Shock for the next month. He then took command of the 31st Field Hospital.
5This was an unfortunate contretemps. Letters had been written by the Surgeon General, Navy, advising all commanders in the Pacific that blood would be shipped from the United States. The letters were to go airmail, but through some error, they were sent by regular mail. The commanders therefore did not receive them until 2 to 4 weeks after the blood program had been set up in the Pacific.


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fusion was rampant, that it was not necessary for a War Department representative to come out and tell them how to run their transfusion service. In an advanced area of the Sixth U.S. Army, his activities were restricted, and he was prohibited from interfering with present policies on the ground that the officers in charge of the program were competent to handle it. By surreptitious methods, Colonel Kendrick provided the surgical consultant, Sixth U.S. Army, with enough information for him to prepare a circular letter on the new service.

2. The blood bank in Honolulu resented being left out of the program, even though its inclusion would have greatly complicated the transportation of blood. The additional supply, in fact, would not have been worth the trouble necessary to secure it.

3. General Denit had not been notified of the program nor had any Army surgeon. Not having received any word on it from the Office of The Surgeon General, Army, they concluded, quite logically, that the program was a Navy responsibility and had sent no information about it to forward hospitals.

4. The arrival of the first shipment of blood in the Southwest Pacific in November 1944 had been reported 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 the odd position of selling a Navy program to the Navy.

5. Because of the lack of official notice of the blood program, it was "existing parasitically," by leaning heavily on personnel and equipment from medical supply companies and other organizations, which could ill afford to spare either. It was Colonel Kendrick's opinion that if the program had concerned anything but blood, it could not have operated.

6. Since no blood distribution teams had been set up, the blood was frequently not being handled properly. Sent through ordinary supply channels, it was taking unnecessarily long in delivery. It was sometimes kept without refrigeration, and not even in insulated boxes. It was sometimes distributed without expendable giving sets. Eventually, during the Leyte campaign, Colonel Kendrick was able to have a distribution team set up in the Philippines and to arrange for transportation, a supply of ice, and other essentials.

7. It was regrettable that, because of some confusion in his orders, which kept him in the Central Pacific for 10 days, his planned meeting with Lieutenant Blake did not occur. The exchange of experiences would have been of great value.

In spite of these difficulties, cooperation had been excellent on the part of all concerned. The Naval Air Transport Service and the Transport Air Group, without written authority, gave Colonel Kendrick a No. 1 priority for blood, and asked no questions about it. Since proof existed that the blood service could be operated with sacrifices on the part of other medical units, he saw no reason why, in view of its importance, it should be hamstrung by lack of its own adequately trained personnel, equipment, and transportation. Responsibility to the services and to the donors of the blood warranted the utilization of the best trained personnel and the most efficient equipment possible. If a commodity such as blood were lost, as the result of incompetence on 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 the following recommendations (20, 21):

1. A circular letter or directive should be issued by the Army and the Navy, together or separately, authenticating the existence of the transfusion service.

2. The transfusion teams recommended by the Office of The Surgeon General in the T/O & E (Table of Organization and Equipment) sent to Army Service Forces on 15 December 1944 should be immediately approved 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 to USASOS, POA.

4. The transfusion service for the entire area should be placed under a single control officer with a combined staff of Army and Navy personnel. The present confusion caused by five or six different officers' being responsible for blood in different installations could no longer be tolerated.

In one way or another, all of these recommendations except No. 4 were implemented by the end of January 1945.

Personnel

When the service to the Pacific was once firmly established, the blood was consistently handled by specialized personnel, by what amounted to a special delivery service, which is the only efficient way to handle such a valuable commodity and, more important, the only safe way. At no stage along the way, from the collecting center in the Zone of Interior to the administration of the blood at the terminal point in the Pacific, was it touched by any but trained, specialized personnel, on permanent assignment. The blood service in the Pacific had its roots in the experiences gained in the Mediterranean and European theaters, as well as in the Zone of Interior.

The initial handling of some of the first blood shipped from Guam to Leyte furnished an excellent example of what could happen to this scarce commodity 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 Interior to Leyte. When they reached Leyte, the bottles of blood were taken out of the insulated containers in which they had traveled up to that time, thrown into the backs of trucks, and transported for 4-5 hours over rough roads to the medical installations 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 have mud on one's shoes and dust in one's eyes at the same time. These shipments were entirely unusable, and if this sort of handling had not been promptly corrected, the whole carefully worked out program would have been in a fair way to 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 of refrigeration and of other precautions in the handling of blood. The practice was therefore instituted of sending a courier with the blood when the first shipments went to areas new to the program.

Transfusion teams-On his return from his first trip to the Pacific, in August 1944, Colonel Kendrick recommended to The Surgeon General that a transfusion team be stationed at Saipan to handle blood drawn in the Zone of Interior, as well as to bleed donors if it became necessary to supplement the supply from this source. A second team should be stationed at some other strategic point, to be selected later, to function in the same fashion.


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The proposal was accepted, and cadres for the teams were trained at the Army Medical Center and then placed on temporary duty at the Red Cross blood donor centers while they waited assignment to the Pacific. On 17 January 1945, arrangements were made with the Personnel Division, Office of The Surgeon General, to send them to Fort Lewis, Wash., to move them on higher priority 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. Noland Carter, MC, that such a low priority had been requested for these transfusion teams 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 teams on a theater troop basis had not been acted on by the POA, and it was therefore impossible to activate these units. Their training period had been extended by 30 days, in the hope of straightening out the difficulties. If arrangements for the dispatch of the teams could not be concluded within this period, there would be nothing to do but scrap them. If General Willis agreed that time was a factor, the theater could request that the officers and men who had been trained could be shipped as casuals, to act as cadres for newly formed units to be activated locally, but this, again, would require nomination of spaces on a theater troop basis.

These teams did not reach the Pacific during the war. When, however, the 317th General Hospital reached the POA, General Willis withdrew the blood transfusion personnel and sent them to the Marianas to form two transfusion teams, one for the Marianas and the other for Okinawa, because be did 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 pilot program, neither distances nor temperatures in that theater presented the handicaps that accompanied the airlift of blood to the Pacific areas (22). The distance from the mainland and the high temperatures in combat areas introduced three operational problems of extreme importance into the Pacific program: (1) transportation; (2) refrigeration; and (3) preservative solutions. All three factors were closely related. A break in any one of them would have made the whole program useless, and, if it had been persisted in, extremely dangerous.

Transportation-Some 7,400 miles of travel were involved in flying blood from the laboratory at Oakland, Calif., to Leyte in the Philippines (map 6). The actual flying time was about 48 hours, but with stopovers at various points and rechecking at the advanced base on Guam, most blood was 4-5 days old when it reached Leyte.

The itinerary involved moving blood from the bleeding centers at 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 Pearl Harbor, 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 upon circumstances, during which time the blood was re-iced by the Naval Air Transport Service, whose personnel had received special training in its care. The blood was flown from Pearl Harbor to Guam, with brief stopovers at Johnston Island and Kwajalein in the Marshall Islands.

The facility at Guam (figs. 137 and 138) received all shipments of blood from the Zone of Interior. The bloods were placed in the refrigerators there within 15 to 20 minutes after the plane had touched down and were allowed to settle for at least 12 hours, to compensate for the agitation induced by transit and movement. After the bottles had been inspected for hemolysis, clots, and possible contamination, they were placed in the re-iced insulated boxes in which they had traveled from the Zone of Interior, and were shipped by planes of the Transport Air Group, according to requirements and requisitions, to:

1. Ulithi, 2½ hours' transport distance from Guam. The planes landed at Falalop Island, where the shipments were immediately transferred to designated fleet units. The liaison at this base with fleet personnel was excellent, and for this reason, and because a senior medical officer was in charge of shipments, the blood was usually in reefers afloat within 6 to 10 hours after it had left Guam. Two inspections of this base by Lieutenant Brown showed that all concerned with the handling of blood fully appreciated the requirements and the possible dangers of the program.

2. Peleliu, 5 hours' transport distance from Guam. Shipments were made by Transport Air Group planes to U.S. Naval Base Hospital 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 to the Philippine Islands. Col. Eliot G. Colby, MC, Surgeon, Headquarters, Island Command, arranged for Lieutenant Brown to visit all hospitals on the island and to make contact with Navy personnel in order to explain the blood program to them. Also, the better to acquaint Army supply personnel on Saipan with the problems of the transportation of whole blood, Colonel Colby sent a technical sergeant to the base bank on Guam for instruction in the processing of blood for shipment to island bases and fleet units and for its care while it was in storage.

5. The Philippine Islands. From Saipan, blood was carried by Army Transport Command planes to Tacloban Airfield, Leyte, where a medical supply depot received the shipments and saw to their refrigeration and re-icing before distribution. Re-icing was essential, for a trip of 30 to 50 miles to forward area hospitals might require as much as 24 hours because of the rough, difficult terrain to be traversed.

Smaller amounts of blood were shipped to various islands as necessary and were cared for by Navy personnel who understood the requirements for refrigeration and storage.

Whole blood had a routine No. 2 priority in Army shipments and could employ a No. 1 priority when necessary. All shipments by Navy agents were 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 similar directive memorandum be issued to Army units, to give official recognition to the program of procurement and distribution of whole blood and in keeping with the combined Army-Navy function of the program (23). This suggestion was duly implemented.


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FIGURE 137.-Blood distribution center, Guam. A. Facilities on airstrip. B. Shipping cases of blood being
loaded aboard C-54 for distribution to Pacific islands. C. Shipping cases received from mainland being brought to distribution center on Guam. D. Receiving platform. E. Shipping cases on platform.

While it might have been better if whole blood had been given a universal No. 1 priority, no criticism of its handling by transport agencies would be warranted. The cooperation of the Army and the Navy Air Forces was always superb, in all areas. They flew blood to combat units in medium bombers before transport planes could land on airstrips. In emergencies, they set up special flights to transport blood. There was not an instance in which blood was needed that it did not leave on the first aircraft available.

Refrigeration-In spite of the handicap of high environmental temperatures, transportation of blood to, and in, the Pacific was far more a matter of training personnel to observe the proper precautions than of 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 a real


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FIGURE 137.-Continued. F. Blood being transferred from shipping cases to walk-in reefer. G. Check of blood in refrigerator. H. Demonstration of equipment for blood distribution. I and J. Processing laboratory on Guam.

disadvantage in an area in which shipping space by land and air was always limited.

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, was expendable.

This chest, which had a hinged cover, measured 21 by 21 by 23 inches. It was made of ⅜-inch plywood and was completely lined with 3 inches of Fiberglas. A cardboard box that fitted into the outside box held two metal receptacles, one on top of the other, each 7 inches high and 13⅓ inches in


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FIGURE 138.-Movement of blood at distributing center on Guam. Lt. Herbert R. Brown, MC, USNR, second from left.

diameter, and each fitted with individual metal racks for eight bottles of blood. In the center of the receptacles was a galvanized iron canister 5½ inches in diameter and 14 inches high, with a detachable cover. It held 15 pounds of ice. There was thus no direct contact between ice and bottles of blood. The box occupied 5.9 cu. ft. of shipping space and, when it was packed with ice and blood, weighed 87 pounds. Testing had been rigorous, but no damage had been sustained by box or contents, even in parachute drops (fig. 141).

Bottles containing ACD (acid-citrate-dextrose) preservative solution were taken directly from the refrigerator to the donor's side. As soon as they were filled, they were placed in a refrigerator cooled to 40° to 45° F. (4.5° to 7° C.) and left there for about 8 hours before they were packed 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 coast was re-iced at Pearl Harbor, a half to three-quarters of the ice placed in the box at Oakland was usually still present in the central compartment, and the inside temperature averaged 44° F. (6.5° C.). Lieutenant Blake's observations on a test shipment showed that temperatures within the chest were maintained at 45.5° to 48° F. (7.5° to 9° C.). Boxes not re-iced at Pearl Harbor but flown straight from Oakland to Guam had inside temperatures no higher than 50° F. (10° C.).

When blood was shipped out from Guam, it was replaced in the expendable Navy boxes in which it had been received. The central ice containers were packed with as much ice as possible, and forward installations, without refrigerating facilities, were instructed to re-ice the boxes every 24 hours; the importance of this precaution was emphasized to all units which received blood.


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FIGURE l39.-Icing center containers of Navy shipping cases on Guam.

Under combat conditions, refrigerators were frequently not available, but daily re-icing of the expendable boxes proved an entirely satisfactory substitute.

In December 1944, requests were put in-and were filled-for the 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 be greatly increased to meet peak loads of combat casualties and that thousands of pints of blood might sometimes have to be handled daily (18).

The standard field refrigerator was used for land transportation of blood.

Preservative solutions-The glucose preservative solutions employed by the Australian blood bank (p. 581) and by the Army bank at Hollandia limited the usable life of blood to 15 days, though permitting its use up to 20 days if refrigeration had been adequate at all times and if marked hemolysis had not occurred (23).

Alsever's solution, as noted elsewhere, was used for the European airlift as a matter of expediency, but its bulk made it undesirable clinically and highly undesirable for an airlift extending over many thousands of miles. The trial runs for the Pacific airlift, begun in September 1944, were made with ACD solution. Their complete success indicated that it would be entirely feasible to ship refrigerated whole blood to the Pacific in this medium. Colonel Kendrick reported on it as follows from his observations in December 1944 (20):


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FIGURE 140.-Loading refrigerated Navy shipping containers with blood on Guam.

The ACD solution has stood all field tests in good order. As you know, I viewed the use of this solution with a critical eye because of the lack of clinical experimental work. Hemolysis has been minimal even with severe handling, heat, changes of temperature and terrible roads sometimes requiring 12 hours for delivery to a hospital. With proper refrigeration, ACD protects blood exceedingly well. A well recorded series of transfusions (700) showed a reaction rate of 1.7 percent, none severe, mostly urticarial. We have used a good many bottles after the expiration date, up to 30 days, 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 have extended the expiration date to 24 days.

Colonel Kendrick also observed that a number of reactions could be traced to the use of locally prepared sets and did not seem related to the 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 defer examination


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FIGURE 141.-Lt. Herbert R. Brown, Jr., MC, USNR, holding blood dropped in test parachute drop on Guam.
The insulated box in which the blood was dropped was used by the Navy during the airlift to the
Pacific and later during the Korean War.

of the bottles for hemolysis, clots, and other abnormalities until 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. The practice of delaying examination for 12 hours or more after the arrival of the blood immediately became routine.

It was soon evident, however, that bottles of blood that would show hemolysis at all would show it on their arrival on Guam, where they could be detected on screening and could be removed from further shipment. It was not desirable to handle blood any more than necessary, but the World War II experience showed that the red cells, for the most part, tolerated transportation without hemolysis. None appeared even when a full box, containing 16 pints of blood, was dropped by parachute from a height of 800 feet. Another experience was even more significant: Because of the sudden cancellation of a flight while the base bank facility was still located at U.S. Naval Base Hospital 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, had to be returned to the reefers. When it was checked 12 hours later, before reshipment, none of the bottles showed any hemolysis and all were considered safe for shipment to Leyte.

The dating period in the Pacific for blood preserved in ACD solution was 21 days after it had been drawn. On numerous occasions, in extreme emergencies, it was used as late as 30 days. Much of it was in excellent condition at this time, and if the war had continued, there seems little doubt that the dating period would have been extended to 28 days, at least for blood that 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 blood bank facility on Guam, Lieutenant Brown, arrived at his post on 17 November 1944. His assistant, Ens. (later Lt. jg) George E. Nicholson, HC, USN, arrived on 21 November 1944 (18, 22, 24).

The day after Lieutenant Brown arrived, the blood bank was set up temporarily at U.S. Naval Base Hospital No. 18, where a 675-cu. ft. refrigerator and an icemaking machine were available. As a temporary arrangement, no fault could be found with this location, but it was evident from the arrival of the first shipment of blood from the Zone of Interior, which Lieutenant 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 later leave by air over several different military transport systems. The hospital was about 17 miles from Agana Airfield, and transportation would not only be inconvenient 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 necessary refrigeration was not available. On this date, a 65-cu. ft. refrigerator was secured on loan, and the bank was temporarily located in a large airfreight terminal. 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 high humidity, and, as a result, the unit had to be defrosted with inconvenient frequency.

When the blood bank finally moved to its permanent facilities at Agana Airfield, the wisdom of the move was immediately apparent. The base communications center was nearby, as were the operational offices of the Military Transport Services. As a result, blood could be delivered with great rapidity. On one occasion, when Lieutenant Brown was on Saipan, visiting the various units afloat and surveying their needs, he sent an operational priority dispatch to Guam for 1,200 pints of blood, with the request that it arrive before dark, as the ships that needed it were sailing that night. The blood depot at Guam received the message through the Port Surgeon's Office at 1300 hours. Planes


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with blood aboard left at 1400 and 1500 hours. When the blood arrived at Saipan, at 1600 hours, it was loaded onto an Army reefer truck, 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 at midnight.

As experience increased, the location of the blood bank became even more important. In March 1945, when the possible need for another blood depot came under discussion, Lieutenant Brown stated that, while the location of such a center would depend upon the tactical situation, it could not be emphasized too strongly that the operational efficiency of a blood distribution center depended upon its immediate connection with a large airbase, where emergency requests could be handled immediately. Hospital connections were not necessary.

Notification of Needs

The blood depot on Guam supplied the urgent needs of the latter part of the campaign on Leyte to the limit of transportation and storage facilities. It also supplied other units of the Army and the Navy ashore and afloat within a radius of 1,100 miles. Hospitals in the Marianas depended entirely on Guam for their large demands for blood. A moderate backlog of blood was maintained in all these hospitals, and cooperation concerning notification of needs was excellent.

All hospitals were informed that a notification of at least 10 days was required for any increase in operational demands, and a notification of 4 to 5 days for emergency requests. Requests for blood were made from Guam to the 12th Naval District in San Francisco, whence they were cleared to the blood donor service. It took about 7 days for donor centers on the mainland to step up their collections to meet increased demands in the Pacific. It was therefore necessary for hospital installations to anticipate their needs and notify the distribution center on Guam, through channels, well in advance of the time the blood would be needed. All requests were on the basis of 1 pint of blood per casualty.

The amount of blood handled through Guam greatly increased as operations were extended to Luzon, and then to Iwo Jima and Okinawa. Between 19 November and 24 December 1944, 6,480 pints of whole blood were received and 5,040 pints were distributed. In February 1945, 16,608 pints were received and 16,563 distributed. On several days during the month, 1,000 pints daily were handled, particularly during the final staging for the Iwo Jima operation. In April, 25,760 pints were received and 30,177 pints, including the excess from March, were distributed (24). Early in the month, it was necessary to distribute the accumulated blood and reduce the supply from the Zone of Interior. Later in the month, the requests to the Zone of Interior had to be increased because of increased demands from the Philippines and a considerable increase in the Okinawa requirements.


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LEYTE

Planning

It was expected that, as the fighting in the SWPA increased in intensity and advanced from New Guinea to the Philippine group, the Japanese would begin to use field artillery of higher caliber, with greater frequency, and that bombing from the air would be heavier and more constant. Since wounds produced by shell and bomb fragments cause shock, hemorrhage, and extensive tissue destruction, ample amounts of both plasma and blood would be necessary. Supplies of plasma furnished no problem; they were always ample, and they were used intelligently.

The Leyte operation was the first in which combined Army and Navy blood banks were used and in which blood was supplied in the first stages of the operation. In general, the plan employed was that recommended to General Denit by Colonel Kendrick, with Captain Newhouser's concurrence, on 19 July 1944 (p. 591). It involved (map 4):

1. The transportation of blood from Sydney to Finschhafen.
2. The establishment of a blood bank at Hollandia.
3. The establishment of a blood bank aboard LST 464 which had been converted into a hospital ship.

The recommended blood bank was set up aboard LST 464, with Lieutenant Muirhead in charge. Its supplies were supplemented by the 27th General Hospital, which began to function as a blood bank on 9 September 1944. By 9 October 1944, plans for the initial supply of whole blood for the Leyte invasion and its maintenance had been agreed upon by representatives of the Sixth U.S. Army (fig. 142), the Medical Supply Section, USASOS, and the Seventh U.S. Fleet.

The blood supply was planned and reported in ETMD (Essential Technical Medical Data) as follows (25):

1. The task force would take 200 liters of blood ashore with it, for use on the beaches. Between D+5 and D+7, 400 additional units of blood would be shipped from Base G (Hollandia) on the 10 returning LST's, for delivery by the Sixth U.S. Army medical supply depot on shore to Sixth U.S. Army medical units.

2. Thereafter, blood would be shipped automatically by the Base G medical supply depot on LST's at the rate of approximately 200 units every 5 days until D+20. These amounts would be varied only on radio instructions from the Sixth U.S. Army to the medical supply depot on Base G. On such instructions, the blood would be flown to Leyte via Biak, where 100 liters was kept as a pool. The first blood for the pool would be brought by an LST which would leave Base G on D+6.

3. LST 464, converted to a hospital ship, would arrive on the beach on D+4, with 100 liters of blood. This ship was equipped to collect and process blood, and it was expected that enough donors could be secured from troops on the beach to provide ample amounts for LST 464 and other LST's caring for casualties. These LST's were located in the harbor at intervals of 1,000 to 2,000 yards apart.

4. LST's arriving in the harbor on D+2 and D+21 would each bring 100 liters of blood.


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FIGURE 142.-Col. (later Brig. Gen.) William A. Hagins, MC, Surgeon, Sixth U.S. Army.

Implementation of Planning

In general, the plans just described were implemented in the Leyte 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 shock without hemorrhage was indisputable, but it was proved again that it was a supplement to, and in no sense a substitute for, whole blood in hemorrhage and that its use might, indeed, give rise to a false sense of security.

On D-day, two 200-cu. ft. mobile reefers, each containing a thousand 500-cc. units of blood, were put ashore on the beaches in which combat activity was greatest. The blood was well used, but it was evident in retrospect that even greater quantities should have been supplied. Multiple transfusions, for instance, often could not be given. Moreover, since whole blood had not been available in previous combat except as it was obtained by on-the-spot donations, some organizations apparently remained ignorant of its ready availability in this operation. Steps were taken to avoid this error in future operations.

Casualties brought to LST 464 received excellent shock treatment and preoperative preparation. Blood was taken from each patient for hemoglobin,


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hematocrit, and protein estimations, and replacement therapy was based on the findings. This was the first time the combined facilities of Army-Navy blood banks were used in the initial stages of an operation, and cooperation was excellent.

LST 464, in addition to treating casualties, drew blood and acted as a blood bank for the 7th Amphibious Force. The great advantage in the use of this particular LST was that she acted primarily as a hospital ship, not primarily as a cargo ship and only secondarily as a hospital ship, after the cargo was unloaded. She was therefore able to remain on station in the harbor and was available for medical service at all times.

LST 464 also received blood from the depot at Biak via the LST's returning to Leyte after taking casualties to Biak. Each convoy scheduled for Leyte, as already noted, received additional stores of blood to take back.

The landing at Leyte presented a problem in the care of casualties not encountered in any previous operation; namely, the bombing attacks on all ships in the harbor, including hospital ships, by Japanese suicide planes. Large numbers of casualties continued to occur in the harbor for 38 days and provided the strongest possible indications for the liberal use of whole blood. They had to be treated aboard ship. It proved impractical and inefficient to take them ashore for treatment because of poor communications, difficulties in beaching, inadequate facilities, poor roads, and lack of transport. The risk of keeping hospital ships on station in the harbor was too great, in view of the indiscriminate bombing, and the problem would have been insoluble 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 used during the first 30 days of the Leyte campaign, including blood from the 27th General Hospital bank at Hollandia, from the relay depot at Biak, and from LST 464. Arrangements had been made to have additional supplies of blood flown from the Australian blood bank at Sydney if it should be necessary to supplement the blood provided for at the beginning of any large operation.

Up to 22 November 1944, all of the blood used in the Leyte operation 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, the Navy, and the American Red Cross, arrived on Leyte with 80 pints of whole group O blood which had been flown from San Francisco via Guam. This was the first blood to arrive from America and it represented a turning point in the transfusion service in the Pacific. With greatly increased supplies available, greatly increased use of blood was possible, and plasma assumed its proper role in replacement therapy as a supplement to whole blood, not as a substitute for it.

Between 19 November and 24 December 1944, 4,256 of the 6,480 units of whole blood received on Guam went to Leyte (22).


619

FIGURE 143.-Lt. Col. Frank Glenn, MC, Consultant in Surgery, Sixth U.S. Army.

LUZON

Planning

The Leyte operation, as already indicated, was the first combined Army-Navy whole blood project, and in retrospect, for a number of reasons, it seems that it could probably have been handled more efficiently. The operation on Luzon was handled better, for two chief reasons:

1. Information concerning the blood supply was well disseminated. Through the efficient cooperation of Maj. (later Lt. Col.) Frank Glenn, MC, Consultant in Surgery, Sixth U.S. Army (fig. 143), Colonel Kendrick was 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 of blood. At this meeting, he was able to demonstrate to these officers that they could have all the blood they needed from the Zone of Interior and that it would be 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, with totally inadequate resources, had done remarkably good work in supplying the Sixth U.S. Army with blood. When he came into the Zone of Interior program, most operational 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 the delivery


620

of blood from Guam according to estimated needs from D-day onward, as follows (26):

1. A responsible officer, either MC or MAC, would be designated in the Sixth U.S. Army to be in charge of the blood bank. He would be adequately assisted by enlisted men and would have the sole responsibility for the operation of the blood bank.

2. Equipment would consist of four 220-cu. ft. reefers with a capacity of 1,600 to 2,000 bottles of blood; one vehicle to take blood from the beach 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 of blood would be requisitioned daily from the States. The four reefers to be used could accommodate 700 to 800 pints each, but for the M-1 (Luzon) operation, only 400 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. On shore, one reefer would be placed behind each division, but as soon as the tactical situation permitted, all four would be brought together, to serve as a central distribution facility. The officer in charge would be responsible for stocking the reefers at the mounting point of the invasion with blood sufficiently 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 the quantity requested for the Navy. The needs of both services for the first 4 days of 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 27th General Hospital in Hollandia and the 9th General Hospital, which then would be serving 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 be supplied from Leyte to the target by LST's or other ships leaving Leyte for Luzon. Blood would be flown in as soon as an airstrip was secured. The blood bank officer would be responsible for developing the line of supply and receiving the blood upon its arrival at the target.

6. If reefer space was limited, the racks containing the blood could be stored without the insulated boxes. The boxes, which contained the giving sets, must be taken aboard the LST's, and the blood must be replaced in them before landing, to keep it cool during its distribution.

A supply of ice to refrigerate the insulated boxes might not be available early in the assault. If this happened, the blood must be delivered directly from the reefer to the using hospital. The ice machine, with a capacity of 800 to 1,000 pounds per day, must be placed ashore and made available to the distribution team at the earliest practical time.

7. On 23 December 1944, the Navy estimated its requirements as 1,200 pints of blood at the mounting area on 3 January 1945; 700 pints on 4 January 1945; and 500 pints on 6, 9, 14, and 20 January. The LST 464 would bring in 1,200 pints for use on D-day and D+1, and would serve as a distribution point for other ships receiving casualties or acting as transports for casualties.

This plan did not include the whole blood supply to convoys departing from Hollandia, Aitape, Noemfoor, and Sansapor, nor did it include the resupply of blood for hospital ships bringing casualties to New Guinea bases. All blood for these purposes would be supplied by the blood bank at Hollandia and the depot at Biak. If the ships departed from Hollandia, the blood would be placed aboard them there. Blood would be flown from Hollandia to Aitape and to Noemfoor for the convoys departing from those points. Blood for


621

convoys leaving Sansapor would be flown from the depot at Biak. Convoys which left Leyte would carry blood from the Zone of Interior.

Implementation of Planning

The scope of the amphibious landings on Luzon was so vast that it was impossible to set up a central distribution point, and the arrangements just outlined had to be substituted. The blood was placed aboard ship just before the convoys departed. All clearing companies, portable surgical hospitals, field hospitals, evacuation hospitals, hospital ships, and cargo LST's with medical officers aboard had fresh refrigerated whole blood with them when they left for the target.

At the beginning of the Luzon operation, equalization of supply and demand furnished something of a problem, which disappeared when better liaison was established between the mainland and forward areas (27). By the end of January, blood was being received at Leyte that still had 17 days of life. It was therefore possible to forward the blood by ship and have it received on Luzon with several days of life still left in it.

The first blood was flown into Luzon from Leyte 12 days after the invasion, by medium bombers, before transport planes could land (18). The Luzon experience suggested that in future operations it might be wise to plan that ships and LST blood banks supply forces ashore for about 14 days; after that time, air transportation could be relied on.

When the system was finally established smoothly, it was considered ideal (28). Blood shipped from Guam on requisition went to Tacloban, on Leyte, where Captain Thorpe screened each shipment before it was placed 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 a stationary refrigerator, provided by the Quartermaster Refrigerator Co., whose 4,300-cu. ft. capacity assured a minimum temperature change when the door was opened. 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 could operate while repairs were being made.

Before the blood was placed in the refrigerator, each box was opened, 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. The blood was refrigerated with the lid of the box propped open, to allow the temperatures inside and outside to equalize and thus to insure a stable temperature while the icebox doors were opened and closed. Each box was re-iced before issue.

Supply was controlled by radiogram to the Island Command, Guam. The bank at Leyte operated on a 24-hour basis for distribution, and arrangements were made with the signal center that all messages concerning blood were reported immediately, by phone, to the bank. Shipments could thus be moved at once. Radio notification of the arrival of the blood, and the use of couriers whenever there might be any delay en route or at the receiving end, insured


622

the arrival of the blood in good condition because refrigeration had been maintained and the boxes re-iced as necessary during transportation.

When necessary, emergency items were requested by radio or telephone and were dropped over the frontlines, often within a matter of minutes, from artillery liaison planes. Recovery was almost 100 percent satisfactory, and even such delicate items as plasma and blood were received in good condition (29).

Plasma was in ample supply and well used (figs. 127-131). The first direct issue of blood in the Manila area was by the 15th Medical Supply Platoon (Aviation) on 11 March 1945. The initial supplies were obtained from Leyte via Base M (San Fernando, La Union). Later shipments were made directly from Leyte to the Nielson Airfield in Manila.

The average daily issue during March to units in the area was 125 pints (30). During April, the daily issue ranged from 160 to 175 pints, and, for the next 3 months, it averaged 175 pints. When casualties began to drop as heavy fighting on Luzon ceased, any blood not utilized before the expiration date was transferred to the Philippine Island Civil Affairs Unit, for use in civilian hospitals. All blood supplied during this period originated in the Zone of Interior.

IWO JIMA

The Iwo Jima operation, which lasted from 19 February to 16 March 1945, was a Navy-Marine operation (18, 31).

OKINAWA

Planning

When Colonel Kendrick was appointed Consultant in Blood and Shock to Col. Frederic B. Westerfelt, MC, Surgeon, Tenth U.S. Army, on 14 March 1945, 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 see that the ships that went to Okinawa from Saipan were loaded with all the blood likely to be needed for the first stage of this operation, which was an Army-Marine responsibility.

The plan for supplying blood for the Okinawa operation, which was incorporated in the III Amphibious Corps Administrative Plan No. 1-45, Annex Easy, was in essence as follows:

1. The Distribution Center at Guam would stock AH's (hospital ships) with suitable quantities of whole blood and would also stock LST 929, which had been designated for medical use by the Commander, Joint Expeditionary Forces.

2. APH's (transports for wounded) and APA's (transports, attack) were scheduled to arrive at the target within the usable limits of the blood carried on the other ships.

3. At the target, LST 929 and AH's would act as 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 also supply blood for the medical units ashore.


623

4. As soon as practical, a temporary whole blood distribution center would be established ashore and would take over the distributing functions of LST 929 and AH's which had been used for this purpose.

5. The distributing center on Guam would supply the distributing center ashore with adequate quantities of blood by air or by fast surface transportation. When hospitals were established, they would receive their blood by air.

6. Personnel, refrigerators, flake ice machines, and other equipment would be supplied to the temporary distribution center and LST 929 by ComServPac (Commander, Service Force, Pacific). Personnel and equipment would be taken ashore in assault shipping as soon as the landing force commander could arrange their transportation.

Implementation of Planning

The plans worked out perfectly. The Fleet drew its whole blood supply in mid-March; some of it was due to expire late in March and the remainder at various dates in early April. In the event that resupply would have been necessary before regular channels of supply could be opened, 75 bottles of blood were prepared to be dropped by parachute at some one of the Fleet refueling stations. This did not prove necessary, though preliminary tests at Agana Bay had proved that this method of delivery was entirely practical and did not 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. The LST(H) 929 (landing ship, tank (casualty evacuation)), designated as the distribution center afloat, arrived at the target on L-day. Because it was a slow ship, it brought in no blood, but it received blood at once from LSV-6 and the U.S.S. Solace (AH). Additional AH's arriving at 2-3 day intervals brought in about 1,700 pints per ship. Any excess over the needs of the casualties on the AH's was transferred to the LST(H) 929, which distributed blood 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, when the blood distribution team set up by Colonel Kendrick was able to go ashore and begin to function. Its arrival at the target had been delayed because the ship on which it had been transported was damaged by a suicide dive bomber and could not be unloaded at once. During this period, the XXIV Corps received all the blood it needed from LST(H) 929 which was lying off Beach Orange 2 in close proximity to it. Blood was supplied to the III Amphibious Corps during the same period by transfer of blood from LST(H) 929 to LST(H) 951, which was conveniently located off Beach Yellow 2, near Corps headquarters. When the III Amphibious 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 surface carrier. Approximately 3,200 pints were retained aboard AH's, LST(H)'s, and APA's for their own use.

The first blood, 200 pints, received by air, arrived on Okinawa on L+17. The distributing center ashore (fig. 144) was set up at Yon-tan Airstrip, where


624

it operated with two 150-cu. ft. refrigerators, equipped with generators. Daily shipments from Guam (200 pints) were received from Guam after L+18.

The original plans called for the provision of 6,000 pints of whole blood for the target on Love Day and the delivery of another 3,000 pints by hospital ship during the first week of the campaign. The course of events made clear the importance of the control of blood by trained personnel if wastage was to be avoided: The casualties in the first days of the Okinawa operation were unexpectedly low. As a result, only 3,000 pints of blood were needed, and the resupplies planned for this period were not needed at all. A small 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 because they were not needed. A medical officer sent to Honolulu to investigate local needs found that most of the blood on which the dating limit was due to expire could be utilized there.

FIGURE 144.-General view of blood distribution center, U.S. Navy, off Route No. 1,
Okinawa, July 1945.

The initial slow pace of the campaign made it possible for Colonel Kendrick, accompanied by Col. George G. Finney, MC, Consultant in Surgery, 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 south as the landings were made, and it was a week before real resistance was encountered. During this interval, it was therefore possible for these officers to visit every field and evacuation hospital ashore, whether Army or Navy, and to pass on to the hospital staffs all the available information about the use and handling of whole blood, including the information Colonel Kendrick had secured in the Mediterranean and European theaters about its correct use in battle casualties. The discussions covered careful triage at the field hospital level after adequate resuscitation (figs. 145, 146, and 147), the physical arrange-


625

FIGURE l45.-Administration of plasma to officer wounded by Japanese sniper, Okinawa, April 1945.

ments of a shock ward (p. 707), the employment of shock teams, and the establishment and observance of a routine of surgical management. When the hard fighting started, the medical officers responsible for the care of battle casualties were well trained in resuscitation procedures and in the use of whole blood.

The daily distribution of blood ashore varied from 5 cases originally to 59 cases. As soon as needs began to increase, the center at Guam was requested to ship 1,000 pints immediately, to provide for a backlog in case of bad weather. As the operation progressed, it was necessary to increase the requisitions to 750 pints per day. Between L+39 and L+42, 2,336 pints were used.


626

FIGURE 146.-Administration of plasma to soldier wounded on Okinawa, 7th Division, May 1945.

Shock Teams

Because large numbers of casualties were anticipated in the Iwo Jima and Okinawa operations, shock teams were used in numerous hospitals. The team attached to the 148th General Hospital was organized on 26 February 1945, on Saipan. It consisted of five medical officers, two nurses, and four enlisted men, so assigned that the team was on duty around the clock. Two of the enlisted 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. Equipment was generally sufficient, but motorized transportation would have saved time because of the extent of ground occupied by the hospital.

All casualties were treated by a regular shock routine, which included immediate determinations of hemoglobin and of the hematocrit and plasma protein values by the copper sulfate technique, which was generally used in the Pacific as soon as it became available. These results were entered on a mimeographed form that bore the patient's name, serial number, and ward assignment 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 the ward officer and provided the proper amount. If, however, a casualty seemed clinically in need of blood, the ward officer, without waiting for the laboratory results, phoned the information to the shock center, which provided the transfusion.


627

FIGURE l47.-Administration of plasma to wounded infantryman on Okinawa, April 1945. A cigarette was often an essential part of resuscitation.

In order to save time and avoid unnecessary repetition of venipunctures, each ward officer gave the shock center each morning a consolidated requisition for the estimated blood and other intravenous fluid needs of all his patients for the next 24 hours.

During the Iwo Jima and Okinawa campaigns, between 24 February and 13 August 1945, the shock team at the 148th General Hospital handled 3,767 patients, who received 4,748 pints of whole blood. The 164 reactions averaged 4.3 per patient and 3.0 per transfusion. Of the 5,412 pints of blood received, 664 had to be discarded because of excessive lipoid content, clotting, overdating, and technical difficulties of administration.

The smooth functioning of this well-organized shock team played an important role in the low mortality rates achieved in both the Iwo Jima and the Okinawa campaigns.

Critique

In his report to General Willis on the blood program for the Okinawa campaign, Colonel Kendrick made the following comments:

1. Overall planning was practical and effective. Shipment of blood by surface carriers provided adequate supplies for the initial phase of the operation. Reefers and an ice-manufacturing machine on LST(H) 929 enabled this ship to act as a distribution center for units afloat and ashore.

2. The LST(H) 929 arrived at the target area without its own supply of blood because its slow speed would have made the blood outdated before its arrival. It had to draw its


628

supplies from other ships before it could begin to function as a distribution center, and this delay, which made the LST(H) 929 dependent on other ships, was responsible for some delay ashore.

3. APH's and APA's were stocked with varying quantities of blood at the assembly point, and certain other ships were also well stocked. All of these ships could have drawn blood, as they needed it, from LST(H) 929, and it 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 as distributing centers for other ships. The AH's carried sufficient blood for this purpose, but no personnel had been designated to act as distribution teams or to keep adequate records of issues of blood. Local distribution could be accomplished with less confusion if some designated LST acted as the other floating distribution center and was made responsible for issues of blood and records of receipts and distribution. If the shoreline in a future operation should be long, another LST could be designated as a subdistribution ship, to supply half of the beachhead, but not to supply other ships. Because of this possible necessity, two LST's should be provided with reefers and ice machines. At Okinawa, LST 951 supplied the III Amphibious Corps and served as a supplementary distribution center.

5. The blood distribution team was delayed in going ashore because the U.S.S. Achinar, on which it traveled, sustained bombing damage. Since the team was not brought in on the LST(H) 929, it provided no support for the distribution activities on that ship. Hereafter, team and equipment should be transported on the LST which is to serve as a distribution center, or on one of the LST's which accompanies it, so that the team can maintain complete control of blood distribution afloat and ashore, part of the team remaining afloat on the LST until the distribution center ashore is functional.

6. Considerable confusion was caused in medical installations ashore by lack of knowledge as to where blood could be obtained. In future operations, instructions should be given by each corps to its medical installations concerning the location of the distribution center afloat. The officer in charge of the blood distribution team should notify each shore part of the location of the floating center and the availability of blood from it.

7. The LST(H) 929 did not have facilities for delivery of blood to the beach when signaled by the shore party.

8. The equipment brought ashore by the distribution team was not completely adequate. The ice machine could not be used because accessory parts were lacking. There was no provision for water for manufacturing ice and for removing latent heat. Water tanks, piping, a water trailer, a water pump, and other supplies could be obtained from Island Command and NCB's (Navy construction battalions) before the center ashore could make its own ice. In the meantime, it had to obtain its ice from LST(H) 929. An ice machine with accessory cooling system should be available for immediate use in future operations.

Another 2½-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 of distribution teams.

9. While a distribution team proved entirely capable of functioning as a blood supply point under the supervision of a hospital corps officer, it was considered imperative that a medical officer be responsible for the proper care and use of blood. He could be in charge of the team or attached to the medical section of the Landing Force Commander's headquarters. The second arrangement would be more desirable, for it would give the officer more latitude in advising on the proper use of whole blood.

Colonel Kendrick made recommendations to cover these various points and also recommended:

1. That the personnel of all medical installations assigned to an amphibious task force be instructed before departure in the principles and practices relating to the treatment of shock and the proper use of whole blood.


629

2. That each field hospital supporting amphibious operations have attached to it four shock teams, each consisting of a medical officer, a nurse, and two enlisted men. It would thus be possible for two teams to be on duty each 12 hours.

TERMINATION OF AIRLIFT

As the campaigns in the Southwest Pacific decreased in intensity and then were concluded, the quantity of whole blood needed and used decreased correspondingly. The blood bank at Hollandia and the depot at Biak were closed at the end of 1944, since planning for the invasion of Japan was predicated on procurement 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 abrupt change in the transfusion service. On 5 September 1945, the commanding generals of all base areas and commands were notified by Colonel Dart, Deputy Chief Surgeon, U.S. Army Forces, Western Pacific, that shipments of whole blood from the Zone of Interior would be discontinued on or about 15 September and that thereafter blood must be obtained from local sources (32). A blood bank had been established at the 19th Medical General Laboratory in Manila to supply blood for hospitals in the Philippine Islands and would begin to function on 15 September.6 Instructions were given for the procurement of blood from this source. The dating period for properly refrigerated blood was set at 30 days. If a hospital needed only small amounts of blood, it should collect it from local donors. Attention was called to the technical instructions on the storage and administration of blood contained in Circular 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 Interior ceased, the blood bank at the 19th Medical General Laboratory in Manila took care of the initial needs of the army of occupation and supplied the needs of all U.S. hospitals in the Philippines as long as they were in operation. The absence of opposition in Japan and adjoining territories soon relieved the blood bank 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 is almost impossible because of the circumstances under which many, perhaps the majority, of transfusions were given. The figures to be cited should therefore be 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 of whole 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


Amounts in units

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


Total

181,555

The wide variations in the monthly amounts, which reflect the varying intensity of fighting, made for difficulties in maintaining collection schedules in the Zone of Interior. The remarkable accuracy of the estimates, however, is evident in the April 1945 report of the distributing center on Guam (24): In that month, it was necessary, for the first time, to distribute excess supplies of blood to general and other hospitals in the bases, instead of sending it forward to combat zones.

Oversea Supply and Distribution

The following general data, which are incomplete and inaccurate because of the circumstances (p. 455), are available for the supply and distribution of blood in the Pacific:

4,260 units (2,130 liters) to U.S. Army bases in New Guinea and the Philippine Islands by the Australian Red Cross Blood Transfusion Service between January 1944 and February 1945 (p. 586).

2,597 units to U.S. bases in New Guinea, the surrounding islands, and the Philippine Islands by the whole blood bank at the 27th General Hospital, Hollandia, New Guinea, between September and December 1944.

88,728 units to U.S. bases in the Philippines by the blood distribution center, Leyte, Philippine Islands, between December 1944 and September 1945. All of this blood was received from the Zone of Interior via Guam (23, 34).

2,145 units to U.S. bases in the Philippine Islands by the blood bank at the 19th Medical General Laboratory, Manila, in September and October 1945, when these tabulations were concluded.

As the result of planned indoctrination combined with the availability of preserved whole blood, the use of blood in all forward installations in the Southwest Pacific increased steadily (35). There were few medical officers who did not eventually realize that lost whole blood can be replaced only by whole blood. The value of massive transfusions was also universally appreciated, and it was not uncommon to encounter patients in rear hospitals who had received from 5,000 to 7,000 cc. within a few hours after wounding. The blood supply was originally on the basis of 1 pint of blood per casualty but frequently much more blood was used. In one series of 6,807 casualties treated surgically, 10,242 units of blood were used, and by the end of the war a ratio of 1.5:1 was the rule.


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While accurate total figures are not available, certain comparative statistics are significant:

The first report for U.S. Naval Whole Blood Distribution Center No. 1 on Guam, from 19 November to 24 December 1944 (22), showed that 6,480 pints were 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 to the 3d Marine Division, 128 pints to the 168th General Hospital, 40 pints for civil emergencies on Guam, 191 pints to three naval base hospitals, and 14 pints to the U.S. Naval Air Base Dispensary. In addition, 76 pints had been discarded for causes not connected with outdating.

The April report from the Guam distribution center (24) showed 5,663 pints of whole blood on hand on 1 April and 25,760 pints received during the month from the United States. Of this amount, 12,568 pints were distributed to the Philippine Islands and 15,916 to the Okinawa operation. By 30 April 1945, a total 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 flown to 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 was the blood (535 pints) that went to hospitals in the Hawaiian Islands when casualties in the first stage of the Okinawa operation proved fewer than had been anticipated (p. 624).

From L-6 to L+43, approximately 25,444 pints of blood were supplied for the Okinawa operation, 12,900 by surface carrier and the remainder by air (31). During this period, there were 23,681 casualties, including killed in action, wounded in action, missing in action, and nonbattle casualties. The ratio of 1 pint of blood per casualty admitted to field hospitals, which had been established in the Mediterranean and European theaters, was thus exceeded in the Okinawa operation, one reason being the kamikaze suicide bombings.

Between 1 April and 21 June 1945, approximately 40,000 units of blood were received by the various hospitals and other medical installations operating on Okinawa.

Losses

Considering the circumstances in the Pacific, it is remarkable that the losses 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 well established that bottles of blood which would become hemolyzed would be in that state on their arrival at Guam, where they could be screened and discarded as necessary (p. 607). It was also found, in the Pacific and elsewhere, that blood could undergo considerable movement without hemolysis.

In the total shipments, excessive hemolysis before the outdating period was reached occurred in less than 5 percent of the flasks. The single serious complaint in respect to this change came from the 2d Field Hospital, which, on one occasion, found 80 percent of its stock hemolyzed. While the precise


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cause was never determined, the most plausible explanation was a break in refrigeration technique.

Breakage.-Breakage was remarkably infrequent. Lieutenant Brown reported no instance of breakage in the blood received at Guam between 25 December 1944 and 31 March 1945, and Captain Thorpe made the same statement in his 4 July 1945 report from the Leyte bank.

Failure of refrigeration-The chief losses from refrigeration failures were in forward hospitals and, for the most part, in hospitals in which the control of blood was not the responsibility of a single medical officer with training in this field. Faulty refrigeration, with temperature fluctuations and storage at too high temperatures, was the chief cause of loss of blood by hemolysis. Base units reported only small losses because of incorrect refrigeration. This would be expected, for they had good refrigerators and experienced mechanics to maintain them.

Outdating-The blood that combat medical units carried 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 be flown in; this was not possible until airstrips were secured. Invasion forces went ashore with supplies of blood adequate for all estimated casualties. Most of the losses-many unrecorded-probably occurred at such times. There was no alternative, however, to the provision of blood on the basis of possible needs. Resupply was on the basis of actual needs; automatic resupply would have occasioned far heavier losses than those that occurred.

The bank at Leyte was at first supplied with blood with only 10 days of life remaining in it, the fresher blood being given to Fleet combat teams. As supply and demand equalized, the bank at Leyte was supplied with fresher blood. It was kept stocked at all times with 3-4 days' supply, to provide for emergency requests and to guard against failure of supplies because of bad flying weather. Not much blood was lost by outdating, and, according to Captain Thorpe, there was never a time during the operation of this bank that blood 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 some discussion in the spring of 1945 about extending the shelf life to 28 days, but no formal action was taken.

The report of the center on Guam for June 1945 showed total losses due to aging in 1945 as 3.6 percent, 2.9 percent for the first quarter and 4.3 percent for the second. During this period there were only three occasions when supply and demand were not well balanced; in January, in preparation for the Luzon invasion; in April, in preparation for the Okinawa invasion; and in June, when there was an unexpectedly rapid cutback of requirements in the POA and SWPA. On all of these occasions, more blood was ordered than was needed for the combat forces, but most of it was used in hospitals to the rear.

The total losses from aging were probably somewhat higher than these figures suggest because they take incomplete account of losses in hospitals,


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particularly the forward hospitals which required only small amounts of blood at irregular intervals but which had to carry a stock large enough for possible emergencies (36).

The use of blood beyond the 21-day limit set was not recommended, but the dating period was occasionally exceeded when the choice lay between outdated blood 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). Two casualties, 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 20 days (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 to Leyte, to discuss all aspects of the supply and use of whole blood with medical officers in General Denit's office and with the Surgeon, Sixth U.S. Army. At this time, there were no personnel in the POA who had the overall responsibility of supervising the reception, storage, and distribution of blood or who had the authority to undertake these tasks.

Also, as might have been expected in the circumstances, there was no general recognition of the importance of the liberal use of whole blood in battle casualties. One of Colonel Kendrick's important tasks, and it was not a particularly easy one, was the indoctrination of medical officers concerning this modality. He had to convince officers of the Sixth U.S. Army, which had been functioning effectively for several years without adequate supplies of whole blood, that the new blood program had a great deal to offer them. Many of them frankly told him that they had got along very well without it and him. He also had to convince medical officers in an army that had never had enough of anything that they could have all the blood they needed and wanted simply by asking for it. His observations in the Mediterranean and European theaters stood him in good stead, for he could bear personal testimony to the feasibility and advantages of the plan he was advocating.

The acceptance of the blood program and the liberal use of whole blood that followed (fig. 148) can be attributed chiefly to the vision and support of the Consultant in Surgery, Sixth U.S. Army, Major Glenn. Without his understanding of the problem, and without the high esteem in which he was held by medical personnel in the Sixth U.S. Army, it would have been far more difficult than it was to support this Army with the blood which it required.

As has been pointed out already, the arrival of the first shipment of blood from the United States changed the whole face of the management of shock and hemorrhage in the Pacific. Up to that time, the ratio of pints of blood to casualties had been about 1:10. The ratio changed to 1:1, and later to 1.5:1.


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FIGURE 148.-Administration of blood to U.S. casualty, wounded when his division command post was shelled, Leyte, Philippine Islands, October 1944.

When whole blood was immediately available as far forward as clearing companies and portable surgical hospitals, it became the practice to use plasma only when blood was not at hand, which was seldom, or to supplement transfusion, but never as a substitute for it. By March of 1945, it was routine for invasion forces to carry blood ashore with them, and it was not uncommon, on reading a casualty's Emergency Medical Tag in a rear hospital, to find that he had 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 hospitals testified to the value of whole blood. The Surgeon, Palawan Task Force, said that the buffered whole blood brought in with medical units on D-day in the Luzon operation proved invaluable: "The value of whole blood over plasma for battle casualties is unquestioned." A surgeon at the 27th Portable Surgical Hospital said that the mortality rate from abdominal wounds dropped 20 percent when transfusions, penicillin, and oxygen therapy became available. A report from the 80th General Hospital stated that the superiority of whole blood over plasma was most striking in casualties with shattered pelvis and associated abdominal injuries, who required 3,000 to 4,000 cc. of blood in the first 24 hours after wounding. The surgeons of the 119th Station Hospital found plasma of little value in casualties received for definitive and convalescent care. "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. In this campaign, for the first time, blood was administered to all patients with severe and moderately severe wounds or with evidence of impending shock, regardless of their status on admission. Those with no signs of shock received 2 pints of blood. Those in moderate shock received from 4 to 6 pints, run in rapidly by gravity. Those in shock from severe hemorrhage sometimes received as much as 10 pints in 90 minutes. One patient received 17 pints in 9 hours. In severely shocked patients, blood was often forced through cannulas into several veins at once by multiple syringes or by pressure gravity techniques. After observation of the results of these practices, it required little effort to convince Sixth U.S. Army medical officers at headquarters or in the field of the value of the whole blood program.

Whole blood was used in chest wounds with the usual precautions against overhydration. It was given liberally in wounds of the abdomen and of the extremities. Its postoperative use was found to be an effective way to prevent wound disruption. Casualties coming from forward hospitals often suffered from hypoproteinemia, and the liberal use of blood and plasma, supplemented by early high-protein feedings, helped to prevent this complication.

Blood was also used as necessary on the medical service. Several patients with 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 in Pacific hospitals were reported in the ETMD for March and April 1945 (35). The container was inverted and agitated gently until the cells had returned to a state of uniform suspension in the plasma. The blood was given either cold as it was taken from the refrigerator or after it had stood at room temperature for a short 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 given over a 30- to 90-minute period, the temperature seemed unimportant.

The time required to administer a unit of blood was widely variable. When pressure was exerted by use of the bulb on a Baumanometer or by some other means, a pint could be given in 5 to 10 minutes. A transfusion could be given rapidly under minimal pressure if a cannula was tied into the long saphenous vein. The intrasternal route was occasionally used. When a casualty was in severe shock, two transfusions could be run into different veins at a rapid rate. As soon as bleeding was controlled and the blood pressure returned to a satisfactory level, the rate of administration was decreased, and the blood was given 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 2½ 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 an active Japanese machinegun. To leave him without treatment would have risked his going into irreversible shock. To move him would have meant certain casualties for the litter squad. A staff sergeant, who was later awarded the Silver Star medal 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 and elevating the bottle of plasma with one hand(38).

Five men in a command post about an hour's litter carry from a battalion aid station were seriously wounded by a short 81-mm. mortar. An enlisted technician on the spot prepared five units of plasma, suspended the bottles by forked sticks in the ground, and had the last infusion flowing before the first was complete.

Many lives were saved because enlisted technicians with supplies of plasma were assigned to companies carrying out flanking attacks in the jungle and operating apart from the battalion.

OTHER REPLACEMENT AGENTS

Serum albumin was available in the Pacific but Captain Newhouser and Colonel Kendrick found that it was not widely used, either ashore or on ships, for several reasons: Many medical officers had never heard of it; the circumstances did not favor rapid dissemination of information. No extensive educational program had been carried out concerning it, and plasma, which had been the subject of careful indoctrination, was universally available and had proved extremely satisfactory. The necessity for using additional fluid with albumin was a distinct disadvantage, for dehydration was a real entity in troops fighting in the Pacific areas.

Many hours were spent on hospital ships and in other Army and Navy installations instructing medical officers on the availability and use of serum albumin. 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 were found in good condition, although some of the tubing had been exposed to temperatures from 85° to 110° F. for 18 months.

CONCLUSIONS

Once the program to supply blood to the Pacific from the mainland had been instituted, there was never a shortage of blood in these areas. At times, when the weather was bad and supplies on hand did not exceed 24-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 Operation OLYMPIC (p. 639) been carried out and the estimated 500,000 to 600,000 casualties come to pass, there is little doubt that sufficient blood would have been provided for all their needs. In one operation out of four, said the May 1945 report of the distribution center at Guam (36), in reference to the early stages of the Okinawa operation, "we had too much too early but in none, including the other phases of the Okinawa operation, to date did we ever have too little too late." That statement continued true until the end of the war.

The experience of the airlift of blood to the Pacific and the handling and use of blood there proved a number of points:

1. That it is perfectly practical to collect blood in the Zone of Interior and deliver it safely to a theater far removed from the point of 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 remote from the point of collection as Okinawa within 6 days after it had been collected.

2. That a theater transfusion officer, with his staff, attached to the office of a theater surgeon and given the proper authority and resources, 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 blood to all medical installations in the theater.

3. That in dealing with a commodity such as blood, which has only a brief life and which is easily contaminated and rendered not only useless but dangerous, handling and distribution must be the responsibility of medical officers and other personnel trained in this particular specialty. For the reasons just stated, blood cannot be handled efficiently or safely through conventional 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 its distribution to widely dispersed medical units on separate land masses require coordination and timing of a high degree. The experience on Okinawa proved that in island operations, in which blood must be carried ashore with landing forces, it is essential that a trained medical officer, with experience in the handling of blood be given the responsibility for prior planning, for distribution, and for resupply, and also be given the resources necessary to discharge his duties. All the blood used at Okinawa came, via Guam, from the United States, 8,000 miles away. With the dating period set at 21 days, it required careful timing to guarantee adequate quantities of blood with minimum wastage from outdating. That the project was accomplished so successfully was due to (1) a highly efficient blood supply system extending from the Zone of Interior to Okinawa and (2) to the assignment of a trained transfusion officer who was responsible for planning, supply, and distribution, and for the proper clinical use of the blood once it had reached the target.

As these conclusions indicate, perhaps the most essential factor in the efficient operation of a transfusion service is the assignment to the office of the theater surgeon of a trained transfusion officer, whose responsibility is overall supervision of the transfusion teams and liaison between hospitals, teams, and the source of blood in the Zone of Interior.

OPERATION OLYMPIC

Just before the end of the campaign on Okinawa, at the suggestion of Col. I. Ridgeway Trimble, MC, Consultant in Surgery, SWPA, General Denit invited Colonel Kendrick to Manila to plan the blood program for the invasion of Japan (Operation OLYMPIC). It was interesting that even at this late date, certain medical personnel in the SWPA, while fully recognizing the urgent need for whole blood, doubted that all that was regarded as necessary for the invasion of Japan could possibly be supplied.

The essentials of the plan developed for Operation OLYMPIC were as follows (39):

1. Whole blood would be flown under refrigeration by an Army-Navy airlift from the Zone of Interior to Guam. All requisitions would clear through this center.

2. Accessory distribution units would be set up in Manila and on Leyte and Okinawa, each to be operated by a well-trained and well-equipped distribution team.

3. Initial supplies of blood would be provided by the Manila center. The center at Okinawa would be responsible for resupply by surface carrier, air, or both means.

4. The blood supply at the target would be provided initially by LST(H)'s designated as blood distribution centers afloat. As soon as possible, blood distribution teams would be put ashore at each of the target areas.

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 be attached to USAFPAC as officer-in-charge of the transfusion service.

2. The two Army transfusion teams on duty in Saipan would be requested from the Commanding General, POA. One team would be assigned to Manila, to serve as a distribution team and, when necessary, as a blood collecting team. The other would serve in Okinawa as a collecting team and would be prepared to furnish distribution personnel to go forward to the target area on call if one of the teams at that point should be incapacitated.

3. Three Navy distribution teams would be attached to the Sixth U.S. Army, one to go in with each assault force. These teams would be transported to the target on the LST(H)'s designated as blood distribution points afloat and would function on them until they went ashore. The center ashore would be centrally located, to supply both installations ashore and ships afloat.

4. One LST(H) would serve as a blood distribution center at each target. It should be provided with adequate reefer space for the necessary amounts of blood and should also be provided with an ice machine. If the beachhead were wide, each LST(H) might need to be supported by other LST(H)'s serving as subsidiary blood distribution points, but all blood should be obtained from the designated whole blood distribution center afloat.

5. Delivery of blood to individual hospitals would be a unit function. If the LST(H) serving as the distribution center afloat were on the beach, the supply of blood to shore units would be simplified. If it were offshore, 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 of blood on the beach.

Blood requirements for the invading Army and Marine troops were estimated at 1.5 pints per casualty and on the assumption that 80 percent of all casualties arriving in forward hospitals would require blood. For the first 15 days of the invasion, 7,780 casualties would require 11,670 pints of blood. The respective cumulative figures for the first 30 days would be 18,060 casualties and 27,090 pints; for the first 60 days, 44,725 casualties and 67,087 pints; and for the first 120 days, 99,948 casualties and 149,922 pints.

To insure adequate supplies, enough blood should be carried ashore initially for a 5-day period; this plan would require 6,000 pints of blood, 2,000 pints to be loaded with each assault force. After the first 5 days, resupply would depend upon placing distribution centers as close to the target as possible, the availability of surface and air transportation, and maintenance of an adequate flow of blood from Guam to the distribution centers at the target. Because of the short haul, it would be most desirable to utilize the distribution center at Okinawa for the resupply of blood until airstrips were available. This center should be familiar with the total blood requirements for Operation OLYMPIC, and requests from the target area should be addressed to it.

The officer in charge of the transfusion service should work out a table showing the amount of blood required, the dates it must arrive, and the points at which it should be delivered from Guam. Lieutenant Brown at Guam should have this information at least 12 days before the blood would be needed at the loading points. This interval would allow the centers on the


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mainland to step up their program to meet requirements. It would take from 4 to 6 days to accumulate the 6,000 pints of blood needed for the first stage of the operation.

Critique

The plan just outlined was presented to General Denit in sufficient time for it to be approved in his office and sent to the Office of The Surgeon General, so that Maj. John J. McGraw, Jr., MC, then serving as his special representative on blood and plasma transfusions, could comment on it in the light of his experience in the Mediterranean theater.

Major McGraw found the plan excellent and noted that there were 11 centers in the United States capable of supplying whole blood at the rate 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 overall responsibility for the transfusion service, to be an essential part of the program. He also emphasized again that blood distribution must not be a function of Medical Supply but the responsibility of blood distribution teams which 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, and AB recipients.

2. The teams assigned to operate the two distribution centers were probably not large enough for the collection, processing, and delivery of significant amounts of blood. It was suggested that they be replaced by 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 forces should be replaced as soon as possible by Army teams, so that all personnel dealing with blood would be under the control of the consultant on transfusion at Headquarters, USAFPAC.

4. The plan of making each hospital responsible for picking up its own blood, by the ambulances bringing patients to hospitals, was considered a hit-or-miss proposition. It was recommended instead that distribution teams make regular rounds to all hospitals, delivering blood as needed and picking up blood nearing its expiration date for delivery to more active units.

These comments were made on 4 August 1945, just 10 days before the cessation of active fighting, which made unnecessary any further action on the blood program for the invasion of Japan. They were also, Colonel Kendrick noted later, made by an officer whose experience with the supply of whole blood, although very extensive, did not include the ship-to-shore operations required in the Pacific areas. Colonel Kendrick considered having hospital ambulances carry their own blood supply almost the heart of the program 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, at the School of Tropical Research, in 1925 (41). When the war broke out in 1939, a transfusion service was set up here for the Indian Army, and another center 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 provide blood for both civilian and military use. All of these centers operated under Government control, but each used techniques to fit the local situation. When they were opened, a Government-sponsored educational program was launched, to overcome the superstitious fears of the polyglot Indian people about giving blood.

Blood was processed into serum in several large cities, and a limited amount of dried plasma was produced in Calcutta. The expansion of the program was hampered by lack of equipment and by long delays in procuring it.

China had no organized blood or plasma program. In 1943, the American Bureau for Medical Aid to China undertook the training of technical personnel in a special donor center in Chinatown in New York. The idea was that this group would be sent to China, as a pilot group to train other technical personnel, who would establish additional centers to bleed donors supplied from military sources. The plan had a limited success.

Blood and Plasma Supplies

When U.S. troops reached India, a basic supply of dried plasma was forwarded to them by air. Maintenance was on the basis of 100 units per month for each 10,000 troop strength. Supplies of plasma were practically always adequate, and it served the same useful purpose that it did in other theaters. Unfortunately, it frequently had to be used when blood would have been more desirable.

The blood bank set up at the 20th General Hospital at Margherita, Assam, in May 1943, also served the 14th and 73d Evacuation Hospitals and all their substations which were accessible by motor transport (42). Wet plasma was also provided, and some serum (figs. 149 and 150). The blood was collected under aseptic precautions by a semiclosed method. It was citrated when it was to be used for whole blood or plasma but not when it was intended for serum. The blood had a shelf life of 10 days. At the end of this time, the plasma 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 refrigerators of 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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FIGURE 149.-Stored blood and plasma at 20th General Hospital, Ledo, September 1944. 
U.S. blood and plasma are on the right, and Chinese blood on the left.

in a serious state of shock, and for civilian-type traumatic injuries. When combat casualties were treated, the indications for transfusion were the same as in other theaters (fig. 151).

Malaria in Donors

The blood of every donor, whether American or Chinese, was examined for malaria, and a Kahn test was also performed. If either reaction were positive, the donation was used for plasma, which was kept in the refrigerator for 14 days before it was used. Information disseminated by the Indian Medical Directorate at New Delhi was to the effect that neither the storage of blood at low temperatures nor the addition of quinine nor Mepacrine (quinacrine hydrochloride) in vitro made malaria-infected blood safe for transfusion (43). If whole blood had to be secured in malarious areas, donors should be selected 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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FIGURE 150.-Processed serum in cold storage at Calcutta Blood Bank, October 1944. 
Note British bottles, which were used by blood bank of India.

Since potential infection had to be assumed in a malarious area during the malaria season, it was recommended in these instructions that the donor, when time allowed, should be given Mepacrine and that the recipient should also be given it for several days after the transfusion, until his condition had improved sufficiently for a frank attack of malaria to be tolerated.

If the recipient developed malaria, or if it were found that malarious blood had been accidentally given, the diagnosis should be confirmed by examination of thick and thin smears, and the standard course of treatment carried out. After giving blood, donors with latent or suppressed malaria 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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FIGURE 151.-Lt. Gen. (later Gen.) Joseph W. Stilwell, USA, and Col. (later Brig. Gen.) Isidor S. Ravdin, MC, visiting battle casualties from Myitkyina, Burma front, at Assam Base Hospital, July 1944.

Supplies for Chinese

One of the chief reasons for the establishment of the blood bank at the 20th General Hospital was to provide blood and plasma for Chinese patients. Only small amounts of plasma and serum were available to them from Chinese sources (fig. 152). Arrangements were made with the Director of the All India Institute of Hygiene and Public Health in Calcutta to lyophilize pooled plasma and serum from Chinese donors, with the idea of building up a reserve for use in forward installations. A small blood bank was maintained at the 20th General Hospital, with limited amounts of wet plasma and serum, but the project did not succeed as it had hoped that it would, and the arrangements made in Calcutta were not utilized because Chinese donations barely met the day-by-day local requirements.

At the 20th General Hospital, it was found that blood was needed in about 30 percent of U.S. patients who required replacement therapy and in about 75 percent of the Chinese patients. The chief reason for the discrepancy was the high incidence of hypoproteinemia and severe anemia in the Chinese, as the result of injury superimposed on disease. Serious anemia was frequently secondary to prolonged malnutrition, severe and recurrent dysenteries, and


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FIGURE 152.-U.S. and Chinese military personnel donating blood at Chinese Services of Supply Headquarters, K'un-ming, China, April 1945.

severe, recurrent malaria. Traumatic rupture of the liver and spleen was also disproportionately frequent in the Chinese soldiers. Enlargement of these organs was 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 and Blood Plasma in the Pacific Operational Area During World War II.

2. Report, Maj. R. J. Walsh, Secretary, New South Wales, Red Cross Transfusion Committee, n.d., subject: New South Wales Red Cross Blood Transfusion Service at the Conclusion of the War (1945).

3. Memorandum, Col. F. H. Petters, MC, to Commanding Officers, 105th General Hospital and 42d General Hospital, 8 Feb. 1943, subject: Blood Bank.

4. 1st Indorsement (Memorandum No. 3) from Col. Maurice C. Pincoffs, MC, 12 Feb. 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 of Whole 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, 2 Mar. 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, Southwest Pacific 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 With Special 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 in the Advanced Bases SWPA.

13. Memorandum, Lt. Col. Bruce P. Webster, MC, to Chief Surgeon, USASOS, 26 June 1944, subject: Informal Report on the Use of Army Personnel as Blood Donors in 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. Kirk to 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 War II. Its Organization and Operation. Washington: The American Red Cross, 1 July 1946.

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 Distribution Center 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. 1 From 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 Blood Distribution 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 of Whole 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 Okinawa Operation.


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32. Letter, Col. Raymond O. Dart, MC, to Commanding Generals, Philippine Base Section, Luzon Area Command, Bases M, X, K, R and S, 5 Sept. 1945, subject: Whole Blood Distribution to Hospitals in the Philippine Islands.

33. Circular Letter No. 38, Office of the Chief Surgeon, General Headquarters, USAFPAC, 20 Aug. 1945, subject: Whole Blood.

34. Report, Capt. Henning H. Thorpe, MC, to Chief Surgeon, Advanced Headquarters, U.S. Army Services of Supply (attention: Central Medical Records Office), 4 Apr. 1945, subject: Initial Quarterly Report for History of Blood Bank Facilities.

35. ETMD, USAFFE, for March-April 1945.

36. Report, Lt. Herbert R. Brown, Jr., MC, USNR, n.d., subject: Operation of U.S. Naval Whole Blood Distribution Center No. 1 for the Period of 1 May to 31 May 1945.

37. Quarterly History, Medical Activities of 7th Portable Surgical Hospital for 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 the Olympic Operation.

40. Memorandum, Maj. John J. McGraw, Jr., MC, to Col. B. N. Carter, MC (for Col. I. Ridgeway Trimble, MC), 4 Aug. 1945, subject: Comment on Proposed Plan for Supply of Whole Blood for Olympic Operation.

41. Memorandum, Col. Elias E. Cooley, MC, to The Adjutant General, War Department, 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, General Headquarters, India, 10 Dec. 1943, subject: Precautions to be Observed When Giving Whole Blood Transfusion in a Malarious Area.

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