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Procurement of Problem Items
Procurement of medical supplies in time of war, as discussed in chapter II, was a complex, ever-changing, and frustrating duty. Among the many different articles needed desperately by the Medical Department, several were called "problem items" because of their great importance, the difficulty of obtaining them, and the large size of the requirement. Surgical dressings, blood plasma, penicillin, spectacles, and surgical instruments headed the list of these special problems.
The surgical dressings procured by the Medical Department consisted 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 aid packets and a few other special-type dressings, all these items were manufactured in large quantities for civilian use before 1939. Consequently, no difficulty was anticipated in obtaining most of them from the usual commercial channels in the event of war. During World War I, the local chapters of the American Red Cross had prepared enormous quantities of bandages, dressings, and sponges for the Medical Department; but supply officers, as late as 1939, thought that such outside aid would no longer be necessary, unless for psychological reasons.
This complacency was rudely jolted in the spring of 1940 when industry spokesmen made it clear that their plant capacity was insufficient for wartime military needs, and that any large increase in capacity would be impractical. The alternative was for the Army to purchase the appropriate material in bolt form and make its own dressings. The Medical Department abruptly 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 sufficient for peace-time needs, it is the studied opinion of this office * * * that in time of emergency full and complete reliance must be had upon the good offices of the Red Cross to furnish ready-made dressings."1
After receiving assurances that the Red Cross would extend its aid as in the First World War, the Surgeon General's Office requested and received authority "to enter into an agreement with the American Red Cross whereby the Medical Department of the United States Army may procure the requisite materials which will be turned over to the American Red Cross and receive in exchange the equivalent in prepared dressings." These dressings were to constitute "an essential war reserve."2
Local chapters of the Red Cross quickly prepared to enlist the women of America in this vital activity. Gauze was purchased from surgical dressing manufacturers, cut into rectangles or squares of the proper size, and shipped to Red Cross chapters throughout the country where volunteer workers processed the material into surgical sponges, surgical masks, and abdominal pads. These supplies were sent to medical depots to be stored until they were shipped overseas or to Zone of Interior installations. Immediately before use, they were sterilized in the central supply rooms of the hospitals to which they were issued.
From August 1942 to the end of 1944, a total of nearly 300 million yards of gauze was purchased by the Medical Department and sent to the Red Cross chapters. From this gauze, it was estimated that approximately 5 billion sponges, masks, and pads were prepared. During the winter and spring of 1945, 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 the workrooms, and in July of that year, production ceased altogether.3
It should not be assumed, however, that the aid extended by the Red Cross, valuable as it was, solved all problems involved in the procurement of surgical dressings. Labor shortages and the lack of adequate plant capacity threatened to restrict production of dressings not prepared by the Red Cross to a quantity far below anticipated requirements. Foreseeing this difficulty, procurement officers of the Medical Section, New York General Depot, New York, N.Y., called a meeting in August 1940 which was attended by representatives of all known manufacturers of surgical dressings. These representatives were informed of the procurement program, the mounting requirements in each item, and the necessity for speedy deliveries. They were told that the quantities required would be allocated to the several manufacturers on the basis of delivery time, price, and the production capacity of each firm. In accordance with these terms, bids were submitted, delivery schedules established, and contracts negotiated. The manufacturers were warned, however, that requirements were constantly increasing, and that only through an expan-
sion of plant capacity could the necessary production be attained. Help was promised in obtaining new tools, equipment, and labor.4
The requirements for surgical dressings were greatly augmented by entry of the United States into the war. In addition, lend-lease requirements and the large quantities of gauze purchased for the Red Cross placed heavy burdens upon an industry ill-equipped to bear them. There was not enough factory space, not enough looms, not enough workers, not enough bleachery capacity. In some instances, there was probably also insufficient incentive on the part of the manufacturers to produce the "gray goods" out of which surgical dressings were made, for the available looms could be far more profitably employed in weaving higher priced material. Manufacturing capacity was increased by the enlargement of factories and the addition of new equipment, usually aided by certificates of necessity providing rapid tax amortization, and by the construction with Defense Plant Corp. funds of a new factory in Greenville, S. C. Known as Convenience, Inc., the new plant produced exclusively for the Medical Department until the latter part of 1944, when a sufficient quantity of most surgical dressings had been procured.
Procurement of some items of surgical dressings was attended with considerable and peculiar difficulties, which deserve a more detailed treatment. The production of camouflage dressings, for example, created problems which could not be solved routinely. By the summer of 1943, it had been well established that white surgical dressings in the Pacific theaters were attracting the attention of Japanese snipers and pilots. The decision was made, therefore, to dye in "field brown" all field dressings used in the Pacific theaters, and in July 1943, instructions were issued to that effect. This decision presented a number of problems to the Supply Service and its contractors, including the toxicity of the dyes, effect on the absorbency of the gauze, the industry's ability to convert to dyed dressings, and the productive capacity of dyers and finishers. Outstanding contracts for several items of white dressings were modified, and work on the field brown dressings was started in September 1943. After several experiments, a nontoxic dye which had only slight 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-inch gauze compresses, compressed bandages, small first aid dressings, large first aid dressings, first aid packets, and triangular bandages were supplied either in field brown or in olive drab No. 7.5
Another production problem was the petrolatum dressing, developed late in the war. This dressing, consisting of a gauze bandage impregnated with petrolatum, permitted the application of sterile petrolatum to a burned surface and thus was a significant medical advance in a war which, more than any previous one, produced many serious and painful burns. Two technical difficulties confronted the sole supplier of this item-the development of a technique to produce a sterile dressing, and the manufacture of a greaseproof package which would withstand high sterilization temperatures. Considerable delay was experienced, also, in building the new plant necessary for the production of this item. The petrolatum and the gauze bandage were sterilized separately and were then brought together under sterile conditions. The envelope for the individual dressing was a lamination of Vinylite and aluminum foil, which was heat-sealed after the bandage was impregnated with the sterile petrolatum. Three of these dressings were then packaged in a Reynolds Metals envelope. The first shipment, consisting of 6,000 dressings, was delivered to the Kansas City Medical Depot, Kansas City, Kans., early in June 1945.6
First Aid Packets
The difficulties involved in the procurement of the first aid packet were more important and continued longer than for the petrolatum dressing. This packet contained a small, sterile dressing and was carried by each soldier in a pouch attached to his belt. Approximately 8 million were required for initial equipment, and the replacement rate was 60 per thousand men per month in the Zone of Interior and 220 per thousand in the overseas theaters.
A contract had been signed with the two suppliers in 1940 calling for the production of 2 million first aid packets, but it was estimated that delivery would not be completed until March 1942. Brass sheeting, needed to manufacture the metal case which enclosed the dressing, could not be obtained in sufficient quantities. To solve this material shortage, copper was substituted for 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 two additional suppliers were obtained who were prevailed upon to provide themselves with 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 aid packet. During the early part of 1943, with production steadily falling behind requirements, a plastic container was developed and put into production, but under field conditions the package warped and broke open. The Medical Department then worked out new specifications calling for a laminated paper and lead foil bag. The new container passed every test applied by the medical equipment laboratory at Carlisle Barracks, Pa., proving in use
to be more satisfactory than even the original brass container. It was, moreover, less expensive to manufacture.7
Although the manufacture of dried blood plasma antedates World War II, this product received such an impetus from wartime needs that it had 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 shipment was received from Sharp and Dohme, Inc., owners of the patent for processing human blood into dried plasma.8 Small additional amounts were procured during the remainder of 1941, but it was not until after the attack upon Pearl Harbor that a large-scale procurement program was launched. Blood plasma was administered to many casualties in that attack, and the beneficial results obtained in the treatment of shock, burns, and other conditions associated with the loss of blood and tissue fluids convinced medical officers that this blood substitute was imperatively demanded.
Through the cooperation of the Army, Navy, National Research Council, American Red Cross, and commercial biological manufacturers, a procurement program was instituted for the production of not less than 700,000 units of dried plasma for the Army.9 By 1943, the Red Cross had organized 33 bleeding centers and was receiving blood donations from the public at a rate of 90,000 per week. Through the efforts of the Medical Department, the patents owned by Sharp and Dohme were made available to eight other commercial laboratories without the payment of royalties. The blood obtained from the public was immediately placed in special containers, where it was kept cool by Dry Ice en route to the processors. The "bleeding" program was so planned that each processor was supplied with all the blood necessary to operate at maximum capacity.
The processing plants received the blood, put it through an intricate manufacturing process, tested the product, and shipped the units of dried plasma to medical depots in all parts of the country. The problems involved in production were numerous and important. Each laboratory had to construct special buildings for the project or convert existing structures; and had to provide itself with many items of new equipment, including refrigerating units, centrifuges, freezing units, drying units, distilling apparatus, sterilizers, and testing equipment. Emergency preference ratings were obtained to expedite production and delivery of this equipment, and, throughout the war, the Medical Department extended its aid in obtaining for the contractors such supplies
as bottles, rubber stoppers, rubber tubing, needles, filters, tin cans, waterproof packing materials, clamps, cartons, and shipping cases.
No problem in medical supplies had caused the prewar planners more concern than the procurement of surgical instruments. From 1922 until procurement planning faded into wartime procurement in 1941, it had been clearly realized that the great quantities of surgical instruments needed could be obtained only with marked difficulty. The main outlines of the problem were deceptively simple. Before 1939, approximately 85 percent of all surgical instruments had been imported from abroad, mainly from Germany. When the British blockade cut off German exports in September 1939, civilian and military users of surgical instruments were forced to turn to the manufacturing resources of the United States, which were equipped to supply only 15 percent of the normal peacetime demand. Even had this country remained at peace and made no preparations for war, the situation would have been serious. As it was, the very event which stopped the importation of surgical instruments-the outbreak of the war in Europe-led to an increase in the Armed Forces of the United States and, in consequence, to an augmented military demand for surgical instruments. The small quantities on hand which were held by importers and dealers soon passed through regular trade channels to ultimate consumers, and within a few months, the supply of instruments was critically low.
Fortunately, a movement was already afoot, even before the outbreak of the war in Europe, to increase the productive capacity of American surgical instrument manufacturers. Some American surgeons who were incensed by the Nazis' treatment of the Jews refused to use German-made instruments and purchased those of American manufacture, despite their higher cost. This provided the first real impetus for domestic manufacturers since World War I. The industry was expanded still further in 1940 and 1941, when the operation of the Selective Service Act, induction of the National Guard, and calling up of Reserves added new increments to the Army, producing still higher requirements for surgical instruments.10
Thus, when Japanese bombs at Pearl Harbor plunged the United States into the war, the Medical Department of the Army had already provided itself with expanded facilities. The next 6 months, however, comprised a hectic period in the Supply Service and one which was not conducive to speedy and orderly procurement procedures. The office was greatly expanded in personnel, but space continued to be so limited that efficient work was nearly impossible.
An inadequate and outmoded system of calculating requirements, aggravated by the paucity of "due-in" data, made it difficult to determine the quantities needed. The Supply Service, therefore, did not authorize any large-scale procurement of surgical instruments until August 1942. Over the next 3 months, the New York General Depot received requisitions for huge quantities of surgical instruments-quantities so large that purchasing officers and industry officials alike were baffled. After changing specifications for some obsolete patterns, contracts were nevertheless negotiated for the bulk of the requisitions.11
Although bids were solicited, the main emphasis was placed upon delivery time rather than low bids. Low-cost producers were paid less, and high-cost producers were paid more. The renegotiation of contracts was expected to capture excessive profits when high-cost producers overestimated their expenses. Thus, all parts of the industry which could produce acceptable surgical instruments were given Government contracts. Later, a cost analysis on all contracts for more than $10,000 was required, but in the summer and fall of 1942, this would not have been practicable. During this rush period, the entire program would have been imperiled if cost figures had been demanded. Indeed, as late as October 1944, the country's largest manufacturer of surgical instruments declared that he was still unable to furnish, in advance, reliable cost statistics.
In accordance with procurement plans prepared in the 1920's, several silverware manufacturers partially converted their plants to the fabrication of surgical instruments. By the end of 1941, five of these manufacturers had received contracts for many thousands of forceps, and, during the heavy procurement of 1942 and 1943, additional contracts were negotiated. Difficult problems developed. Experience in manufacturing surgical instruments was, of course, totally lacking. The necessary machine tools were not readily available. Workers did not possess the requisite skills. Through the cooperation of standard instrument manufacturers, these problems were solved. Skilled craftsmen were loaned to the new manufacturers to train the workers, supervise production, and establish assembly line techniques. In many ways, the standard manufacturers placed their experience and technical resources at the disposal of the erstwhile silverware makers.
The first instruments produced by the new plants did not always meet the specifications, but within a few months, the newcomers were making an acceptable product. By concentrating their energies on a few relatively simple patterns which were needed in great quantities, they ably supplemented the efforts of the regular manufacturers, making it possible for the Medical Department to satisfy its huge requirements for these items.
The lack of an approved line of samples was another obstacle to the rapid completion of the contracts, and was partly responsible for the delivery of some substandard instruments. Representatives of contractors visited medical
depots and searched the open markets to see the patterns they had been engaged to produce. Some of them later reported that they were shown samples of Japanese instruments from World War I. Finally, in the early part of 1944, a sampleroom was established at the Army Medical Purchasing Office, New York, where a display of all acceptable patterns was maintained (fig. 12).
Inadequate specifications on newer type instruments constituted another difficulty. For a number of instruments, none had been written; and when specifications were available, they frequently afforded meager data. In 1944, a program was inaugurated to bring all specifications up to date and to include specific dimensions as well as drawings.
These problems delayed production and detracted somewhat from the quality of the finished product, but the tremendous program launched in the fall of 1942 was successfully completed. Estimated deliveries of surgical instruments amounted to $25 million in 1943 and $15.5 million in 1944. In some instances, patterns were too far below the standard to be acceptable; in others, instruments that were satisfactory for their intended purpose were accepted even though they did not meet the specifications. There were a few complaints from the field, but most of these related to instruments which had been produced during World War I.12
By the spring of 1943, there was reason to believe that the incoming supply of surgical instruments was badly balanced, that many types of forceps, for example, were in "short supply," and that a surplus of other instruments was being piled up. A stock survey was promptly made which definitely proved that the patterns were ill-balanced. Drastic cutbacks were made in some contracts, and quantities were increased in others. By the end of September 1944, surpluses were fast disappearing, and additional orders were placed for many items which had been canceled in 1943.
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 was first used in the Army early in 1943, when small quantities were obtained for experimental purposes. Within a few months, it was produced in tremendous quantities and was made available to Army installations all over the world. In no other drug was the gap between experimentation and widespread use bridged with such amazing speed.
The Army program of penicillin experimentation began at Bushnell General Hospital, Brigham City, Utah, in April 1943. In June of the same 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 out with the strictest economy and solely to ascertain its usefulness, to determine its indications and contraindications, and to standardize therapeutic procedures associated with its use.13 In the meantime, penicillin was first purchased in May 1943, when two contracts were placed for 1,200 vials, each containing 100,000 Oxford units. These were special experimental contracts, for the manufacturing processes were so unsettled at the time, and the purity and potency of the product were so uncertain, that the standard contract forms did not 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 plant facilities, materials, and labor required for production. During the summer and early fall of 1943, sufficient quantities of the drug were procured to continue the experiments in Army hospitals, to determine its effectiveness, and to supply a small portion of the current needs. This period of experimental manufacture and procurement was also invaluable in providing a wealth of experience in production and packaging techniques. The period of experimental purchase ended on 1 October 1943 when standard Army contracts were awarded to eight contractors.14
This marked the beginning of the real "penicillin program" which engrossed the efforts of many purchasing officers and which was granted the highest priority accorded to any military item except the atomic bomb. Nearly every piece of equipment needed to expand production was scarce, including stainless steel piping and tanks, centrifuges, vacuum pumps, and refrigeration equipment. Building material for new production was difficult to obtain. The necessary labor in the "tight labor areas" created serious problems. In these
difficulties, the Medical Department rendered all types of effective aid within its power. Quite naturally, however, the most critical problems-production, testing, and packaging-could be solved only by the efforts of the contractors themselves.
At first, the "surface culture" method of production was universally employed, but late in 1943, experiments with the "deep vat method," similar to a process employed by brewers and probably suggested by that industry, proved successful. Most contractors made the changes in equipment necessary to use this improved technique, which resulted in a far greater production. The problem of packaging was serious. Since penicillin was administered by injection, it was necessary to produce and package it under sterile conditions. In the new plants, the walls were constructed of glass so they could easily be scrubbed with an antiseptic solution. Ultraviolet lamps were used to kill microbes in the atmosphere, for germ-free air was required. The rooms were under a slight pressure so that sterile air would leak out and contaminated air would not leak in. Finally, all workers in the packaging rooms took many precautions that a surgeon takes in the operating room, such as scrubdowns and sterile clothing.15
One of the greatest handicaps in the beginning was the refusal of the Food and Drug Administration to approve penicillin in rubber-capped vials, for sufficient experience had not accumulated to determine that the product would maintain its potency and sterility in this type of container. For many months, therefore, it was necessary for the manufacturer to package penicillin in sealed glass vials. Early in 1944, the rubber-capped vial was accepted, and it greatly speeded production. Another improvement, which came in 1945 and which appreciably lessened packaging problems, was the change to the 200,000 Oxford-unit vial. This vial, although the same size and sealed in the same manner, held twice as much penicillin powder and reduced packaging time and materials by virtually 50 percent.
As the manufacture of penicillin progressed, improvements were made in the product itself. Originally, the product contained less than 20 units per milligram; by 1945, the drug contained nearly 1,000 units per milligram. The absolutely pure product, a white crystalline powder, would contain about 1,666 units per milligram. Early in 1943, all penicillin was given a "dating period" of 3 months; later in the year, this period was increased to 6 months; in 1944, it was placed at 9 months; and in 1945, seven producers were furnishing penicillin with a dating period of 18 months. These increased dating periods were a great advantage, for they made packaging problems less acute, and they permitted shipment of the product to distant theaters of war.16
The proper distribution of penicillin required the shortest possible time lapse between date of manufacture and date of actual use. It was impracti-
cable, therefore, for the depots and camps to carry stocks of the item. Penicillin was shipped by the manufacturers to the Kansas City Medical Depot; from there, it was given automatic and immediate distribution to the various theaters of operations and to Army hospitals within the United States. The Surgeon General's Penicillin Board was established to divide the drug among the various theaters and Zone of Interior installations needing it; monthly meetings were held for this purpose.
Until May 1945, penicillin production was rigidly controlled and allocated by the War Production Board. Each month, the Medical Department received its allocation, the remainder of the product going to the Navy and to civilian hospitals. In July 1943, the Medical Department received 4,290 vials of penicillin. The quantity each month slowly climbed until it reached 52,729 vials in December 1943. It was in 1944 that real quantity production began. Receipts climbed from 75,700 vials in January to 200,000 in April, to 1,628,000 in October, and to 1.9 million in December. Steady, but less spectacular, increases continued during the first 3 months of 1945, the March receipts being approximately 2 million vials. Substantially the same quantity was received each month until August, when the end of hostilities led to sizable contract cancellations. During the 2-year period from June 1943 to June 1945, a reduction in price approximated 97 percent of the original price-the most remarkable price decline of any item procured by the Medical Department.17
So far as medical supplies are concerned, the most important effect of the early Japanese successes in the Far East was the loss of the Dutch East Indies. With a few sharp military strokes early in 1942, the Japanese monopolized 90 percent of the world's supply of quinine. Even if the United States had remained at peace, this would have been a serious development, for quinine 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 most malarious part of the world-the South Pacific-the problem attained grave proportions. Stockpiles of quinine held by the United States and her allies were low, 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-range project; but, since the process required 10 years, it offered no hope of immediate relief.
A synthetic substitute for quinine which could be produced quickly and in large quantities was vitally needed. Such a drug had been developed by German scientists. With the use of that drug-Atabrine (quinacrine hydrochloride)-American soldiers were able to wage successful campaigns against Germany and her allies in the Pacific and in North Africa, Sicily, and Italy.
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 year later, the commercial synthesis was begun by a process for which some intermediate chemicals had to be imported. Under these circumstances, Winthrop's production between 1933 and 1940 averaged 5 million tablets per year; which was sufficient 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 from dependence on foreign sources. The chemists found that a raw material obtainable in the United States could be converted, by two processing steps, into the intermediate which formerly had been imported. At the same time, procedures were developed for synthesizing the side-chain intermediates from domestic materials. All eight individual steps in the complete Atabrine synthesis were perfected on a laboratory scale within a few months. In March 1940, construction was begun on a plant for the production of Atabrine from American materials; in September, the first factory batches of intermediates were produced; in October, the first Atabrine of entirely domestic origin was manufactured. By the end of 1941, the annual production rate was 160 million tablets. During this year, moreover, additional equipment was installed to increase the annual capacity to 227 million tablets-a quantity which, then, was considered sufficient to treat 15 million cases of malaria.
In the meantime, the Medical Department, the Air Surgeon, and the National Research Council were experimenting to determine the usefulness and toxicity of Atabrine. Although the test results were favorable, less than 9 million tablets were purchased for military purposes before 30 March 1942. By that time, a stockpile of approximately 35 million tablets had been accumulated by the Winthrop Co., and the stockpile was constantly increasing for production was steadily rising.18
During 1942, Army requirements for Atabrine increased tremendously, but the expansion of the Winthrop plant enabled that firm to fill all orders. A total of 146,987,300 tablets was procured by the Medical Department during that year. The campaign in the Solomon Islands, which revealed a heavy incidence of malaria, made the Medical Department thoroughly aware of the increased demands for Atabrine. Accordingly, an Atabrine program was launched in 1943, which dwarfed the production of prior years. The sole patent holder, the Winthrop Chemical Co., was unable to meet the heavy requirements. The War Production Board, which assumed responsibility for the program, made a survey and found six additional firms that could manufacture the two intermediates of the product. The Winthrop Co. licensed these companies and shared with them its manufacturing knowledge. The principal problem was to increase the production of powder which, in a final step, was
pressed into tablet form. Some of the new sources produced the complete Atabrine powder. Others manufactured one or both intermediates. Still others manufactured one of the intermediates, received the other from another manufacturer, and then combined the two into the complete Atabrine powder. In addition to the firms developed by the War Production Board to produce the powder, five plants were given contracts to manufacture the tablets. Three of these tabletmakers established units to combine the two intermediates into the complete powder.
From April to June 1943, production increased 60 percent, and by the latter month, the program outlined above was well underway. In December 1943, approximately 85 percent of the scheduled capacity was producing with regularity. Early in the following year, all projected facilities were operating 100 percent of planned capacity, with the result that all requirements (civilian, military, and lend-lease) were being fully supplied. Monthly production of Atabrine was thus increased from 100 million tablets in 1943 to more than 300 million in June 1944. In 1943, a total of 1,758,444,858 tablets were delivered to the Medical Department; this was increased to 2,544,135,000 tablets in 1944. If necessary, 1944's total could have been far exceeded in 1945, but requirements were so fully met that no increase in production was needed during the remainder of the war.19
Although spectacles had been furnished to U.S. soldiers in World 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 March 1939 was that the American Red Cross could be persuaded to provide any needed spectacles. The Red Cross proved obdurate, but more than a year later, in May 1940, the Army still had not come to grips with the problem. Augmented by the National Guard and by the first increment of draftees under the Selective Service Act, the number of erstwhile civilians in the Army continued to increase throughout the year. But the only provisions for furnishing spectacles to military personnel remained those contained in Army Regulations No. 40-1705, which authorized procurement of spectacles only when they were necessary to correct visual defects resulting from violence suffered in the performance of duty. In all other cases, Army doctors were authorized to make examinations and write prescriptions, but it was the responsibility of the soldier to have the prescription filled at his own expense if he desired spectacles.20
However effective this system may have been for Regular Army volunteers, who received an exacting physical examination upon enlistment, it was
inappropriate for selective service inductees, many of whom were accepted with faulty eyesight. The problem became clear in the first 6 months of compulsory military service. The Medical Department was alerted in May 1941 by the commanding officer of the post hospital at Fort McClellan, Ala., who reported 75 enlisted men with glasses broken in line of duty who could not afford replacements, and others for whom glasses had been prescribed but who had no money to buy them. In less than a month, on recommendation of The Surgeon General, the Medical Department was directed to provide spectacles, repairs, and replacements to all military personnel needing them. In the meantime, a plan had been developed to obtain spectacles by letting contracts with optical suppliers in each of the nine corps areas. Since this would have involved nine separate contracts with widely separated contractors, some of whom were unable to fill the requirements, this plan was abandoned; and a strongly centralized procurement program was adopted.21
Requirements-Neither the official history of the Medical Department's participation in World War I, nor any other available records, contained information as to probable requirements for spectacles. There was, therefore, no basis in experience for the estimate by medical supply officers that 10 percent of military personnel would have defective vision, that one-half of those would enter the Army with their own spectacles, and that the remaining half would have to be supplied with new spectacles or with replacements during the course of a year. In terms of this formula, it was estimated that during 1942 a total of 200,000 pairs of spectacles would be required. Each individual needing spectacles for the efficient performance of his military duties was to receive one pair as soon as possible after induction and a second pair when he embarked for overseas.22
After determining requirements and basis of issue, the next step was the selection of the most suitable spectacle frame for military personnel. By a process of elimination, the choice was a metal of 10 percent nickel silver, with reinforced bridge constructed to withstand rough usage. It was discovered later that this frame, in warm climates, corroded easily where it came into contact with the skin, in some instances causing discoloration of the skin and dermatitis. This was corrected by increasing the nickel silver content to 18 percent and by constructing the pad arm, pad arm assembly, endpieces, and cable windings of pure nickel.23
When it became known that the Medical Department was launching a large program to supply the troops with spectacles, numerous bids were received from optical companies in all parts of the Nation, but only the American Optical Co. and the Bausch & Lomb Optical Co. had dispensing facilities throughout the country. Of the two, the American Optical Co. was the low
bidder and received the contract. It was clear within a few months, however, that the American Optical Co. could supply neither the frames nor the lenses in sufficient quantity. A contract for lenses (called a prescription contract because the product was made to fill individual prescriptions) was then given to the Bausch & Lomb Co., and contracts for spectacle frames were apportioned among nine manufacturers on the basis of their production. These manufacturers constructed the frames and shipped them to the two prescription companies, which then divided them among their branch offices.
This spectacle program was soon beset with many troubles. The original unsubstantiated estimate, that 10 percent of the troops would have defective vision and that one-half of these would enter the Army with their own spectacles, proved to be seriously in error. In fact, 18 to 20 percent of all military personnel required visual correction, and only a very small portion of these entered the service with spectacles sturdy enough to withstand field usage. The need for replacements was scarcely considered in the first estimates; the original requirement figures were thought to be large enough to absorb replacements. But the experience of 1942-43 indicated that a replacement factor of 30 percent annually was necessary.
Delivery problems-The arrangement under which the soldier received one pair of spectacles while in training and a second pair when he embarked for an overseas station created a heavy burden at the staging areas and ports of embarkation. The optical companies were unable to meet the 3-day deadline, with the result that most spectacles were mailed to APO (Army Post Office) addresses and, in many instances, were never received by those needing them. To solve this problem, orders were issued in 1943 directing the issuance of both pairs of spectacles early in the training period. This change resulted in an ultimate improvement in delivery, but its most immediate effect was to deluge the branch offices with far more prescriptions than they could fill.
The original erroneous estimates of requirements, the changes in the basis of issue, and the increased rate of inductions greatly impeded the spectacle program during 1942-43. It had been estimated that 250,000 pairs would be required in 1943. Actually, 2,250,000 pairs were issued. Since, on the average, 5 months were required to allocate materials, process the frames and lenses, and ship them to branch offices, it is evident that the sudden increase in requirements could not promptly be translated into increased production. The results were soon apparent. Although the contracts stipulated that the spectacles 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. In some instances, men completed their training and were shipped overseas before they received spectacles which had been ordered during basic training. In numerous other instances, spectacles were delivered after the soldier had left the camp in which he had been examined. Eventually, the spectacles were forwarded to his next post, only to arrive once more after the soldier had departed. Thus, spectacles followed soldiers through many posts in the Zone of Interior, and then repeated the process overseas. Some men never received
their spectacles; some had spectacles delivered to them at a place and time so far removed from the eye examination that all memory of the refraction and the prescription had been erased from their minds.24
Most delivery problems arose because production could not keep pace with rising requirements, but some were due to other causes. The Bausch & Lomb Optical Co. established 12 shops, strategically located throughout the country, which concentrated their attention exclusively upon military orders. Since the total capacity of these shops exceeded by 10 percent the quantity of spectacles under contract, slow deliveries were not numerous after requirements had been stabilized. The American Optical Co., on the other hand, depended upon a network of 250 branches and affiliated companies, each with 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 remote from centers of population. An early attempt was made to hasten deliveries by the establishment of "farm-out points." When prescriptions received by a branch exceeded the capacity allocated to military orders, the surplus was reported to the zone headquarters, which farmed out the work to another branch office. This system was satisfactory, except that much time was consumed in transmitting surplus prescriptions to a zone headquarters and then to another branch. At the insistence of the Medical Department, the procedure was changed so that any overflow of work was immediately and directly farmed out to the nearest branch office, and the latter delivered the spectacles to the Army installation which placed the orders. This change produced some improvement; but when the war ended, medical supply officers were convinced that the American Optical Co. could have given better service had it emulated the system of Bausch & Lomb.
Some delays in delivery were caused by the medical installations which performed the eye examinations. They frequently kept prescriptions on hand until 7-10 days had elapsed, and then mailed the accumulated total to the branch office of the optical company. Usually this represented several times the capacity of the branch office, and thus it was impossible for that office to allocate its work to provide the 3-day service for which the contracts called. Many letters were written to the service command headquarters of the negligent installations, inspecting officers of the Surgeon General's Office protested vigorously, and crisply worded directives were issued on the subject. But failure attended all these efforts to persuade the eye clinics to mail their prescriptions daily. When the war ended, a large number of the clinics, in quiet defiance of the directives, continued to accumulate the prescriptions and to send them en masse to overworked branch offices.25
Payment techniques.-Even after the spectacles had been delivered and the soldier was pursuing his training duties with corrected vision, there still remained a serious and troublesome problem-auditing the optical company's invoice and certifying it for payment. At the beginning of the spectacle program, all invoices were forwarded to the Finance Branch, Finance and Supply Service, and there were audited and sent to the Finance Office for payment. This function was soon decentralized to 12 fiscal branch offices throughout the country, and eventually was concentrated in the regional fiscal office at St. Louis, Mo. But the auditing of spectacle invoices, wherever it was accomplished, involved a unique problem and a prodigious amount of work. For each pair of spectacles, unless two pairs were ordered for the same individual at the same time, there was a separate invoice which carried an individual price. The uniqueness of the problem lay in the fact that the accuracy of each price had to be determined by interpreting the prescription and by comparing the invoice price with the contract price stipulated for that particular correction. The prodigious amount of work arose from the fact that thousands of these invoices poured in each month. In the original contracts, a price was indicated for almost every conceivable visual correction. Since the ophthalmological profession did not subscribe to the view that prescriptions should be written in a uniform manner, the interpretation and transposition of prescriptions became necessary.
At first, the officers and civilian employees of the Finance Branch attempted to audit these invoices by following traditional methods. But when the documents had piled up in such quantities that their sheer bulk seriously restricted the amount of space left for typewriters, adding machines, and other office equipment, it became necessary to improvise speedier and more effective procedures. This was accomplished by the adoption of an "assembly line" method, in which each clerk performed a single auditing function on each invoice and then passed it on to the next clerk. The advantages derived from this division of labor enabled the fiscal officers to reduce the huge backlog, but the enormous amount of work involved convinced them that invoices for spectacles should be audited in the fiscal branch offices established early in 1943. When the work was decentralized to the field offices, the assembly line method was retained; and, after the auditing of all spectacle invoices was concentrated in St. Louis, a high degree of speed and efficiency was obtained.
Even after these improvements, the optical companies complained that payments were being delayed, sometimes for as long as 5 or 6 months after an order had been filled. An investigation revealed that many medical installations retained the order form26 until a large number had accumulated before they were forwarded to the fiscal branch office. This was caused, in part, by allowing the order forms to accumulate for weeks, and in some instances for
months, before the medical supply officer took a day off to sign the receiving reports. Some improvement was effected by directing the medical supply officers to sign each receiving report on the day the spectacles arrived, and by instructing the installations to forward order forms to the fiscal branch offices in groups of 100, or at least once weekly if this number had not been accumulated.
No figures are available which show the total cost of the spectacle program, but prices stipulated in contracts indicate that the spectacles were procured at a moderate cost. The metal frames, throughout the war years, cost about $1 per pair. For simple visual corrections, lenses cost as little as 75 cents; for the more complex corrections, the cost rose to as high as $6. Considering all types of corrections, however, the Army procured complete spectacles 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 furnish commercial-type spectacles made it necessary to provide for spectacles to be worn beneath the gas mask. The most important problem involved in this program was the design of the spectacle frames. The British attacked the problem by producing all-purpose spectacles, practical for ordinary wear and for wear beneath the gas mask. This was a round-eye frame with the endpiece flush against the eye wire and with flat temples. The Germans and Japanese, on the other hand, provided spectacles of the goggle variety which were held to the face by an elastic band encircling the head.27
In the design of gas mask spectacles for U.S. military personnel, both types were considered. The German and Japanese type was rejected as unsuitable, for the elastic band forced the bridge of the goggle frame too severely against the nose, causing great discomfort. In addition, this elastic band caused a leakage at the temples. The British-type spectacle was finally adopted after changes were made which, it was believed, rendered it suitable for wear beneath the Army gas mask. After some tests were made, the spectacles were procured and issued in the manner already described for commercial-type spectacles. At first, it was directed that all individuals requiring visual correction be furnished gas mask spectacles when they moved to a staging area or a port. On this basis of issue, the requirements were very high, while the period of time for issue was so short that many men were shipped overseas without the spectacles. Regulations were soon changed to provide that only those individuals with a binocular visual acuity of 20/70 or worse would be furnished gas 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-
plete, and a leakage at the temples was produced. Why this was not discovered when the spectacles were first tested has not been satisfactorily determined; but obviously upon the basis of inadequate and misleading tests, an unsuitable type of gas mask spectacles was adopted, and at least 100,000 pairs were procured and issued. Not until complaints had been received from the field did the Medical Department become aware of this serious defect. Exhaustive tests were then instituted, which proved that the spectacles were entirely unsuitable because they induced discomfort and caused the gas mask to leak. A directive was immediately issued, prohibiting their use with the gas mask and directing that they be employed as an auxiliary pair for ordinary wear.
This development left the U.S. Army, in 1943, without any type of visual correction to be worn beneath the gas mask. Very promptly, however, the "gas mask insert" (officially designated as the M-1 Gas Mask Eyeglass) was designed and accepted as standard.28 This consisted of an eye wire supported by three brackets and attached to a frame inserted beneath the gas mask next to the lens. The fitting problems were far more complex than those encountered
in commercial-type spectacles. Each individual appeared with his gas mask, and the position he required was then determined. Later in the program, this was simplified by the adoption of a plastic guide which was marked with the standard positions.
The basis of issue of the gas mask inserts was the same as that finally adopted for the gas mask spectacles. Military personnel alerted for overseas movement and who had a binocular visual acuity of 20/70 or worse were supplied with the inserts. Procurement requirements were rather moderate-approximately 7 percent of all military personnel, with an annual maintenance or replacement factor of 30 percent.
Prescribing and fitting gas mask inserts in Zone of Interior installations involved no important difficulties other than those mentioned above, but overseas distribution was far more complicated. By the time the insert 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 reply sent requirements figures to the Surgeon General's Office. Stocks of fitting cases, frame inserts, and pre-edged lenses of all conceivable foci were shipped to the theaters, but there were many delays before military personnel overseas were equipped with this type of visual correction. If gas warfare had been employed in 1942 and 1943, uncorrected visual defects clearly would have appreciably weakened American fighting forces.
Optical Repair Units
For the repair and replacement of commercial-type spectacles and gas mask inserts in overseas installations, the Medical Department developed a number of repair units and, in addition, established a stockpile at the Binghamton 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, and frames. The entire unit was carried in a 2½-ton truck, but was designed to be removed easily and operated in a building. Eight units were purchased and shipped to overseas installations, but the need was soon felt for a self-contained unit that could be operated in the truck body. This led to the development of a second mobile unit in which the optical equipment was permanently housed in a 2½-ton truck. The unit was heated, had water and lights, and could be operated under all weather conditions. In designing this unit, it was decided that all equipment should be permanently mounted on benches and that these benches should be securely attached to the floor of the body (fig. 15). Later experience suggested, however, that it would have been wiser to make the
equipment removable, for occasionally a unit operated far behind 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 was transported by jeep and ¼-ton trailer (fig. 16). It consisted of two Medical Department chests containing a moderate assortment of lenses and frames, a hand-operated edging machine, a cutter, and miscellaneous optical tools. Experience in the field indicated that this unit did not carry a sufficiently wide range of foci and that the edging machine was difficult to operate. Accordingly, a third chest was recommended for standardization, which would include additional lenses, fronts, temples, and an electric motor to be used with the edging equipment. Before the third chest could be placed in procurement, the war ended and the plan was abandoned.
When the repair units were first distributed to overseas troops, the basis of issue was one mobile unit and two portable units to each medical supply depot.30 The mobile unit, operating with the depot, could perform about 100
jobs a day; each portable unit, moving with depot sections, furnished optical repairs and replacements to troops in forward areas, its capacity being 15 to 20 prescription jobs a day. So far as maintaining the efficiency of combat troops was concerned, these units were valuable adjuncts to the medical service. Before they were used, soldiers who damaged or lost their spectacles were sent far to the rear for replacements, resulting in much lost time and a drain upon transportation facilities. There is reason to believe that many spectacles were deliberately damaged or thrown away by soldiers who were eager to move back from the fighting lines. When mobile and portable units accompanied field armies, repairs and replacements were made in forward positions
with a minimum loss of time (fig. 17). Line officers noted with pleasure, but with little astonishment, that the need for spectacle repairs diminished when the repair units began to operate near the fronts. During the fiscal year ending 30 June 1945, approximately 500,000 pairs of spectacles were repaired or replaced in all theaters of operations. This was accomplished by 50 mobile units and 100 portable units.31
Continuous support from the Zone of Interior in both personnel 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 were provided by a training school at the St. Louis Medical Depot, where officer and enlisted personnel having optical experience in civilian life were given an orientation course and were instructed in the use of Army equipment. The graduates 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 the Binghamton Medical
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 of operations established stockpiles of their own, maintained by requisitioning from the Binghamton Medical Depot, to supply the needs of the repair units. All requisitions from theaters were first edited by the Supply Service of the Surgeon General's Office, and then transmitted to Binghamton. This editing served the twofold purpose of consolidating issue experience and maintaining control over the distribution of scarce items.32
ARTIFICIAL EYE PROGRAM
Before World War II, glass used in the manufacture of artificial eyes, as well as the glass eyes themselves, were imported from Germany and other foreign sources. As early as 1917, an interest was evidenced in domestic production of artificial eyes for the Army. To further this end, a series of experiments were conducted; although adequate glass eyes were ultimately produced, they were not equal in quality to those of foreign manufacture. These experiments were discontinued before World War II when a survey indicated that domestic dealer stocks would probably be adequate to meet Army demands.33 This judgment appears to have been sustained by the course of events for a long time. Artificial eyes were procured on an individual basis by local purchase from the nearest civilian shop dealing in these items. Even the requirement that purchase requests be submitted to the Surgeon General's Office for approval before procurement action was dropped in August 1942.
Not until July 1943 was there any need for an overall supply program. At that time, the New York Medical Department Procurement District was directed to purchase 30,000 artificial eyes for use in overseas theaters. They were 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 by procurement through British channels. Demands for artificial eyes continued to increase during the latter part of 1943 as a result of battle casualties and induction of personnel with one sightless eye. It has been estimated that between 8,000 and 10,000 men with only one eye were inducted into the service.34
These developments forced the establishment of an artificial eye program late in 1943. The Medical Department employed an expert technician and purchased a large assortment of glass eyes from the country's depleted stocks. Each eye purchased was handpicked by this technician. The best quality eyes thus obtained were hurriedly shipped to the theaters of operations, where the need was rapidly becoming acute. Each Army hospital in the Zone of Interior received a quantity of eyes, and the remainder were placed in the optical stockpile at Binghamton. In addition, a number of expert artificial eyemakers were employed to visit Army hospitals and to furnish custom-made artificial eyes to 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 threatened to exhaust the available resources. It was becoming clear, also, that glass artificial eyes possessed certain characteristics that rendered them unsatisfactory for military personnel. The glass eye, either stock or custom-made, became discolored and
roughened after 18 to 24 months, thus creating a large and continuous replacement problem. In addition, the glass eye was subject to accidental and intentional destruction; of the latter, there appears to have been a considerable amount, especially among the one-eyed inductees. Many individuals considered their induction to be unnecessary for the Army and unduly burdensome to themselves. They retaliated by dropping or breaking their glass eyes while inserting or washing them. This led to their hospitalization for several weeks, awaiting the arrival of stock eyes. When the replacements were received, the patients asserted that the new eyes did not fit and that they could not bear the resultant discomfort. Whereupon they were sent to one of the general hospitals, and there waited 1 or 2 months while custom-made eyes were prepared for them. Under these circumstances, many individuals were issued three or four artificial eyes during a single year, with a consequent hospitalization of 6 or 8 months.36
Still another disadvantage was attached to the procurement and issue of glass artificial eyes. They were manufactured in the United States by a few highly skilled craftsmen. Under ordinary circumstances, it would have been difficult to recruit and train additional eyemakers, and thus increase production. But the circumstances were not ordinary. The craftsmen who manufactured glass eyes looked upon themselves as the possessors of lucrative trade secrets, which they had no intention of imparting to others. They possessed a monopoly, and they were determined to maintain it. Consequently, the production of this item could not be appreciably increased.
The foregoing disadvantages of the glass eye led the Medical Department to seek a substitute. While on a trip to the European theater early in 1944, The Surgeon General learned that Capt. (later Maj.) Stanley F. Erpf, DC, and Capt. Sidney J. Karash, MC, had been experimenting with the fabrication of plastic artificial eyes since July 1943. Captain Erpf was recalled to the United 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, the developmental process was complete. An acrylic artificial eye was produced which was superior to any type of prosthesis previously used. The iris was more closely duplicated; the fit was more nearly exact; the eye would not break; it could be worn for long periods of time without cleaning; and, most important of all, it could be fabricated from domestic raw materials by technicians of modest training and experience.
The manufacturing process was comparatively simple and required only about 40 man-hours for each eye. After 100 patients had been satisfactorily
fitted with the new eye, it was decided that only the plastic artificial eye would be issued in the future. A training program was instituted at Valley Forge General Hospital; and the co-inventors taught 12 dental officers, who were then ordered to 12 general hospitals strategically located throughout the country. To these general hospitals, all patients needing artificial eyes were transferred. As the number of eye casualties increased, additional officers were trained, so that by July 1945, 32 general hospitals had established laboratories for the fabrication of plastic artificial eyes. During the period December 1944 to December 1945, these general hospitals fitted 7,500 patients with the plastic eye.37
In the meantime, the theaters of operations were affected by these developments. As a part of the program in the United States, several dental officers were trained and sent to the Pacific theaters to introduce the new prosthesis. The European theater opened its own school and trained dental officers in eye fabrication. These officers were then dispatched to general hospitals in France and Germany, where they produced plastic eyes for battle casualties. No figures are available which show the number of eyes fabricated in overseas installations, but it is known that the speedy production and fitting of this prosthesis made a significant contribution to the medical service in combat areas.
Early in the war, The Surgeon General established the policy that hearing aids would be furnished to military personnel suffering from hearing 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 General Hospital, Chickasha, Okla. These centers were furnished special personnel and equipment and were authorized to purchase the appropriate hearing aids from local distributors. The purchase price, which included servicing, ranged from approximately $135 to $160 each.
The Medical Supply Service during mid-1944, in consultation with the Surgical Division of the Surgeon General's Office and upon advice of the National Research Council and Harvard University, developed a list of satisfactory commercial hearing aids. It was determined that a considerable saving in cost could be effected by centralized procurement directly from the manufacturers. Open-end contracts were accordingly let with several hearing aid firms for approximately 1,000 instruments. These contracts permitted the three aural rehabilitation centers to order prescribed hearing aids directly from the manufacturer, at a cost approximating $50 each.
Concurrently with the establishment of central procurement, a program was developed to furnish each new user with a listing of repair parts peculiar to his type of instrument and with a letter of authorization to obtain a "loaner" hearing aid through medical supply channels if his personal instrument became defective (fig. 18). He was also furnished with a 3-month supply of batteries and cords. Replacements could be obtained from his nearest aural rehabilitation center. Medical supply within the centers was responsible for returning all defective hearing aids to the appropriate manufacturer for repair.
The method of central procurement remained in effect until 1 June 1945 when aural rehabilitation centers were directed to submit requisitions for hearing aids and accessories directly to the Chief, Inventory Control Branch, Army Medical Purchasing Office.38
ORTHOPEDIC EQUIPMENT AND SUPPLIES
At the beginning of World War II, certain prewar named general hospitals were authorized orthopedic shop equipment, but the capability of each varied. All of these hospitals were directed to meet individual requirements beyond their capability through local procurement of commercial items. With the mushrooming of hospitals throughout the country, many in isolated areas, and with troops being mustered in by the thousands, accidents increased proportionately; hence, the Medical Supply Service was suddenly besieged with requests for orthopedic facilities. Many hospitals at posts, camps, and stations, however, needed only limited facilities to prepare patients for evacuation to designated hospitals for definitive treatment.
At the outset, there was no standard list of equipment and supplies for authorized shops. Furthermore, some steel items being supplied to existing shops by medical depots from World War I stocks were found to be unsatisfactory. Attempts to effect local procurement of steel were hampered by War Production Board controls. The situation was reviewed in June 1943, when it was decided that all named general hospitals (eventually 65) and 6 specific station hospitals should have orthopedic shops (fig. 19). The only exception was Darnall General Hospital, Danville, Ky., which had mostly neuropsychiatric patients. By mid-September, equipment lists for an orthopedic shop (equipment and supplies) and occupational therapy equipment had been updated including addition of new items. The St. Louis Medical Depot was designated as the key depot for orthopedic supplies, but station requisitions were to be submitted to designated distribution depots for editing before being transmitted to St. Louis for supply action.
The number of named general hospitals meanwhile increased steadily. Convalescent and additional station hospitals were added to the list of those authorized to operate shops, while other hospitals, already on the list, were expanded to the extent that their shop facilities were inadequate. Also, new items were added to the equipment list for shops, and additional tools were required for training technicians (fig. 20). Certain items were procured by The Quartermaster General and delivered to medical depots, but virtually every item of orthopedic equipment and supply, such as machines, steel, and leather, encountered a low priority rating from the War Production Board.
Delays ensued, and constant and aggressive action by the Medical Supply Service was imperative to obtain material and spread the meager available stocks to the best advantage in the face of valid demands from the hospital. 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 Reynolds and Peterson concluded that availability of trained orthopedic technicians was a better guideline for establishing and enlarging orthopedic shops
than was the patient load. Long-range planning, assuming an adequate supply of technicians, was to be based on 40 percent orthopedic patients in general hospitals and 66 percent in convalescent hospitals. To meet this load, orthopedic shop equipment would have to be increased by 30 percent.39Shoes
Requirements for orthopedic shoes for severely deformed feet surpassed the capability of the shops, and eventually the volume was so great that local procurement became impractical. In January 1945, The Quartermaster General
accepted responsibility for the item on a reimbursable basis. At that time, instructions were published to the field on the source of supply and method of acquiring orthopedic shoes. Prescriptions were prepared by medical officers; in severe cases, a cast of the foot was furnished to the Boston Quartermaster Depot, Boston, Mass. Less serious requirements were supplied by the nearest quartermaster shop or through local procurement.40
General hospitals designated as amputation centers were directed to furnish prostheses for amputees. Such centers obtained components under contracts established by the Supply Service of the Surgeon General's Office. Shops for each center fabricated the stump sockets and assembled the components, adjusting and fitting each prosthesis to the patient (fig. 21). Upon discharge from the Army, in addition to the prostheses, each amputee was issued one pair of shoes and three light woolen stump socks for each amputation. He was advised that replacements of stump socks would be furnished by facilities of the Veterans' Administration.
By 1944, production was not keeping abreast of requirements and there was a desire to improve the prostheses. After considerable experience and study, it was estimated that 500 artificial hands would be required by the Army during fiscal year 1945. One firm was located which produced a satisfactory item. Each hand was fabricated manually, however, with a maximum monthly production of 8 to 10. Efforts by the Surgeon General's Office to place a contract with this firm for 200 hands were fruitless because the output was already committed for the Navy and Veterans' Administration. The best that could be done was an agreement among representatives of the armed services, the War Production Board, and the manufacturer that the latter should be assisted in obtaining the necessary machine tools and jigs to increase production. It was expected that such assistance would permit an output of 50 to 60 hands per month for the Army. Further study and experience suggested combined requirements for Army, Navy, and Veterans' Administration would total 2,000 artificial hands for calendar year 1945. Hence, in October 1944, The Surgeon General was authorized to contract for that quantity at a price sufficiently high to permit the company to amortize the cost of necessary equipment. Under this arrangement the Navy Department and the Veterans' Administration requisitioned their requirements from the Surgeon General's Office. In early December, the contract was canceled because of the contractor's failure to cooperate, and a new contract was awarded to another firm at a lower cost.
Concurrently with this action on artificial hands, in the fourth quarter of 1944 the Soviet Purchasing Commission requested information regarding availability of artificial limbs for the Russian Government. Although no firm requirements were given, it was indicated that probably 50,000 to 100,000 limbs would be required. Anticipating firm requirements from the Russians, and because the Medical Department had encountered considerable difficulty in obtaining deliveries of artificial limbs in the quantities required by the Army's amputation centers, a review of artificial limb production was initiated.
Artificial limbs also had been produced in this country by several small firms and, here again, interchangeability of parts was virtually nil. To meet
Russia's potential demands and U.S. Army requirements, a program was initiated to develop improved limbs with standard interchangeable parts which could be manufactured on a volume basis. Furthermore, it was agreed that limbs should be of such design that competitive bids could be obtained.
During the first quarter of 1945, the National Bureau of Standards and several representatives of limb manufacturers were consulted to resolve the problem. The best features of limbs submitted by the various manufacturers were adopted and specifications were written to incorporate the selected features. Specifications for the composite limb were written so that the fiber, metal, or plastic shin sections and thigh sections could be furnished, and the limbs could be assembled from a standard scale of sizes by orthopedic shops at amputation centers. Although this program gained some ground in standardization, it did not attain the anticipated perfection on interchangeability.41
BOOKS AND JOURNALS
Before World War II, a monetary credit was established at the New York General Depot for professional books required by stations worldwide. Requisitions were submitted by these activities to the New York General Depot where annual procurement was made and distribution effected.
By the latter part of 1942, selected books had become standard items of supply, having been added to the Medical Supply catalog and to Medical Department equipment lists. Medical units were authorized to submit requisitions, using standard equipment lists or other tables of authorization as a basis for completing their libraries.
In November 1942, the Medical Section of the Chicago Quartermaster Depot, Chicago, Ill., was designated as the key depot for procurement, 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 for furnishing books for unit assembly programs assigned to individual depots. Books were not packed in Zone of Interior assemblies; instead, when the requisition was prepared, a simultaneous requisition was sent to the Chicago Quartermaster Depot for direct shipment of the appropriate books to the station.
Beginning with fiscal year 1944, a specified monetary allowance was also granted each Zone of Interior station, against which it could select and purchase professional books not included in authorization lists. This action further
decentralized control of book purchasing and distribution and proved to be most satisfactory.
Until the latter part of 1943, books were purchased mostly from dealers, since their price quotations were practically identical with those of the publishers, with the advantage of cutting down materially on the number of contracts to be written. Because most publishers were having difficulty in obtaining sufficient paper stocks under the War Production Board priority system, a meeting was held in November 1943 attended by publishers, dealers, and Medical Department procurement personnel. It was decided that future quantity purchases would be placed directly with the publishers. Only if the quantity of books purchased was small would the Medical Department buy from dealers as in the past.
In March 1944, procurement of books was assigned to the Army Medical Purchasing Office, excepting emergency shipments for overseas, which could be purchased by the St. Louis Medical Depot if necessary. In the meantime, storage and issue of all professional books was assigned to that depot.42 Accordingly, all books in stock at the Chicago Quartermaster Depot were shipped to St. Louis.
Due to the publication of new editions of professional books which resulted in stocks becoming obsolete, it was decided shortly after the war to abandon the practice of purchasing books for stock.
Before World War II, the Surgeon General's Office placed subscriptions for professional journals determined to be required by medical units throughout the Army. This system continued until mid-1943, when a monetary allowance was provided against which stations could purchase journals of their own selection which did not appear in the allowance list.43
Purchasing or placing of subscriptions for Medical Department professional journals was transferred from the Surgeon General's Office to the Army Medical Purchasing Office at the same time that book purchasing was transferred, in March 1944.44
One of the main difficulties with journals was that of late receipt or non-receipt by units in the overseas theaters. During the early part of the war, journals were sent to the headquarters of the various theaters for subsequent redistribution or circulation to Medical Department units within their commands. Complaints of late receipt were continually received in the Surgeon General's Office until the practice was discontinued in late 1943. From that time, journals were mailed by publishers or dealers directly to the APO for individual medical units. This system also soon came under fire as it was next to impossible to keep current addresses for continually moving units. Further, the Internal Security Division maintained that changing APO numbers constituted a security breach, and directed that the first APO number assigned to a unit should be used in all future mailings of journals. Activation and deactivation of units brought forth a perpetual flow of correspondence relative to procedures for supply of journals, a problem that remained until the end of the war.
PROPERTY EXCHANGE ITEMS
The Medical Service had a peculiar problem relating to those items of supply and equipment which were evacuated with patients. Commonly called "property exchange items," these comprised blankets, litters, pajamas, splints, tracheotomy tubes, and Levin tubes, which had to be conserved and used again. In the classical system of property exchange, each element in the evacuation chain was stocked with these items. When a vehicle of whatever sort discharged its patients, it received an exact replacement for those items that accompanied the patient. The vehicle then returned to its forward point of origin and similarly replaced the items in that element. The system could be
operated, at least in theory, from the frontlines back through the communications zone to the Zone of Interior and to the hospital of final destination.45
Wherever the classical system of property exchange could be used, the forward elements in the chain of evacuation were automatically restocked and problems were minimal. Where it could not be used, the forward elements were rapidly depleted of these items and problems of resupply developed.
The system works more smoothly when motor ambulances, hospital trains, and hospital ships, all under medical control, are the vehicles used. When vehicles serve a dual purpose of evacuating patients to the rear and of carrying personnel or general supplies on their trips forward, the system breaks down and other means must be used to replace losses in the forward elements. In World War II, evacuation of patients by air, whenever practicable, soon became the method of choice. Almost all cargo planes were equipped with brackets and straps to hold litter patients. Rarely, however, on their trips forward did these planes carry medical property exchange items. Other cargo, either personnel or supplies, usually had a higher priority. The consequent inability to utilize the classical property exchange system, except on a small scale, resulted in huge requirements for these items to keep the slow-moving supply pipeline full and assure replenishment in forward units. Blankets and litters, for example, were under constant procurement throughout the war, and reserve stocks were positioned in the Zone of Interior and at many points overseas.