History

CHAPTER III

Procurement of Problem Items

Procurement of medical supplies in time of war, as discussedin chapter II, was a complex, ever-changing, and frustrating duty. Among themany different articles needed desperately by the Medical Department, severalwere called "problem items" because of their great importance, thedifficulty of obtaining them, and the large size of the requirement. Surgicaldressings, blood plasma, penicillin, spectacles, and surgical instruments headedthe list of these special problems.

SURGICAL DRESSINGS

The surgical dressings procured by the Medical Departmentconsisted of approximately 75 items, including bandages, absorbent cotton,gauze, surgical masks, abdominal packs, adhesive plaster, pads, plaster of paris,first aid dressings, and surgical sponges. With the exception of the first aidpackets and a few other special-type dressings, all these items weremanufactured in large quantities for civilian use before 1939. Consequently, nodifficulty was anticipated in obtaining most of them from the usual commercialchannels in the event of war. During World War I, the local chapters of theAmerican Red Cross had prepared enormous quantities of bandages, dressings, andsponges for the Medical Department; but supply officers, as late as 1939,thought that such outside aid would no longer be necessary, unless forpsychological reasons.

Procurement Problems

This complacency was rudely jolted in the spring of 1940 whenindustry spokesmen made it clear that their plant capacity was insufficient forwartime military needs, and that any large increase in capacity would beimpractical. The alternative was for the Army to purchase the appropriatematerial in bolt form and make its own dressings. The Medical Departmentabruptly dropped its procurement plans and appealed to the Red Cross for aid."Since it has been definitely established," The Surgeon General wrote,"that machine-made dressings can be produced in quantity only sufficientfor peace-time needs, it is the studied opinion of this office * * * thatin time of emergency full and complete reliance must be had upon the goodoffices of the Red Cross to furnish ready-made dressings."¹

¹(1) Letter, Louis H. Nichols, Manager, Hospital Sales, Lewis Manufacturing Co., to George Smith, Director of Purchasing, American Red Cross, 29 Apr. 1940. (2) Letter, Maj. Gen. James C. Magee, The Surgeon General, to Col. James D. Fife, American Red Cross, 20 June 1940.

After receiving assurances that the Red Cross would extendits aid as in the First World War, the Surgeon General's Office requested andreceived authority "to enter into an agreement with the American Red Crosswhereby the Medical Department of the United States Army may procure therequisite materials which will be turned over to the American Red Cross andreceive in exchange the equivalent in prepared dressings." These dressingswere to constitute "an essential war reserve."²

Local chapters of the Red Cross quickly prepared to enlistthe women of America in this vital activity. Gauze was purchased from surgicaldressing manufacturers, cut into rectangles or squares of the proper size, andshipped to Red Cross chapters throughout the country where volunteer workersprocessed the material into surgical sponges, surgical masks, and abdominalpads. These supplies were sent to medical depots to be stored until they wereshipped overseas or to Zone of Interior installations. Immediately before use,they were sterilized in the central supply rooms of the hospitals to which theywere issued.

From August 1942 to the end of 1944, a total of nearly 300million yards of gauze was purchased by the Medical Department and sent to theRed Cross chapters. From this gauze, it was estimated that approximately 5billion sponges, masks, and pads were prepared. During the winter and spring of1945, production of these supplies continued at such a rate that, by April 1945,sufficient stocks had been built up to warrant the gradual closing of theworkrooms, and in July of that year, production ceased altogether.³

It should not be assumed, however, that the aid extended bythe Red Cross, valuable as it was, solved all problems involved in theprocurement of surgical dressings. Labor shortages and the lack of adequateplant capacity threatened to restrict production of dressings not prepared bythe Red Cross to a quantity far below anticipated requirements. Foreseeing thisdifficulty, procurement officers of the Medical Section, New York General Depot,New York, N.Y., called a meeting in August 1940 which was attended byrepresentatives of all known manufacturers of surgical dressings. Theserepresentatives were informed of the procurement program, the mountingrequirements in each item, and the necessity for speedy deliveries. They weretold that the quantities required would be allocated to the severalmanufacturers on the basis of delivery time, price, and the production capacityof each firm. In accordance with these terms, bids were submitted, deliveryschedules established, and contracts negotiated. The manufacturers were warned,however, that requirements were constantly increasing, and that only through anexpan-

²(1) Letter, Col. James E. Baylis, MC, to The Adjutant General, 6 Aug. 1940, subject: Surgical Dressings. (2) Letter, Lt. Col. F. C. Tyng, MC, to American Red Cross, attention: Mr. DeWitt Smith, 4 Sept. 1940.
³(1) Memorandum, Maj. C. E. G. Reeves, MAC, to the Historical Division, 23 Oct. 1944, subject: American Red Cross Surgical Dressings Program. (2) Annual Report, Liaison Branch, Purchases Division, Supply Service, OTSG, fiscal year 1945.

sion of plant capacity could the necessary production be attained. Help waspromised in obtaining new tools, equipment, and labor.⁴

The requirements for surgical dressings were greatlyaugmented by entry of the United States into the war. In addition, lend-leaserequirements and the large quantities of gauze purchased for the Red Crossplaced heavy burdens upon an industry ill-equipped to bear them. There was notenough factory space, not enough looms, not enough workers, not enough bleacherycapacity. In some instances, there was probably also insufficient incentive onthe part of the manufacturers to produce the "gray goods" out of whichsurgical dressings were made, for the available looms could be far moreprofitably employed in weaving higher priced material. Manufacturing capacitywas increased by the enlargement of factories and the addition of new equipment,usually aided by certificates of necessity providing rapid tax amortization, andby the construction with Defense Plant Corp. funds of a new factory inGreenville, S. C. Known as Convenience, Inc., the new plant produced exclusivelyfor the Medical Department until the latter part of 1944, when a sufficientquantity of most surgical dressings had been procured.

Camouflage Dressings

Procurement of some items of surgical dressings was attendedwith considerable and peculiar difficulties, which deserve a more detailedtreatment. The production of camouflage dressings, for example, created problemswhich could not be solved routinely. By the summer of 1943, it had been wellestablished that white surgical dressings in the Pacific theaters wereattracting the attention of Japanese snipers and pilots. The decision was made,therefore, to dye in "field brown" all field dressings used in thePacific theaters, and in July 1943, instructions were issued to that effect.This decision presented a number of problems to the Supply Service and itscontractors, including the toxicity of the dyes, effect on the absorbency of thegauze, the industry's ability to convert to dyed dressings, and the productivecapacity of dyers and finishers. Outstanding contracts for several items ofwhite dressings were modified, and work on the field brown dressings was startedin September 1943. After several experiments, a nontoxic dye which had onlyslight effect on the absorbency of the gauze was produced. By November 1943,more than 13 million individual dyed dressings had been delivered to the depots.Throughout the remainder of the war, adhesive compresses, 2-inch and 4-inchgauze compresses, compressed bandages, small first aid dressings, large firstaid dressings, first aid packets, and triangular bandages were supplied eitherin field brown or in olive drab No. 7.⁵

⁴Hornbacher, Arthur: Negotiations-Surgical Dressings. [Official record.]⁵Davis, Lewis W.: Development of Field Brown (Camouflaged) Surgical Dressings. [Official record.] The British had been confronted with the same problem during World War I when they developed a khaki bandage for field use. It appears, however, that officers of the Supply Service were unacquainted with the British experience and so derived no profit from it. See MacPherson, Maj. Gen. Sir William G.: History of the Great War. Medical Services General History. London: His Majesty's Stationery Office, 1921, Vol. I, p. 168.

Petrolatum Dressings

Another production problem was the petrolatum dressing,developed late in the war. This dressing, consisting of a gauze bandageimpregnated with petrolatum, permitted the application of sterile petrolatum toa burned surface and thus was a significant medical advance in a war which, morethan any previous one, produced many serious and painful burns. Two technicaldifficulties confronted the sole supplier of this item-the development of atechnique to produce a sterile dressing, and the manufacture of a greaseproofpackage which would withstand high sterilization temperatures. Considerabledelay was experienced, also, in building the new plant necessary for theproduction of this item. The petrolatum and the gauze bandage were sterilizedseparately and were then brought together under sterile conditions. The envelopefor the individual dressing was a lamination of Vinylite and aluminum foil,which was heat-sealed after the bandage was impregnated with the sterilepetrolatum. Three of these dressings were then packaged in a Reynolds Metalsenvelope. The first shipment, consisting of 6,000 dressings, was delivered tothe Kansas City Medical Depot, Kansas City, Kans., early in June 1945.⁶

First Aid Packets

The difficulties involved in the procurement of the first aidpacket were more important and continued longer than for the petrolatumdressing. This packet contained a small, sterile dressing and was carried byeach soldier in a pouch attached to his belt. Approximately 8 million wererequired for initial equipment, and the replacement rate was 60 per thousand menper month in the Zone of Interior and 220 per thousand in the overseas theaters.

A contract had been signed with the two suppliers in 1940calling for the production of 2 million first aid packets, but it was estimatedthat delivery would not be completed until March 1942. Brass sheeting, needed tomanufacture the metal case which enclosed the dressing, could not be obtained insufficient quantities. To solve this material shortage, copper was substitutedfor brass in contracts negotiated after March 1941, but, by the end of the year,copper was no more available than brass. Steel was then substituted and twoadditional suppliers were obtained who were prevailed upon to provide themselveswith dies. Shortly after contracts had been made with these two firms, however,the War Production Board refused to allocate any more steel for the first aidpacket. During the early part of 1943, with production steadily falling behindrequirements, a plastic container was developed and put into production, butunder field conditions the package warped and broke open. The Medical Departmentthen worked out new specifications calling for a laminated paper and lead foilbag. The new container passed every test applied by the medical equipmentlaboratory at Carlisle Barracks, Pa., proving in use

⁶Annual Report, Buying Branch No. 2, Army Medical Purchasing Office, 1945.

to be more satisfactory than even the original brasscontainer. It was, moreover, less expensive to manufacture.⁷

BLOOD PLASMA

Although the manufacture of dried blood plasma antedatesWorld War II, this product received such an impetus from wartime needs that ithad many characteristics of a new item. So far as the U.S. Army was concerned,the procurement of blood plasma began in February 1941, when a small shipmentwas received from Sharp and Dohme, Inc., owners of the patent for processinghuman blood into dried plasma.⁸ Smalladditional amounts were procured during the remainder of 1941, but it was notuntil after the attack upon Pearl Harbor that a large-scale procurement programwas launched. Blood plasma was administered to many casualties in that attack,and the beneficial results obtained in the treatment of shock, burns, and otherconditions associated with the loss of blood and tissue fluids convinced medicalofficers that this blood substitute was imperatively demanded.

Through the cooperation of the Army, Navy, National ResearchCouncil, American Red Cross, and commercial biological manufacturers, aprocurement program was instituted for the production of not less than 700,000units of dried plasma for the Army.⁹By1943, the Red Cross had organized 33 bleeding centers and was receiving blooddonations from the public at a rate of 90,000 per week. Through the efforts ofthe Medical Department, the patents owned by Sharp and Dohme were madeavailable to eight other commercial laboratories without the payment ofroyalties. The blood obtained from the public was immediately placed in specialcontainers, where it was kept cool by Dry Ice en route to the processors. The"bleeding" program was so planned that each processor was suppliedwith all the blood necessary to operate at maximum capacity.

The processing plants received the blood, put it through anintricate manufacturing process, tested the product, and shipped the units ofdried plasma to medical depots in all parts of the country. The problemsinvolved in production were numerous and important. Each laboratory had toconstruct special buildings for the project or convert existing structures; andhad to provide itself with many items of new equipment, including refrigeratingunits, centrifuges, freezing units, drying units, distilling apparatus,sterilizers, and testing equipment. Emergency preference ratings were obtainedto expedite production and delivery of this equipment, and, throughout the war,the Medical Department extended its aid in obtaining for the contractors suchsupplies

⁷(1) Memorandum, Lt. Col. F. C. Tyng, MC, to The Adjutant General, 10 Dec. 1940. (2) Memorandum, Lt. Col. C. F. Shook, MC, to Col. John B. Huggins, MC, Army-Navy Munitions Board, 18 Mar. 1941, subject: Purchases Under the 1941 Appropriation Act. (3) Annual Report, Supply Service, OTSG, 1943. (4) Davis, Lewis W.: Production and Packaging Problems. [Official record.] The inclusion in 1943 of sulfa drugs in the first aid packet caused some technical difficulties in manufacturing, but they were soon overcome.
⁸Annual Report, Renegotiation Division, OTSG, 1944.
⁹Annual Report, OTSG, fiscal year 1942, p. 27. A portion of the dried plasma was supplied to the Navy, and the Navy procured dried human albumin for the Army.

as bottles, rubber stoppers, rubber tubing, needles, filters, tin cans,waterproof packing materials, clamps, cartons, and shipping cases.

SURGICAL INSTRUMENTS

No problem in medical supplies had caused the prewar plannersmore concern than the procurement of surgical instruments. From 1922 untilprocurement planning faded into wartime procurement in 1941, it had been clearlyrealized that the great quantities of surgical instruments needed could beobtained only with marked difficulty. The main outlines of the problem weredeceptively simple. Before 1939, approximately 85 percent of all surgicalinstruments had been imported from abroad, mainly from Germany. When the Britishblockade cut off German exports in September 1939, civilian and military usersof surgical instruments were forced to turn to the manufacturing resources ofthe United States, which were equipped to supply only 15 percent of the normalpeacetime demand. Even had this country remained at peace and made nopreparations for war, the situation would have been serious. As it was, the veryevent which stopped the importation of surgical instruments-the outbreak ofthe war in Europe-led to an increase in the Armed Forces of the United Statesand, in consequence, to an augmented military demand for surgical instruments.The small quantities on hand which were held by importers and dealers soonpassed through regular trade channels to ultimate consumers, and within a fewmonths, the supply of instruments was critically low.

Fortunately, a movement was already afoot, even before theoutbreak of the war in Europe, to increase the productive capacity of Americansurgical instrument manufacturers. Some American surgeons who were incensed bythe Nazis' treatment of the Jews refused to use German-made instruments andpurchased those of American manufacture, despite their higher cost. Thisprovided the first real impetus for domestic manufacturers since World War I.The industry was expanded still further in 1940 and 1941, when the operation ofthe Selective Service Act, induction of the National Guard, and calling up ofReserves added new increments to the Army, producing still higher requirementsfor surgical instruments.¹⁰

Thus, when Japanese bombs at Pearl Harbor plunged the UnitedStates into the war, the Medical Department of the Army had already provideditself with expanded facilities. The next 6 months, however, comprised a hecticperiod in the Supply Service and one which was not conducive to speedy andorderly procurement procedures. The office was greatly expanded in personnel,but space continued to be so limited that efficient work was nearly impossible.

¹⁰Shea, Elmer A.: History of the Participation of theSurgical Section of Purchasing Branch 2, A.M.P.O., in the Medical DepartmentProcurement Program. [Official record.] This document has been used as a sourcethroughout this section. During the prewar period, there was an ad valorem dutyof approximately 55 percent on imported surgical instruments. In spite of thisduty, importers could still sell foreign instruments at prices lower than thosecharged for the American product.

An inadequate and outmoded system of calculatingrequirements, aggravated by the paucity of "due-in" data, made itdifficult to determine the quantities needed. The Supply Service, therefore, didnot authorize any large-scale procurement of surgical instruments until August1942. Over the next 3 months, the New York General Depot received requisitionsfor huge quantities of surgical instruments-quantities so large thatpurchasing officers and industry officials alike were baffled. After changingspecifications for some obsolete patterns, contracts were neverthelessnegotiated for the bulk of the requisitions.¹¹

Although bids were solicited, the main emphasis was placedupon delivery time rather than low bids. Low-cost producers were paid less, andhigh-cost producers were paid more. The renegotiation of contracts was expectedto capture excessive profits when high-cost producers overestimated theirexpenses. Thus, all parts of the industry which could produce acceptablesurgical instruments were given Government contracts. Later, a cost analysis onall contracts for more than $10,000 was required, but in the summer and fall of1942, this would not have been practicable. During this rush period, the entireprogram would have been imperiled if cost figures had been demanded. Indeed, aslate as October 1944, the country's largest manufacturer of surgicalinstruments declared that he was still unable to furnish, in advance, reliablecost statistics.

In accordance with procurement plans prepared in the 1920's,several silverware manufacturers partially converted their plants to thefabrication of surgical instruments. By the end of 1941, five of thesemanufacturers had received contracts for many thousands of forceps, and, duringthe heavy procurement of 1942 and 1943, additional contracts were negotiated.Difficult problems developed. Experience in manufacturing surgical instrumentswas, of course, totally lacking. The necessary machine tools were not readilyavailable. Workers did not possess the requisite skills. Through the cooperationof standard instrument manufacturers, these problems were solved. Skilledcraftsmen were loaned to the new manufacturers to train the workers, superviseproduction, and establish assembly line techniques. In many ways, the standardmanufacturers placed their experience and technical resources at the disposal ofthe erstwhile silverware makers.

The first instruments produced by the new plants did notalways meet the specifications, but within a few months, the newcomers weremaking an acceptable product. By concentrating their energies on a fewrelatively simple patterns which were needed in great quantities, they ablysupplemented the efforts of the regular manufacturers, making it possible forthe Medical Department to satisfy its huge requirements for these items.

The lack of an approved line of samples was another obstacleto the rapid completion of the contracts, and was partly responsible for thedelivery of some substandard instruments. Representatives of contractors visitedmedical

¹¹Recollections of Col. Paul I. Robinson, MC, conveyed toCapt. Richard E. Yates, MAC, January 1946. The heaviest buying in World War Ioccurred in the period 1 July-l1 Nov. 1918-16 months after the declarationof war.

FIGURE 12.-Samples of surgical instruments.

depots and searched the open markets to see the patterns theyhad been engaged to produce. Some of them later reported that they were shownsamples of Japanese instruments from World War I. Finally, in the early part of1944, a sampleroom was established at the Army Medical Purchasing Office, NewYork, where a display of all acceptable patterns was maintained (fig. 12).

Inadequate specifications on newer type instrumentsconstituted another difficulty. For a number of instruments, none had beenwritten; and when specifications were available, they frequently afforded meagerdata. In 1944, a program was inaugurated to bring all specifications up to dateand to include specific dimensions as well as drawings.

These problems delayed production and detracted somewhat fromthe quality of the finished product, but the tremendous program launched in thefall of 1942 was successfully completed. Estimated deliveries of surgicalinstruments amounted to $25 million in 1943 and $15.5 million in 1944. In someinstances, patterns were too far below the standard to be acceptable; in others,instruments that were satisfactory for their intended purpose were accepted eventhough they did not meet the specifications. There were a few complaints fromthe field, but most of these related to instruments which had been producedduring World War I.¹²

By the spring of 1943, there was reason to believe that theincoming supply of surgical instruments was badly balanced, that many types offorceps, for example, were in "short supply," and that a surplus ofother instruments was being piled up. A stock survey was promptly made whichdefinitely proved that the patterns were ill-balanced. Drastic cutbacks weremade in some contracts, and quantities were increased in others. By the end ofSeptember 1944, surpluses were fast disappearing, and additional orders wereplaced for many items which had been canceled in 1943.

¹²Annual Report, Army Medical Purchasing Office,fiscal year 1944.

PENICILLIN

No new item of medical supplies attracted as much attention,or grew so rapidly in importance, as did penicillin. Widely hailed as a"miracle drug" in magazines and newspapers, this curative agent wasfirst used in the Army early in 1943, when small quantities were obtained forexperimental purposes. Within a few months, it was produced in tremendousquantities and was made available to Army installations all over the world. Inno other drug was the gap between experimentation and widespread use bridgedwith such amazing speed.

The Army program of penicillin experimentation began atBushnell General Hospital, Brigham City, Utah, in April 1943. In June of thesame year, studies were started at Halloran General Hospital, Staten Island, N.Y. The supply of the drug was still so limited, however, that it was doled outwith the strictest economy and solely to ascertain its usefulness, to determineits indications and contraindications, and to standardize therapeutic proceduresassociated with its use.¹³In the meantime, penicillin was firstpurchased in May 1943, when two contracts were placed for 1,200 vials, eachcontaining 100,000 Oxford units. These were special experimental contracts, forthe manufacturing processes were so unsettled at the time, and the purity andpotency of the product were so uncertain, that the standard contract forms didnot apply. In July, contracts were placed with seven commercial laboratories,also on an experimental basis. Close contact was maintained with the suppliers,and many types of aid were extended to them while they assembled the plantfacilities, materials, and labor required for production. During the summer andearly fall of 1943, sufficient quantities of the drug were procured to continuethe experiments in Army hospitals, to determine its effectiveness, and to supplya small portion of the current needs. This period of experimental manufactureand procurement was also invaluable in providing a wealth of experience inproduction and packaging techniques. The period of experimental purchase endedon 1 October 1943 when standard Army contracts were awarded to eightcontractors.¹⁴

This marked the beginning of the real "penicillinprogram" which engrossed the efforts of many purchasing officers and whichwas granted the highest priority accorded to any military item except the atomicbomb. Nearly every piece of equipment needed to expand production was scarce,including stainless steel piping and tanks, centrifuges, vacuum pumps, andrefrigeration equipment. Building material for new production was difficult toobtain. The necessary labor in the "tight labor areas" created seriousproblems. In these

¹³Annual Report of The Surgeon General of the Army for theCommanding General, Army Service Forces, fiscal year 1944.
¹⁴(1) Memorandum, Lt. Col. Robert J. Carpenter, MC,Executive Officer, OTSG, to Commanding General, Army Service Forces, 11 Oct. 1944, subject:Checklist for Reports by Government Agencies on Technical Research and Development Work. (2) Memorandum,Lt. Col. Roger G. Prentiss, Jr., MC, Chief, Research Coordination Branch, Operations Service, OTSG,to Director, Procurement Division, Supply Service, OTSG, 19 Aug. 1943, subject: PenicillinProcurement and Delivery Schedule for September 1943.

difficulties, the Medical Department rendered all types ofeffective aid within its power. Quite naturally, however, the most criticalproblems-production, testing, and packaging-could be solved only by theefforts of the contractors themselves.

At first, the "surface culture" method ofproduction was universally employed, but late in 1943, experiments with the"deep vat method," similar to a process employed by brewers andprobably suggested by that industry, proved successful. Most contractors madethe changes in equipment necessary to use this improved technique, whichresulted in a far greater production. The problem of packaging was serious.Since penicillin was administered by injection, it was necessary to produce andpackage it under sterile conditions. In the new plants, the walls wereconstructed of glass so they could easily be scrubbed with an antisepticsolution. Ultraviolet lamps were used to kill microbes in the atmosphere, forgerm-free air was required. The rooms were under a slight pressure so thatsterile air would leak out and contaminated air would not leak in. Finally, allworkers in the packaging rooms took many precautions that a surgeon takes in theoperating room, such as scrubdowns and sterile clothing.¹⁵

One of the greatest handicaps in the beginning was therefusal of the Food and Drug Administration to approve penicillin inrubber-capped vials, for sufficient experience had not accumulated to determinethat the product would maintain its potency and sterility in this type ofcontainer. For many months, therefore, it was necessary for the manufacturer topackage penicillin in sealed glass vials. Early in 1944, the rubber-capped vialwas accepted, and it greatly speeded production. Another improvement, which camein 1945 and which appreciably lessened packaging problems, was the change to the200,000 Oxford-unit vial. This vial, although the same size and sealed in thesame manner, held twice as much penicillin powder and reduced packaging time andmaterials by virtually 50 percent.

As the manufacture of penicillin progressed, improvementswere made in the product itself. Originally, the product contained less than 20units per milligram; by 1945, the drug contained nearly 1,000 units permilligram. The absolutely pure product, a white crystalline powder, wouldcontain about 1,666 units per milligram. Early in 1943, all penicillin was givena "dating period" of 3 months; later in the year, this period wasincreased to 6 months; in 1944, it was placed at 9 months; and in 1945, sevenproducers were furnishing penicillin with a dating period of 18 months. Theseincreased dating periods were a great advantage, for they made packagingproblems less acute, and they permitted shipment of the product to distanttheaters of war.¹⁶

The proper distribution of penicillin required the shortestpossible time lapse between date of manufacture and date of actual use. It wasimpracti-

¹⁵Address, Brig. Gen. Edward Reynolds to Medical Departmentofficers assembled at Walter Reed General Hospital, 19 Sept. 1945, subject: Medical SupplyProblems of World War II. [Official record.]
¹⁶(1) See footnotes 3(2), p. 64; and 15, above. (2)Hornbacher, Arthur: Production Problem: Penicillin. [Official record.]

cable, therefore, for the depots and camps to carry stocks ofthe item. Penicillin was shipped by the manufacturers to the Kansas City MedicalDepot; from there, it was given automatic and immediate distribution to thevarious theaters of operations and to Army hospitals within the United States.The Surgeon General's Penicillin Board was established to divide the drugamong the various theaters and Zone of Interior installations needing it;monthly meetings were held for this purpose.

Until May 1945, penicillin production was rigidly controlledand allocated by the War Production Board. Each month, the Medical Departmentreceived its allocation, the remainder of the product going to the Navy and tocivilian hospitals. In July 1943, the Medical Department received 4,290 vials ofpenicillin. The quantity each month slowly climbed until it reached 52,729 vialsin December 1943. It was in 1944 that real quantity production began. Receiptsclimbed from 75,700 vials in January to 200,000 in April, to 1,628,000 inOctober, and to 1.9 million in December. Steady, but less spectacular, increasescontinued during the first 3 months of 1945, the March receipts beingapproximately 2 million vials. Substantially the same quantity was received eachmonth until August, when the end of hostilities led to sizable contractcancellations. During the 2-year period from June 1943 to June 1945, a reductionin price approximated 97 percent of the original price-the most remarkableprice decline of any item procured by the Medical Department.¹⁷

ATABRINE

So far as medical supplies are concerned, the most importanteffect of the early Japanese successes in the Far East was the loss of the DutchEast Indies. With a few sharp military strokes early in 1942, the Japanesemonopolized 90 percent of the world's supply of quinine. Even if the UnitedStates had remained at peace, this would have been a serious development, forquinine was used in great quantities to treat malaria in the Southern States.Since it was virtually certain that long campaigns would be fought in the mostmalarious part of the world-the South Pacific-the problem attained graveproportions. Stockpiles of quinine held by the United States and her allies werelow, and there was no reasonable hope that they could be appreciably increased.The growing of cinchona trees in South America was promising as a long-rangeproject; but, since the process required 10 years, it offered no hope ofimmediate relief.

A synthetic substitute for quinine which could beproduced quickly and in large quantities was vitally needed. Such a drug hadbeen developed by German scientists. With the use of that drug-Atabrine (quinacrinehydrochloride)-American soldiers were able to wage successful campaignsagainst Germany and her allies in the Pacific and in North Africa, Sicily, andItaly.

¹⁷(1) See footnote 15, p. 72. (2) AnnualReport, BuyingBranch No. 1, Army Medical Purchasing Office, fiscal year 1945.

American experience with this drug was not advanced in 1942,but a substantial beginning had been made. In 1931, the Winthrop Chemical Co.started the clinical investigation of Atabrine in the United States. One yearlater, the commercial synthesis was begun by a process for which someintermediate chemicals had to be imported. Under these circumstances, Winthrop'sproduction between 1933 and 1940 averaged 5 million tablets per year; which wassufficient to satisfy peacetime demands.

In September 1939, the chemical staff of the Winthrop Co.initiated a research program designed to free the United States completely fromdependence on foreign sources. The chemists found that a raw material obtainablein the United States could be converted, by two processing steps, into theintermediate which formerly had been imported. At the same time, procedures weredeveloped for synthesizing the side-chain intermediates from domestic materials.All eight individual steps in the complete Atabrine synthesis were perfected ona laboratory scale within a few months. In March 1940, construction was begun ona plant for the production of Atabrine from American materials; in September,the first factory batches of intermediates were produced; in October, the firstAtabrine of entirely domestic origin was manufactured. By the end of 1941, theannual production rate was 160 million tablets. During this year, moreover,additional equipment was installed to increase the annual capacity to 227million tablets-a quantity which, then, was considered sufficient to treat 15million cases of malaria.

In the meantime, the Medical Department, the Air Surgeon, andthe National Research Council were experimenting to determine the usefulness andtoxicity of Atabrine. Although the test results were favorable, less than 9million tablets were purchased for military purposes before 30 March 1942. Bythat time, a stockpile of approximately 35 million tablets had been accumulatedby the Winthrop Co., and the stockpile was constantly increasing for productionwas steadily rising.¹⁸

During 1942, Army requirements for Atabrine increasedtremendously, but the expansion of the Winthrop plant enabled that firm to fillall orders. A total of 146,987,300 tablets was procured by the MedicalDepartment during that year. The campaign in the Solomon Islands, which revealeda heavy incidence of malaria, made the Medical Department thoroughly aware ofthe increased demands for Atabrine. Accordingly, an Atabrine program waslaunched in 1943, which dwarfed the production of prior years. The sole patentholder, the Winthrop Chemical Co., was unable to meet the heavy requirements.The War Production Board, which assumed responsibility for the program, made asurvey and found six additional firms that could manufacture the twointermediates of the product. The Winthrop Co. licensed these companies andshared with them its manufacturing knowledge. The principal problem was toincrease the production of powder which, in a final step, was

¹⁸Hornbacher, Arthur: Production of Atabrine. [Officialrecord.] The length and complexity of the manufacturing process is indicated bythe fact that 1¹/2 tons of chemicals were required to make 100 pounds ofAtabrine-a ratio of 30 to 1. See footnote 15, p. 72.

pressed into tablet form. Some of the new sources producedthe complete Atabrine powder. Others manufactured one or both intermediates.Still others manufactured one of the intermediates, received the other fromanother manufacturer, and then combined the two into the complete Atabrinepowder. In addition to the firms developed by the War Production Board toproduce the powder, five plants were given contracts to manufacture the tablets.Three of these tabletmakers established units to combine the two intermediatesinto the complete powder.

From April to June 1943, production increased 60 percent, andby the latter month, the program outlined above was well underway. In December1943, approximately 85 percent of the scheduled capacity was producing withregularity. Early in the following year, all projected facilities were operating100 percent of planned capacity, with the result that all requirements(civilian, military, and lend-lease) were being fully supplied. Monthlyproduction of Atabrine was thus increased from 100 million tablets in 1943 tomore than 300 million in June 1944. In 1943, a total of 1,758,444,858 tabletswere delivered to the Medical Department; this was increased to 2,544,135,000tablets in 1944. If necessary, 1944's total could have been far exceeded in1945, but requirements were so fully met that no increase in production wasneeded during the remainder of the war.¹⁹

SPECTACLES

Commercial-Type Spectacles

Although spectacles had been furnished to U.S. soldiers inWorld War I, it was not anticipated that this service would again be required.Indeed, the official belief of the Surgeon General's Office as late as March1939 was that the American Red Cross could be persuaded to provide any neededspectacles. The Red Cross proved obdurate, but more than a year later, in May1940, the Army still had not come to grips with the problem. Augmented by theNational Guard and by the first increment of draftees under the SelectiveService Act, the number of erstwhile civilians in the Army continued to increasethroughout the year. But the only provisions for furnishing spectacles tomilitary personnel remained those contained in Army Regulations No. 40-1705,which authorized procurement of spectacles only when they were necessary tocorrect visual defects resulting from violence suffered in the performance ofduty. In all other cases, Army doctors were authorized to make examinations andwrite prescriptions, but it was the responsibility of the soldier to have theprescription filled at his own expense if he desired spectacles.²⁰

However effective this system may have been for Regular Armyvolunteers, who received an exacting physical examination upon enlistment, itwas

¹⁹See footnotes 13, p. 71; and 18, p. 74.
²⁰Rybak, Stanley W.: History of the Optical Program.[Official record.] This valuable essay was written by a civilian employee of theSupply Service, OTSG, who was engaged in the optical program for 4 years. Exceptas otherwise noted, Rybak's account of the optical program has been followedhere.

inappropriate for selective service inductees, many of whomwere accepted with faulty eyesight. The problem became clear in the first 6months of compulsory military service. The Medical Department was alerted in May1941 by the commanding officer of the post hospital at Fort McClellan, Ala., whoreported 75 enlisted men with glasses broken in line of duty who could notafford replacements, and others for whom glasses had been prescribed but who hadno money to buy them. In less than a month, on recommendation of The SurgeonGeneral, the Medical Department was directed to provide spectacles, repairs, andreplacements to all military personnel needing them. In the meantime, a plan hadbeen developed to obtain spectacles by letting contracts with optical suppliersin each of the nine corps areas. Since this would have involved nine separatecontracts with widely separated contractors, some of whom were unable to fillthe requirements, this plan was abandoned; and a strongly centralizedprocurement program was adopted.²¹

Requirements-Neither the official history of theMedical Department's participation in World War I, nor any other availablerecords, contained information as to probable requirements for spectacles. Therewas, therefore, no basis in experience for the estimate by medical supplyofficers that 10 percent of military personnel would have defective vision, thatone-half of those would enter the Army with their own spectacles, and that theremaining half would have to be supplied with new spectacles or withreplacements during the course of a year. In terms of this formula, it wasestimated that during 1942 a total of 200,000 pairs of spectacles would berequired. Each individual needing spectacles for the efficient performanceof his military duties was to receive one pair as soon as possible afterinduction and a second pair when he embarked for overseas.²²

After determining requirements and basis of issue, the nextstep was the selection of the most suitable spectacle frame for militarypersonnel. By a process of elimination, the choice was a metal of 10 percentnickel silver, with reinforced bridge constructed to withstand rough usage. Itwas discovered later that this frame, in warm climates, corroded easily where itcame into contact with the skin, in some instances causing discoloration of theskin and dermatitis. This was corrected by increasing the nickel silver contentto 18 percent and by constructing the pad arm, pad arm assembly, endpieces, andcable windings of pure nickel.²³

When it became known that the Medical Department waslaunching a large program to supply the troops with spectacles, numerous bidswere received from optical companies in all parts of the Nation, but only theAmerican Optical Co. and the Bausch & Lomb Optical Co. had dispensingfacilities throughout the country. Of the two, the American Optical Co. was thelow

²¹Letter, Lt. Col. F. C. Tyng, MC, to The Adjutant General,5 June 1941, subject: Spectacles for Military Personnel.
²²(1) Recollections of Col. Paul I. Robinson, MC, conveyedto Capt. Richard E. Yates, MAC, September 1944. (2) See footnote 9, p. 75.
²³See footnote 20, p. 75. In a few cases, it was necessaryto furnish Xylonite frames to individuals who were extremely susceptible todermatitis caused by contact with metal. These requirements, however, weresmall, and no special provisions were necessary to supply the frames.

bidder and received the contract. It was clear within a fewmonths, however, that the American Optical Co. could supply neither the framesnor the lenses in sufficient quantity. A contract for lenses (called aprescription contract because the product was made to fill individualprescriptions) was then given to the Bausch & Lomb Co., and contracts forspectacle frames were apportioned among nine manufacturers on the basis of theirproduction. These manufacturers constructed the frames and shipped them to thetwo prescription companies, which then divided them among their branch offices.

This spectacle program was soon beset with many troubles. Theoriginal unsubstantiated estimate, that 10 percent of the troops would havedefective vision and that one-half of these would enter the Army with their ownspectacles, proved to be seriously in error. In fact, 18 to 20 percent of allmilitary personnel required visual correction, and only a very small portion ofthese entered the service with spectacles sturdy enough to withstand fieldusage. The need for replacements was scarcely considered in the first estimates;the original requirement figures were thought to be large enough to absorbreplacements. But the experience of 1942-43 indicated that a replacementfactor of 30 percent annually was necessary.

Delivery problems-The arrangement under which thesoldier received one pair of spectacles while in training and a second pair whenhe embarked for an overseas station created a heavy burden at the staging areasand ports of embarkation. The optical companies were unable to meet the 3-daydeadline, with the result that most spectacles were mailed to APO (Army PostOffice) addresses and, in many instances, were never received by those needingthem. To solve this problem, orders were issued in 1943 directing the issuanceof both pairs of spectacles early in the training period. This change resultedin an ultimate improvement in delivery, but its most immediate effect was todeluge the branch offices with far more prescriptions than they could fill.

The original erroneous estimates of requirements, the changesin the basis of issue, and the increased rate of inductions greatly impeded thespectacle program during 1942-43. It had been estimated that 250,000 pairswould be required in 1943. Actually, 2,250,000 pairs were issued. Since, on theaverage, 5 months were required to allocate materials, process the frames andlenses, and ship them to branch offices, it is evident that the sudden increasein requirements could not promptly be translated into increased production. Theresults were soon apparent. Although the contracts stipulated that thespectacles would be delivered not later than 3 days after receipt of an order,it was not unusual for deliveries to be delayed as much as 3 or 4 months. Insome instances, men completed their training and were shipped overseas beforethey received spectacles which had been ordered during basic training. Innumerous other instances, spectacles were delivered after the soldier had leftthe camp in which he had been examined. Eventually, the spectacles wereforwarded to his next post, only to arrive once more after the soldier haddeparted. Thus, spectacles followed soldiers through many posts in the Zone ofInterior, and then repeated the process overseas. Some men never received

their spectacles; some had spectacles delivered to them at aplace and time so far removed from the eye examination that all memory of therefraction and the prescription had been erased from their minds.²⁴

Most delivery problems arose because production could notkeep pace with rising requirements, but some were due to other causes. TheBausch & Lomb Optical Co. established 12 shops, strategically locatedthroughout the country, which concentrated their attention exclusively uponmilitary orders. Since the total capacity of these shops exceeded by 10 percentthe quantity of spectacles under contract, slow deliveries were not numerousafter requirements had been stabilized. The American Optical Co., on the otherhand, depended upon a network of 250 branches and affiliated companies, eachwith a daily capacity ranging from 30 to 300 jobs. A portion of this capacity,however, was necessarily devoted to civilian needs. The larger branches,moreover, were located in the larger cities while Army camps tended to be remotefrom centers of population. An early attempt was made to hasten deliveries bythe establishment of "farm-out points." When prescriptions received bya branch exceeded the capacity allocated to military orders, the surplus wasreported to the zone headquarters, which farmed out the work to another branchoffice. This system was satisfactory, except that much time was consumed intransmitting surplus prescriptions to a zone headquarters and then to anotherbranch. At the insistence of the Medical Department, the procedure was changedso that any overflow of work was immediately and directly farmed out to thenearest branch office, and the latter delivered the spectacles to the Armyinstallation which placed the orders. This change produced some improvement; butwhen the war ended, medical supply officers were convinced that the AmericanOptical Co. could have given better service had it emulated the system of Bausch& Lomb.

Some delays in delivery were caused by the medicalinstallations which performed the eye examinations. They frequently keptprescriptions on hand until 7-10 days had elapsed, and then mailed theaccumulated total to the branch office of the optical company. Usually thisrepresented several times the capacity of the branch office, and thus it wasimpossible for that office to allocate its work to provide the 3-day service forwhich the contracts called. Many letters were written to the service commandheadquarters of the negligent installations, inspecting officers of the SurgeonGeneral's Office protested vigorously, and crisply worded directives wereissued on the subject. But failure attended all these efforts to persuade theeye clinics to mail their prescriptions daily. When the war ended, a largenumber of the clinics, in quiet defiance of the directives, continued toaccumulate the prescriptions and to send them en masse to overworked branchoffices.²⁵

²⁴Spectacles that could not be delivered were shipped tothe central stockpile at Binghamton Medical Depot. Their salvage value wassmall, for only the fronts and temples could again be utilized. The lenses,which constituted two-thirds of the cost, were scrapped. Only an expensive andelaborate salvage system could have made it possible to use them.
²⁵(1) War Department Pamphlet No. 8-5, 20 June 1944,subject: Procurement of Spectacles for Military and Other Authorized Personnel.(2) See footnote 20, p. 75.

Payment techniques.-Even after the spectacles had beendelivered and the soldier was pursuing his training duties with correctedvision, there still remained a serious and troublesome problem-auditing theoptical company's invoice and certifying it for payment. At the beginning ofthe spectacle program, all invoices were forwarded to the Finance Branch,Finance and Supply Service, and there were audited and sent to the FinanceOffice for payment. This function was soon decentralized to 12 fiscal branchoffices throughout the country, and eventually was concentrated in the regionalfiscal office at St. Louis, Mo. But the auditing of spectacle invoices, whereverit was accomplished, involved a unique problem and a prodigious amount of work.For each pair of spectacles, unless two pairs were ordered for the sameindividual at the same time, there was a separate invoice which carried anindividual price. The uniqueness of the problem lay in the fact that theaccuracy of each price had to be determined by interpreting the prescriptionand by comparing the invoice price with the contract price stipulated for thatparticular correction. The prodigious amount of work arose from the fact thatthousands of these invoices poured in each month. In the original contracts, aprice was indicated for almost every conceivable visual correction. Since theophthalmological profession did not subscribe to the view that prescriptionsshould be written in a uniform manner, the interpretation and transposition ofprescriptions became necessary.

At first, the officers and civilian employees of the FinanceBranch attempted to audit these invoices by following traditional methods. Butwhen the documents had piled up in such quantities that their sheer bulkseriously restricted the amount of space left for typewriters, adding machines,and other office equipment, it became necessary to improvise speedier and moreeffective procedures. This was accomplished by the adoption of an "assemblyline" method, in which each clerk performed a single auditing function oneach invoice and then passed it on to the next clerk. The advantages derivedfrom this division of labor enabled the fiscal officers to reduce the hugebacklog, but the enormous amount of work involved convinced them that invoicesfor spectacles should be audited in the fiscal branch offices established earlyin 1943. When the work was decentralized to the field offices, the assembly linemethod was retained; and, after the auditing of all spectacle invoices wasconcentrated in St. Louis, a high degree of speed and efficiency was obtained.

Even after these improvements, the optical companiescomplained that payments were being delayed, sometimes for as long as 5 or 6months after an order had been filled. An investigation revealed that manymedical installations retained the order form²⁶ until a large number hadaccumulated before they were forwarded to the fiscal branch office. This wascaused, in part, by allowing the order forms to accumulate for weeks, and insome instances for

²⁶The order form was a combined delivery order,contractor's invoice, and receiving report. The delivery order was signed whenthe spectacles were prescribed, the contractor's invoice was signed when thespectacles were shipped, and the receiving report was signed when the spectaclesarrived at the medical installation that had ordered them. This three-part formand the appropriate contract constituted all the documents needed to audit theaccount and certify it for payment.

months, before the medical supply officer took a day off tosign the receiving reports. Some improvement was effected by directing themedical supply officers to sign each receiving report on the day the spectaclesarrived, and by instructing the installations to forward order forms to thefiscal branch offices in groups of 100, or at least once weekly if this numberhad not been accumulated.

No figures are available which show the total cost of thespectacle program, but prices stipulated in contracts indicate that thespectacles were procured at a moderate cost. The metal frames, throughout thewar years, cost about $1 per pair. For simple visual corrections, lenses cost aslittle as 75 cents; for the more complex corrections, the cost rose to as highas $6. Considering all types of corrections, however, the Army procured completespectacles at an average price of approximately $2.50 per pair.

Gas Mask Spectacles and Inserts

The visual defects in soldiers which led the Army to furnishcommercial-type spectacles made it necessary to provide for spectacles to beworn beneath the gas mask. The most important problem involved in this programwas the design of the spectacle frames. The British attacked the problem byproducing all-purpose spectacles, practical for ordinary wear and for wearbeneath the gas mask. This was a round-eye frame with the endpiece flushagainst the eye wire and with flat temples. The Germans and Japanese, on theother hand, provided spectacles of the goggle variety which were held to theface by an elastic band encircling the head.²⁷

In the design of gas mask spectacles for U.S. militarypersonnel, both types were considered. The German and Japanese type was rejectedas unsuitable, for the elastic band forced the bridge of the goggle frame tooseverely against the nose, causing great discomfort. In addition, this elasticband caused a leakage at the temples. The British-type spectacle was finallyadopted after changes were made which, it was believed, rendered it suitable forwear beneath the Army gas mask. After some tests were made, the spectacles wereprocured and issued in the manner already described for commercial-typespectacles. At first, it was directed that all individuals requiring visualcorrection be furnished gas mask spectacles when they moved to a staging area ora port. On this basis of issue, the requirements were very high, while theperiod of time for issue was so short that many men were shipped overseaswithout the spectacles. Regulations were soon changed to provide that only thoseindividuals with a binocular visual acuity of 20/70 or worse would be furnishedgas mask spectacles; these men were to be fitted when their unit was alerted,which allowed 4 to 12 weeks for prescription and issue. This proved to be ample.

Difficulty was also encountered in fitting the spectacles (fig. 13), and in keeping them in adjustment; but there was another and far more serious defect. When the gas mask spectacles were worn, closure of the mask was not com-

²⁷See footnote 20, p. 75.

FIGURE 13.-Fitting gas mask spectacles in the Europeantheater before D-day.

plete, and a leakage at the temples was produced. Why thiswas not discovered when the spectacles were first tested has not beensatisfactorily determined; but obviously upon the basis of inadequate andmisleading tests, an unsuitable type of gas mask spectacles was adopted, and atleast 100,000 pairs were procured and issued. Not until complaints had beenreceived from the field did the Medical Department become aware of this seriousdefect. Exhaustive tests were then instituted, which proved that the spectacleswere entirely unsuitable because they induced discomfort and caused the gas maskto leak. A directive was immediately issued, prohibiting their use with the gasmask and directing that they be employed as an auxiliary pair for ordinary wear.

This development left the U.S. Army, in 1943, without anytype of visual correction to be worn beneath the gas mask. Very promptly,however, the "gas mask insert" (officially designated as the M-1 GasMask Eyeglass) was designed and accepted as standard.²⁸Thisconsisted of an eye wire supported by three brackets and attached to a frameinserted beneath the gas mask next to the lens. The fitting problems were farmore complex than those encountered

²⁸Although procured and distributed in large numbers,the gas mask insert was never considered to be more than a satisfactorymakeshift. There is no record, however, of any efforts to develop a moresatisfactory device. Instead, supply officers of the Medical Department appearedhopeful that the Chemical Warfare Service would ultimately design and adopt agas mask with which the commercial-type spectacles could be worn. This hopenever received any encouragement.

in commercial-type spectacles. Each individual appeared withhis gas mask, and the position he required was then determined. Later in theprogram, this was simplified by the adoption of a plastic guide which was markedwith the standard positions.

The basis of issue of the gas mask inserts was the same asthat finally adopted for the gas mask spectacles. Military personnel alerted foroverseas movement and who had a binocular visual acuity of 20/70 or worse weresupplied with the inserts. Procurement requirements were rather moderate-approximately 7 percent of all military personnel, with an annual maintenance orreplacement factor of 30 percent.

Prescribing and fitting gas mask inserts in Zone of Interiorinstallations involved no important difficulties other than those mentionedabove, but overseas distribution was far more complicated. By the time theinsert was developed (summer of 1943), large numbers of troops were overseas,none of whom had any suitable visual correction for use with the gas mask.Queries were addressed to the various theaters of operations, which in replysent requirements figures to the Surgeon General's Office. Stocks of fittingcases, frame inserts, and pre-edged lenses of all conceivable foci were shippedto the theaters, but there were many delays before military personnel overseaswere equipped with this type of visual correction. If gas warfare had beenemployed in 1942 and 1943, uncorrected visual defects clearly would haveappreciably weakened American fighting forces.

Optical Repair Units

For the repair and replacement of commercial-type spectaclesand gas mask inserts in overseas installations, the Medical Department developeda number of repair units and, in addition, established a stockpile at theBinghamton Medical Depot, N.Y., which furnished these units with frames, lenses,and other ophthalmic supplies.

In 1942, the Mobile Optical Repair Unit was developed (fig.14). This consisted of edging equipment, miscellaneous optical machinery(without surfacing equipment), and a large assortment of lenses, screws, andframes. The entire unit was carried in a 2?-ton truck, but wasdesigned to be removed easily and operated in a building. Eight units werepurchased and shipped to overseas installations, but the need was soon felt fora self-contained unit that could be operated in the truck body. This led to thedevelopment of a second mobile unit in which the optical equipment waspermanently housed in a 2?-ton truck. The unit was heated, hadwater and lights, and could be operated under all weather conditions. Indesigning this unit, it was decided that all equipment should be permanentlymounted on benches and that these benches should be securely attached to thefloor of the body (fig. 15). Later experience suggested, however, that it wouldhave been wiser to make the

FIGURE 14.-Mobile optical repair unit which enabled repairof spectacles closer to frontlines.

equipment removable, for occasionally a unit operated farbehind the lines and could have done better work in a building.²⁹

In addition to these two units, a third was devised in 1943.Called the Portable Optical Repair Unit, it was operated by two men and wastransported by jeep and ?-ton trailer (fig. 16). It consisted oftwo Medical Department chests containing a moderate assortment of lenses andframes, a hand-operated edging machine, a cutter, and miscellaneous opticaltools. Experience in the field indicated that this unit did not carry asufficiently wide range of foci and that the edging machine was difficult tooperate. Accordingly, a third chest was recommended for standardization, whichwould include additional lenses, fronts, temples, and an electric motor to beused with the edging equipment. Before the third chest could be placed inprocurement, the war ended and the plan was abandoned.

When the repair units were first distributed to overseastroops, the basis of issue was one mobile unit and two portable units to eachmedical supply depot.³⁰ The mobile unit, operating withthe depot,could perform about 100

²⁹See footnotes 9, p. 67; and 20, p. 75.
³⁰It was soon discovered that this basis of issue produced awaste of optical repair facilities; and in April 1944, a new Table ofOrganization and Equipment 8-500 provided a mobile unit for each 150,000troops, to be augmented by one portable unit when troops were scattered over alarge area.

FIGURE 15.-Interior of mobile optical repair unit.

jobs a day; each portable unit, moving with depot sections,furnished optical repairs and replacements to troops in forward areas, itscapacity being 15 to 20 prescription jobs a day. So far as maintaining theefficiency of combat troops was concerned, these units were valuable adjuncts tothe medical service. Before they were used, soldiers who damaged or lost theirspectacles were sent far to the rear for replacements, resulting in muchlost time and a drain upon transportation facilities. There is reason to believethat many spectacles were deliberately damaged or thrown away by soldiers whowere eager to move back from the fighting lines. When mobile and portableunits accompanied field armies, repairs and replacements were made in forwardpositions

FIGURE 16.-Portable optical repair unit loaded on jeep (?-ton vehicle).

with a minimum loss of time (fig. 17). Line officers notedwith pleasure, but with little astonishment, that the need for spectacle repairsdiminished when the repair units began to operate near the fronts. During thefiscal year ending 30 June 1945, approximately 500,000 pairs of spectacles wererepaired or replaced in all theaters of operations. This was accomplished by 50mobile units and 100 portable units.³¹

Continuous support from the Zone of Interior in bothpersonnel and supplies was required to operate the repair facilities overseas.To each mobile unit, one officer and six enlisted men were assigned,while two enlisted men operated the portable unit. These skilled personnel wereprovided by a training school at the St. Louis Medical Depot, where officer andenlisted personnel having optical experience in civilian life were given anorientation course and were instructed in the use of Army equipment. Thegraduates of this 6-week course were assigned to medical depot companies, which,in turn, formed a part of field armies.

To supply the optical repair units with stocks of frames,lenses, tools, and equipment, an optical stockpile was established at theBinghamton Medical

³¹(1) See footnote 3(2), p. 64. (2) The extent to whichthese units preserved the fighting efficiency of the troops is indicated by areport of optical activity in the European theater during the first half of 1945. The author of that report estimatedthat it would have been necessary to evacuate approximately 10,000 per month if repair facilitieshad not been available on the spot. See Greear, Lt. Col. JamesN., Jr., MC: Semi-Annual Report for Ophthalmology, 1 Jan. to 30 June 1945,European Theater.

FIGURE 17.-Portable optical repair unit in use at Oahu,Hawaii.

Depot. This stockpile contained large quantities of lenses,fronts, temples, nosepads, screws, surfacing machines, edgers, lensometers,lens cutters, and other supplies and equipment. The active theaters ofoperations established stockpiles of their own, maintained by requisitioningfrom the Binghamton Medical Depot, to supply the needs of the repair units. Allrequisitions from theaters were first edited by the Supply Service of theSurgeon General's Office, and then transmitted to Binghamton. This editingserved the twofold purpose of consolidating issue experience and maintainingcontrol over the distribution of scarce items.³²

³²See footnote 20, p. 75.

ARTIFICIAL EYE PROGRAM

Before World War II, glass used in the manufacture ofartificial eyes, as well as the glass eyes themselves, were imported fromGermany and other foreign sources. As early as 1917, an interest was evidencedin domestic production of artificial eyes for the Army. To further this end, aseries of experiments were conducted; although adequate glass eyes wereultimately produced, they were not equal in quality to those of foreignmanufacture. These experiments were discontinued before World War II when asurvey indicated that domestic dealer stocks would probably be adequate to meetArmy demands.³³ This judgment appears to have been sustained by thecourse of events for a long time. Artificial eyes were procured on an individualbasis by local purchase from the nearest civilian shop dealing in these items.Even the requirement that purchase requests be submitted to the Surgeon General'sOffice for approval before procurement action was dropped in August 1942.

Not until July 1943 was there any need for an overall supplyprogram. At that time, the New York Medical Department Procurement District wasdirected to purchase 30,000 artificial eyes for use in overseas theaters. Theywere to be stocked at the Binghamton Medical Depot, for export and distribution.Since there were then no stocks of U.S. artificial eyes in the European theater,supply to members of the U.S. Army in that theater was accomplished byprocurement through British channels. Demands for artificial eyes continued toincrease during the latter part of 1943 as a result of battle casualties andinduction of personnel with one sightless eye. It has been estimated thatbetween 8,000 and 10,000 men with only one eye were inducted into the service.³⁴

These developments forced the establishment of an artificialeye program late in 1943. The Medical Department employed an expert technicianand purchased a large assortment of glass eyes from the country's depletedstocks. Each eye purchased was handpicked by this technician. The best qualityeyes thus obtained were hurriedly shipped to the theaters of operations, wherethe need was rapidly becoming acute. Each Army hospital in the Zone of Interiorreceived a quantity of eyes, and the remainder were placed in the opticalstockpile at Binghamton. In addition, a number of expert artificial eyemakerswere employed to visit Army hospitals and to furnish custom-made artificial eyesto patients who could not be properly fitted with stock eyes.³⁵

These measures proved to be effective for only a few months.Following the Normandy landings, casualties needing artificial eyes threatenedto exhaust the available resources. It was becoming clear, also, that glassartificial eyes possessed certain characteristics that rendered themunsatisfactory for military personnel. The glass eye, either stock orcustom-made, became discolored and

³³Medical Department, United States Army. Surgery in WorldWar II. Ophthalmology and Otolaryngology. Washington: U.S. Government PrintingOffice, 1957, pp. 33-35.³⁴Randolph, M. E.: History of the Artificial EyeProgram (Glass and Plastic), 2 Jan. 1946. [Official record.]
³⁵Annual Report, Optical Section, Army Medical PurchasingOffice, 1945.

roughened after 18 to 24 months, thus creating a large andcontinuous replacement problem. In addition, the glass eye was subject toaccidental and intentional destruction; of the latter, there appears to havebeen a considerable amount, especially among the one-eyed inductees. Manyindividuals considered their induction to be unnecessary for the Army and undulyburdensome to themselves. They retaliated by dropping or breaking their glasseyes while inserting or washing them. This led to their hospitalization forseveral weeks, awaiting the arrival of stock eyes. When the replacements werereceived, the patients asserted that the new eyes did not fit and that theycould not bear the resultant discomfort. Whereupon they were sent to one of thegeneral hospitals, and there waited 1 or 2 months while custom-made eyes wereprepared for them. Under these circumstances, many individuals were issued threeor four artificial eyes during a single year, with a consequent hospitalizationof 6 or 8 months.³⁶

Still another disadvantage was attached to the procurementand issue of glass artificial eyes. They were manufactured in the United Statesby a few highly skilled craftsmen. Under ordinary circumstances, it would havebeen difficult to recruit and train additional eyemakers, and thus increaseproduction. But the circumstances were not ordinary. The craftsmen whomanufactured glass eyes looked upon themselves as the possessors of lucrativetrade secrets, which they had no intention of imparting to others. Theypossessed a monopoly, and they were determined to maintain it. Consequently, theproduction of this item could not be appreciably increased.

The foregoing disadvantages of the glass eye led the MedicalDepartment to seek a substitute. While on a trip to the European theater earlyin 1944, The Surgeon General learned that Capt. (later Maj.) Stanley F. Erpf,DC, and Capt. Sidney J. Karash, MC, had been experimenting with the fabricationof plastic artificial eyes since July 1943. Captain Erpf was recalled to theUnited States and, with two other dental officers-Majors Victor H. Dietz, DC,and Milton S. Wirtz, DC-was transferred to Valley Forge General Hospital,Phoenixville, Pa., to develop a plastic eye. By the end of September 1944, thedevelopmental process was complete. An acrylic artificial eye was produced whichwas superior to any type of prosthesis previously used. The iris was moreclosely duplicated; the fit was more nearly exact; the eye would not break; itcould be worn for long periods of time without cleaning; and, most important ofall, it could be fabricated from domestic raw materials by technicians of modesttraining and experience.

The manufacturing process was comparatively simple andrequired only about 40 man-hours for each eye. After 100 patients had beensatisfactorily

³⁶See footnote 34, p. 87. There is nodirect evidencetending to prove that th.e glass eyes were intentionally broken; but thewidespread incidence of breakage, so much higher than in civilian life, and theresentful attitude of the men together offer a strong presumption that manyalleged accidents were in fact intentional.

fitted with the new eye, it was decided that only the plasticartificial eye would be issued in the future. A training program was institutedat Valley Forge General Hospital; and the co-inventors taught 12 dentalofficers, who were then ordered to 12 general hospitals strategically locatedthroughout the country. To these general hospitals, all patients needingartificial eyes were transferred. As the number of eye casualties increased,additional officers were trained, so that by July 1945, 32 general hospitals hadestablished laboratories for the fabrication of plastic artificial eyes. Duringthe period December 1944 to December 1945, these general hospitals fitted 7,500patients with the plastic eye.³⁷

In the meantime, the theaters of operations were affectedby these developments. As a part of the program in the United States, severaldental officers were trained and sent to the Pacific theaters to introduce thenew prosthesis. The European theater opened its own school and trained dentalofficers in eye fabrication. These officers were then dispatched to generalhospitals in France and Germany, where they produced plastic eyes for battlecasualties. No figures are available which show the number of eyes fabricated inoverseas installations, but it is known that the speedy production and fittingof this prosthesis made a significant contribution to the medical service incombat areas.

HEARING AIDS

Early in the war, The Surgeon General established the policythat hearing aids would be furnished to military personnel suffering fromhearing defects incurred in line of duty and in certain other special cases.Aural rehabilitation centers were established at Deshon General Hospital,Butler, Pa.; Hoff General Hospital, Santa Barbara, Calif.; and Borden GeneralHospital, Chickasha, Okla. These centers were furnished special personnel andequipment and were authorized to purchase the appropriate hearing aids fromlocal distributors. The purchase price, which included servicing, ranged fromapproximately $135 to $160 each.

The Medical Supply Service during mid-1944, inconsultation with the Surgical Division of the Surgeon General's Office andupon advice of the National Research Council and Harvard University, developed alist of satisfactory commercial hearing aids. It was determined that aconsiderable saving in cost could be effected by centralized procurementdirectly from the manufacturers. Open-end contracts were accordingly let withseveral hearing aid firms for approximately 1,000 instruments. These contractspermitted the three aural rehabilitation centers to order prescribed hearingaids directly from the manufacturer, at a cost approximating $50 each.

³⁷(1) See footnote 34, p. 87. (2) Plastic Artificial EyeProgram, Valley Forge General Hospital, 1945. [Official record.] (3) War Department Circular No. 398,10 Oct. 1944. Section I: Artificial Eye Program.

FIGURE 18.-Fitting a hearing aid.

Concurrently with the establishment of central procurement, aprogram was developed to furnish each new user with a listing of repair partspeculiar to his type of instrument and with a letter of authorization to obtaina "loaner" hearing aid through medical supply channels if his personalinstrument became defective (fig. 18). He was also furnished with a 3-monthsupply of batteries and cords. Replacements could be obtained from his nearestaural rehabilitation center. Medical supply within the centers was responsiblefor returning all defective hearing aids to the appropriate manufacturer forrepair.

The method of central procurement remained in effect until 1June 1945 when aural rehabilitation centers were directed to submitrequisitions for hearing aids and accessories directly to the Chief, InventoryControl Branch, Army Medical Purchasing Office.³⁸

³⁸(1) War Department Circular No. 192, 27 Aug. 1943. SectionVI: Hearing Aids for Military Personnel. (2) War Department Circular No. 235, 12June 1944, subject: General Hospitals for Specialized Treatment. (3) Seefootnote 3(2), p. 64.

ORTHOPEDIC EQUIPMENT AND SUPPLIES

Orthopedic Shops

At the beginning of World War II, certain prewar namedgeneral hospitals were authorized orthopedic shop equipment, but the capabilityof each varied. All of these hospitals were directed to meet individualrequirements beyond their capability through local procurement of commercialitems. With the mushrooming of hospitals throughout the country, many inisolated areas, and with troops being mustered in by the thousands, accidentsincreased proportionately; hence, the Medical Supply Service was suddenlybesieged with requests for orthopedic facilities. Many hospitals at posts,camps, and stations, however, needed only limited facilities to prepare patientsfor evacuation to designated hospitals for definitive treatment.

At the outset, there was no standard list of equipment andsupplies for authorized shops. Furthermore, some steel items being supplied toexisting shops by medical depots from World War I stocks were found to beunsatisfactory. Attempts to effect local procurement of steel were hampered byWar Production Board controls. The situation was reviewed in June 1943, when itwas decided that all named general hospitals (eventually 65) and 6 specificstation hospitals should have orthopedic shops (fig. 19). The only exception wasDarnall General Hospital, Danville, Ky., which had mostly neuropsychiatricpatients. By mid-September, equipment lists for an orthopedic shop (equipmentand supplies) and occupational therapy equipment had been updated includingaddition of new items. The St. Louis Medical Depot was designated as the keydepot for orthopedic supplies, but station requisitions were to be submitted todesignated distribution depots for editing before being transmitted to St. Louisfor supply action.

The number of named general hospitals meanwhile increasedsteadily. Convalescent and additional station hospitals were added to the listof those authorized to operate shops, while other hospitals, already on thelist, were expanded to the extent that their shop facilities were inadequate.Also, new items were added to the equipment list for shops, and additional toolswere required for training technicians (fig. 20). Certain items were procuredby The Quartermaster General and delivered to medical depots, but virtuallyevery item of orthopedic equipment and supply, such as machines, steel, andleather, encountered a low priority rating from the War Production Board.

Delays ensued, and constant and aggressive action by theMedical Supply Service was imperative to obtain material and spread the meageravailable stocks to the best advantage in the face of valid demands from thehospital. In January 1944, the situation was again reviewed by Col. (later Brig.Gen.) Edward Reynolds, MAC, Chief of the Supply Service, and Col. Leonard T.Peterson, MC, Orthopedic Consultant to The Surgeon General. Colonels Reynoldsand Peterson concluded that availability of trained orthopedic technicians was abetter guideline for establishing and enlarging orthopedic shops

FIGURE 19.-Artificial limb fitting laboratory, Lawson General Hospital, Atlanta, Ga.

FIGURE 20.-Technicians make artificial limbs in theProcessing and Fitting Shop, Lawson General Hospital, Atlanta, Ga.

than was the patient load. Long-range planning, assuming an adequate supplyof technicians, was to be based on 40 percent orthopedic patients in generalhospitals and 66 percent in convalescent hospitals. To meet this load,orthopedic shop equipment would have to be increased by 30 percent.³⁹

Shoes

Requirements for orthopedic shoes for severely deformed feet surpassed thecapability of the shops, and eventually the volume was so great that localprocurement became impractical. In January 1945, The Quartermaster General

³⁹(1) Memorandum, Maj. Frederick Fink, MC, Chief, Procurement Advisory Branch, to Chief, Supply Service, 15 June 1943, subject: Orthopedic Shops. (2) Supply Service Code Letter IX-31, 22 Sept. 1943, subject: Station Stock Control-Orthopedic Shops. (3) Supply Service Code Letter IX-33, 29 Sept. 1943, subject: Station Stock Control-OrthopedicShop Equipment. (4) Memorandum, Col. S. B. Hays, MC, Director, Distributionand Requirements Division, to Mr. [Edward] Reynolds, Acting Chief, Supply Service, 4 Oct. 1943, subject: OrthopedicShop and Occupational Therapy Equipment. (5) Memorandum, Col. Edward Reynolds, MAC, to Lt. Col.[Oscar B.] Griggs, MC, Issue Div., and Maj. [Alvin F.] Schultz, MAC, Requirements Branch, 6 Jan.1944, subject: Preliminary Orthopedic Shop Requirements for Expanding General andConvalescent Hospitals.

accepted responsibility for the item on a reimbursable basis.At that time, instructions were published to the field on the source of supplyand method of acquiring orthopedic shoes. Prescriptions were prepared by medicalofficers; in severe cases, a cast of the foot was furnished to the BostonQuartermaster Depot, Boston, Mass. Less serious requirements were supplied bythe nearest quartermaster shop or through local procurement.⁴⁰

Prostheses

General hospitals designated as amputation centers weredirected to furnish prostheses for amputees. Such centers obtained componentsunder contracts established by the Supply Service of the Surgeon General'sOffice. Shops for each center fabricated the stump sockets and assembled thecomponents, adjusting and fitting each prosthesis to the patient (fig. 21). Upondischarge from the Army, in addition to the prostheses, each amputee was issuedone pair of shoes and three light woolen stump socks for each amputation. He wasadvised that replacements of stump socks would be furnished by facilities of theVeterans' Administration.

By 1944, production was not keeping abreast of requirementsand there was a desire to improve the prostheses. After considerable experienceand study, it was estimated that 500 artificial hands would be required by theArmy during fiscal year 1945. One firm was located which produced a satisfactoryitem. Each hand was fabricated manually, however, with a maximum monthlyproduction of 8 to 10. Efforts by the Surgeon General's Office to place acontract with this firm for 200 hands were fruitless because the output wasalready committed for the Navy and Veterans' Administration. The best thatcould be done was an agreement among representatives of the armed services, theWar Production Board, and the manufacturer that the latter should be assisted inobtaining the necessary machine tools and jigs to increase production. It wasexpected that such assistance would permit an output of 50 to 60 hands per monthfor the Army. Further study and experience suggested combined requirements forArmy, Navy, and Veterans' Administration would total 2,000 artificial handsfor calendar year 1945. Hence, in October 1944, The Surgeon General wasauthorized to contract for that quantity at a price sufficiently high to permitthe company to amortize the cost of necessary equipment. Under this arrangementthe Navy Department and the Veterans' Administration requisitioned theirrequirements from the Surgeon General's Office. In early December, thecontract was canceled because of the contractor's failure to cooperate, and anew contract was awarded to another firm at a lower cost.

⁴⁰(1) War Department Circular No. 152, 3 July 1943,Section IV: Minor Orthopedic Shoe Adjustments and Repairs. (2) Letter, Maj. W.J. Tobin, MC, Chief, Orthopedic Section, Cushing General Hospital, to Col.Leonard T. Peterson [MC], OTSG, 22 Nov. 1944, subject: Report of Meeting Relativeto the Construction of Specially-built Shoes. (3) OTSG Code Letter IX-206, 12Feb. 1945, subject: Station Stock Control-1. Requisitions for SpecialMeasurement Shoes. (4) Letter, Col. Leonard T. Peterson, MC, to The SurgeonGeneral, 26 Mar. 1945, subject: Special Built Shoes. (5) Letter, Brig. Gen. RaymondW. Bliss, Chief,Operations Services, OTSG, to Office of The Quartermaster General, attention:Maj. D. W. Black, QMC, 2 Apr. 1945, subject: Special Built Shoes. (6) WarDepartment Circular No. 346, 16 Nov. 1945, Section IV: Footwear.

FIGURE 21.-Making the final adjustment on a prosthesis.

Concurrently with this action on artificial hands, in thefourth quarter of 1944 the Soviet Purchasing Commission requested informationregarding availability of artificial limbs for the Russian Government. Althoughno firm requirements were given, it was indicated that probably 50,000 to100,000 limbs would be required. Anticipating firm requirements from theRussians, and because the Medical Department had encountered considerabledifficulty in obtaining deliveries of artificial limbs in the quantitiesrequired by the Army's amputation centers, a review of artificial limbproduction was initiated.

Artificial limbs also had been produced in this country byseveral small firms and, here again, interchangeability of parts was virtuallynil. To meet

Russia's potential demands and U.S. Army requirements, aprogram was initiated to develop improved limbs with standard interchangeableparts which could be manufactured on a volume basis. Furthermore, it was agreedthat limbs should be of such design that competitive bids could be obtained.

During the first quarter of 1945, the National Bureau ofStandards and several representatives of limb manufacturers were consulted toresolve the problem. The best features of limbs submitted by the variousmanufacturers were adopted and specifications were written to incorporate theselected features. Specifications for the composite limb were written so thatthe fiber, metal, or plastic shin sections and thigh sections could befurnished, and the limbs could be assembled from a standard scale of sizes byorthopedic shops at amputation centers. Although this program gained some groundin standardization, it did not attain the anticipated perfection oninterchangeability.⁴¹

BOOKS AND JOURNALS

Books

Before World War II, a monetary credit was established at theNew York General Depot for professional books required by stations worldwide.Requisitions were submitted by these activities to the New York General Depotwhere annual procurement was made and distribution effected.

By the latter part of 1942, selected books had becomestandard items of supply, having been added to the Medical Supply catalog and toMedical Department equipment lists. Medical units were authorized to submitrequisitions, using standard equipment lists or other tables of authorization asa basis for completing their libraries.

In November 1942, the Medical Section of the ChicagoQuartermaster Depot, Chicago, Ill., was designated as the key depot forprocurement, storage, and issue of professional books (fig. 22). Stations,however, submitted requisitions to their regular distribution depot for editing,approval, and forwarding to Chicago.

The Surgeon General's Office prepared requisitions forfurnishing books for unit assembly programs assigned to individual depots. Bookswere not packed in Zone of Interior assemblies; instead, when the requisitionwas prepared, a simultaneous requisition was sent to the Chicago QuartermasterDepot for direct shipment of the appropriate books to the station.

Beginning with fiscal year 1944, a specified monetaryallowance was also granted each Zone of Interior station, against which it couldselect and purchase professional books not included in authorization lists. Thisaction further

⁴¹(1) War Department Circular No. 347, 25 Aug. 1944.SectionI: General Hospital. (2) War Department Circular No. 367, 9 Sept. 1944. Section II:Amputation Center. (3) Supply Service Notes For The Surgeon General's Notebook (8 September to 22September), 22 Sept. 1944. (4) Supply Service Notes For The Surgeon General's Notebook (23October to 8 November), 8 Nov. 1944. (5) Supply Service Notes For The Surgeon General'sNotebook (8 December to 26 December), 26 Dec. 1944. (6) See footnote 3(2), p. 64.

FIGURE 22.-Packing room and book section, Medical Section,Chicago Quartermaster Depot.

decentralized control of book purchasing and distribution andproved to be most satisfactory.

Until the latter part of 1943, books were purchased mostlyfrom dealers, since their price quotations were practically identical with thoseof the publishers, with the advantage of cutting down materially on the numberof contracts to be written. Because most publishers were having difficulty inobtaining sufficient paper stocks under the War Production Board prioritysystem, a meeting was held in November 1943 attended by publishers, dealers, andMedical Department procurement personnel. It was decided that future quantitypurchases would be placed directly with the publishers. Only if the quantity ofbooks purchased was small would the Medical Department buy from dealers as inthe past.

In March 1944, procurement of books was assigned to the ArmyMedical Purchasing Office, excepting emergency shipments for overseas, whichcould be purchased by the St. Louis Medical Depot if necessary. In the meantime, storage and issue of all professional books was assigned to thatdepot.⁴² Accordingly, all books in stock at the Chicago QuartermasterDepot were shipped to St. Louis.

⁴²War Department Supply Bulletin SB 8-3, 21 Mar.1944, subject: Medical Department Professional Books.

Due to the publication of new editions of professional bookswhich resulted in stocks becoming obsolete, it was decided shortly after the warto abandon the practice of purchasing books for stock.

Journals

Before World War II, the Surgeon General's Office placedsubscriptions for professional journals determined to be required by medicalunits throughout the Army. This system continued until mid-1943, when a monetaryallowance was provided against which stations could purchase journals of theirown selection which did not appear in the allowance list.⁴³

Purchasing or placing of subscriptions for Medical Departmentprofessional journals was transferred from the Surgeon General's Office to theArmy Medical Purchasing Office at the same time that book purchasing wastransferred, in March 1944.⁴⁴

One of the main difficulties with journals was that of latereceipt or non-receipt by units in the overseas theaters. During the early partof the war, journals were sent to the headquarters of the various theaters forsubsequent redistribution or circulation to Medical Department units withintheir commands. Complaints of late receipt were continually received in theSurgeon General's Office until the practice was discontinued in late 1943.From that time, journals were mailed by publishers or dealers directly to theAPO for individual medical units. This system also soon came under fire as itwas next to impossible to keep current addresses for continually moving units.Further, the Internal Security Division maintained that changing APO numbersconstituted a security breach, and directed that the first APO number assignedto a unit should be used in all future mailings of journals. Activation anddeactivation of units brought forth a perpetual flow of correspondence relativeto procedures for supply of journals, a problem that remained until the end ofthe war.

PROPERTY EXCHANGE ITEMS

The Medical Service had a peculiar problem relating to thoseitems of supply and equipment which were evacuated with patients. Commonlycalled "property exchange items," these comprised blankets, litters,pajamas, splints, tracheotomy tubes, and Levin tubes, which had to be conservedand used again. In the classical system of property exchange, each element inthe evacuation chain was stocked with these items. When a vehicle of whateversort discharged its patients, it received an exact replacement for those itemsthat accompanied the patient. The vehicle then returned to its forward point oforigin and similarly replaced the items in that element. The system could be

⁴³SGO Circular Letter No. 126 (Supply No. 36), 16 July 1943,subject: Medical Books and Journals, Including Authorization for Limited LocalProcurement.
⁴⁴War Department Supply Bulletin SB 8-4, 21 Mar. 1944,subject: Medical Department Professional Journals.

operated, at least in theory, from the frontlines backthrough the communications zone to the Zone of Interior and to the hospital offinal destination.⁴⁵

Wherever the classical system of property exchange could beused, the forward elements in the chain of evacuation were automaticallyrestocked and problems were minimal. Where it could not be used, the forwardelements were rapidly depleted of these items and problems of resupplydeveloped.

The system works more smoothly when motor ambulances,hospital trains, and hospital ships, all under medical control, are the vehiclesused. When vehicles serve a dual purpose of evacuating patients to the rear andof carrying personnel or general supplies on their trips forward, the systembreaks down and other means must be used to replace losses in the forwardelements. In World War II, evacuation of patients by air, whenever practicable,soon became the method of choice. Almost all cargo planes were equipped withbrackets and straps to hold litter patients. Rarely, however, on their tripsforward did these planes carry medical property exchange items. Other cargo,either personnel or supplies, usually had a higher priority. The consequentinability to utilize the classical property exchange system, except on a smallscale, resulted in huge requirements for these items to keep the slow-movingsupply pipeline full and assure replenishment in forward units. Blankets andlitters, for example, were under constant procurement throughout the war, andreserve stocks were positioned in the Zone of Interior and at many pointsoverseas.

⁴⁵Based on recollections of Maj. Gen. Silas B. Hays,formerly Chief, Supply Service, European theater, and later The Surgeon General.

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