U.S. Army Medical Department, Office of Medical History
Skip Navigation, go to content

HISTORY OF THE OFFICE OF MEDICAL HISTORY

AMEDD BIOGRAPHIES

AMEDD CORPS HISTORY

BOOKS AND DOCUMENTS

HISTORICAL ART WORK & IMAGES

MEDICAL MEMOIRS

AMEDD MEDAL OF HONOR RECIPIENTS External Link, Opens in New Window

ORGANIZATIONAL HISTORIES

THE SURGEONS GENERAL

ANNUAL REPORTS OF THE SURGEON GENERAL

AMEDD UNIT PATCHES AND LINEAGE

THE AMEDD HISTORIAN NEWSLETTER

Chapter V

Contents

CHAPTER V

Storage and Distribution of Medical Supplies

PACKING AND PACKAGING PROBLEMS

When the United States entered World War II and began to ship great quantities of medical supplies to overseas theaters, no preparations had been made to meet the packing problems which soon developed. The sturdy wooden boxes which had been used in peacetime became scarce because of acute lumber shortages. Packing specifications continued to call for containers designed "in accordance with good commercial practices" or provided that the supplies "shall be packed in a manner to withstand shipment and reshipment," but interpretation of these specifications soon became more lenient. In 1942, the customary shipping containers were flimsy, open-slatted crates, thin plywood boxes for heavier items, and corrugated paper cartons and boxes for bottles, textiles, and miscellaneous items. No special efforts were made to prevent corrosion, rust, insect damage, or other ill effects of exposure to dampness, heat, and rough treatment in handling.1

The circumstances under which the Medical Department dispatched its supplies to overseas stations had unfortunate effects upon the weak, ill-designed packing containers. Large quantities of supplies, hurriedly assembled at overloaded ports, were stored in the holds of crowded vessels, often by inexperienced and poorly supervised stevedores. Lack of adequate harbor facilities and the exigencies of amphibious assaults frequently subjected supplies to sea water when they were unloaded on rafts or were thrown overboard and floated ashore. They might also be dropped on loading platforms, rolled, squeezed, and jostled before being jounced on trucks over shell-scarred roads. Even when delivered to the depots, there was no assurance that the supplies would be protected from further inroads of the elements, for covered storage space in the theaters of operations was far from sufficient.2

These storage and handling conditions which prevailed in the overseas theaters had prompt and disastrous effects upon the shipping containers which the Medical Department used throughout 1942 and part of 1943. The medical supplies and equipment were subjected to every type of damage that can be caused by rough treatment and exposure to the elements.

1Record of the Processing and Packaging Conference-Exhibit, Toledo Medical Depot, 4-5 January 1945.
2Odenheimer, Robert K.: Report of Inspection and Investigation, Medical Department, Packing and Packaging, Southwest Pacific Area, March-April 1945.


120

New Packaging Techniques

Reports from the South Pacific and from North Africa resulted in prompt action. U.S. Army Specification No. 100-14A, issued late in 1942, described requirements for all types of containers, both interior and exterior, including waterproof papers, and the meager knowledge then available regarding methods of corrosion prevention. This specification corrected the most obvious and the most serious errors in export packing. During 1943, specifications were issued which eliminated fiberboard cartons as export shipping containers, standardized box construction, reduced the weight of individual boxes, and provided for the general use of waterproof case liners. These improved packing methods were adopted by manufacturers slowly and with great difficulty. By summer 1943, however, most contracts for later delivery of supplies included packing specifications which reflected Medical Department experience during the preceding 18 months. In 1944, additional and stricter specifications sought to correct packing deficiencies which still existed, particularly in the field of corrosion prevention. ASF (Army Service Forces) Manual 406, published in December 1943, was instrumental in the development and widespread use of specifications designed to protect all types of equipment subject to corrosion. A Packaging and Packing Section was established at the Army Medical Purchasing Office. This section, in addition to drafting packing specifications, maintained close contact with the manufacturers and aided in the practical application of the specifications.3

From the end of 1942 until the close of the war, depots assumed the main burden of the packaging problem, the repacking of supplies. Each depot relied initially upon experimentation and improvisation, but considerable progress was made in late 1943 when a Packing and Crating Unit was established in the Office of the Assistant Chief, Supply Service.4 The unit was charged with two jobs: the writing of packing specifications and the institution of approved methods of repacking in the depots.

The manufacturers of medical supplies encountered many problems in adhering to packing specifications. In the summer of 1943, for example, the lumber shortage became more acute, adversely affecting all packing and forcing resort to substitute materials. V-board, made of superstrength all-kraft fibers, was then adopted as a substitute for wooden boxes and as a successor to corrugated fiberboard of the non-water-resistant type. This V-board made a waterproof box which was satisfactory when packed with light, closely fitting items, such as blood plasma. It was widely used, however, to contain a number of items which could not be shipped safely in such a flimsy box. Consequently, there were numerous reports from overseas, describing unsatisfactory results obtained with V-board-crushed, torn, and perforated boxes, which caused

3Pile, Benjamin D.: Development of Packaging and Packing in the Medical Department During the Present Emergency, 16 Oct. 1945. [Official record.]
4Supply Service Memorandum No. 6, 8 Mar. 1943, subject: Packing and Crating Organization.


121

the ruin of valuable supplies. Finally, in spring 1945, V-board was abandoned by the Medical Department, except for a restricted group of items.5

Serious shortages were encountered in many other types of packing materials, including steel strapping, staples, strapping equipment, waterproof case liners, waterproof cement, cellophane bags, chipboard, and foil barrier materials. Some shortages, caused by ineptly worded specifications, should have been corrected promptly, but most were caused by scarcities in basic materials and manpower. Often, the Medical Department hastened the completion of a contract by using its influence to obtain higher preference ratings for the required packing materials.

The two problems which appeared to be the most serious and immediate were breakage in overseas shipments and damage by water. Supply officers in the depots applied themselves to the solution of these problems. Considerable progress was made in solving the breakage problem by the construction of sawed-board, nailed, metal-strapped boxes; the use of adequate bracing and blocks in packing equipment such as X-ray machines, sterilizers, and operating lamps; placing a maximum load-limit on the contents of shipping containers; and the lavish use of ground cork, excelsior, and other cushioning materials.

Shortages of packing materials and the press of work were attacked by preference ratings to the suppliers of packing materials, the employment of additional civilian personnel, and the introduction of assembly line procedures in the packing rooms.6

In devising methods of waterproof packing, the depots soon made distinguished progress. Waterproof case liners, made of asphalt-base laminated materials, were adopted for all boxes intended for export shipping. The case liner was first arranged in the box; then, the supplies were carefully packed in the liner; and, finally, the liner was sealed, and the box was nailed and strapped. This produced a shipping container that admitted no water, even when immersed. However, additional precautions were frequently taken. Cement-coated, rustproof nails were used in the construction of the boxes. Waterproof labels and markings were used on the exterior. In packing electrical equipment, a vaporproof barrier and a desiccant included within the package were used to exclude moisture from delicate contact points (fig. 27.).7 For expendable supplies, this method was satisfactory. Overseas installations received the boxes and opened them as the supplies were needed. When the tactical situation required a move, only a small quantity of unpacked supplies had to be dealt with. Nonexpendable supplies and equipment, on the other hand, had to be repacked, and few mobile units had either skilled labor or packing materials to provide waterproof containers. The Supply Service

5See footnote 3, p. 120.
6See footnote 1, p. 119.
7Memorandum, Capt. Paul Lipman, MAC, Asst. Purchasing and Contract Officer, to Lt. Col. E. A. Shea, MAC, Chief, Purchasing Division No. 4, AMPO, 31 May 1945, subject: Annual Report for Fiscal Year 1945.


122

FIGURE 27.-One of many packaging problems of the Medical Department was to provide adequate protection for tubes and gages on sterilizers. Toledo Medical Depot, Toledo, Ohio, December 1943.


123

developed the "amphibious box" to meet this particular need. The box, when fully packed, could sustain a drop of 15 feet without loosening the watertight gaskets. This container proved to be invaluable in the functional packing of field installations for supplies and equipment could be quickly repacked when the unit moved. While the unit was in operation, the tops were removed and the boxes stacked on their sides, thus providing tiers of shelves for the storage and issue of supplies. The amphibious box was a relatively expensive item, costing the Medical Department $16 each, but its usefulness was so great that more than 72,000 were purchased.8

Scarcity of material forced depots to procure high grade lumber for overpacking; for example, shipments processed by the depot at San Francisco, Calif., contained high grade redwood. Although this was inconsistent with the prevailing policy, recipients of medical supplies in the Pacific were highly pleased, as shipments were received intact and the lumber was used to good advantage in fabricating hospital furniture, floors, and similar items not otherwise available.

Preservation of Instruments

Soon after heavy overseas shipments began in 1942, it became apparent that one of the most serious problems would be the protection of surgical instruments (fig. 28) from corrosion. Numerous reports from theaters of operations called attention to instruments which had corroded so badly that they were useless. At first, transportation and storage conditions overseas were blamed for this deterioration in the instruments, and efforts were redoubled to pack them in moistureproof containers; but depot inspections revealed that surgical instruments in stock were imperfectly protected. Moisture in the air industrial fumes, dirt, and even perspiration traces left by handlers caused corrosion. It was discovered, also, that many box-lock instruments were corroding in the locks, a condition caused by a scale formation.9

One solution of this corrosion problem involved a thorough processing of the instruments in the following manner: The instruments were placed in a metal basket and lowered into a tank filled with stoddard solvent, which removed dirt, grease, and other organic residue. A second tank, filled with the same solvent, provided a rinse. Next, the instruments were immersed in a third tank which was filled with specialized solvent, a fingerprint neutralizer. After draining, the instruments were placed in a drying oven heated by infrared lamps. The dry instruments were removed from the oven, allowed to cool for 2 or 3 minutes, and dipped into a preserving tank containing an oil or grease which was especially adapted to the items being processed. Finally, they were sealed in laminated foil bags, and were then ready for storage. Zone of Interior issue, or overseas shipment.10

8The Amphibious Box. Bull. U.S. Army M. Dept. 4: 424, October 1945.
9Shea, Elmer A.: Surgical Instruments. [Official record.]
10See footnote 9, above.


124

FIGURE 28.-Sample board used as guide to identify medical instruments processed and packed in assemblies. Medical Section, Atlanta Quartermaster Depot, Atlanta, Ga., January 1943.


125

In 1943, orders were issued to process all surgical, dental, and veterinary instruments, but precise specifications as to how this was to be done were not laid down. The results were so generally unsatisfactory as to demonstrate the need for a technique that would be at once simple and effective. After considerable experimentation, an electrochemical process was devised and made standard in time to be widely used during the latter part of 1944. The instruments were thoroughly cleaned, immersed in a light oil, wrapped tightly in nearly pure aluminum foil, and finally were packaged in metal-lined, heat-sealed envelopes. The process gave adequate protection against all the well-known causes of corrosion and the little-known cause of scale formation. Instruments thus processed and packaged were safe from corrosion for extended periods of time and under all conditions. In addition, they were ready for use after the envelope was opened, the foil wrapper removed, and the instruments sterilized. This ended the time-consuming removal of heavy greases, wax, and resin coatings, with which instruments formerly had been protected.11

It was intended that all processing of instruments would be done at the medical depots at St. Louis, Mo., and Kansas City, Kans., but the shortage of personnel made it expedient to engage a private contractor in St. Louis. The purchasing office in New York prepared lists of instruments to be processed, grouping them according to patterns. Instructions were then issued to the various Medical Department depots, requiring them to ship approximately 100,000 per week to the St. Louis depot. This depot released the instruments to the contractor on an established schedule; and after the instruments were processed, they were placed in the St. Louis depot stock. This program began in the fall of 1944. By 30 November 1944, approximately 1,250,000 instruments had been processed, and during succeeding months, nearly 2 million more were given this protection against corrosion.12

Unfortunately, this new process was developed too late to be of great practical benefit in World War II. The heaviest shipments of surgical instruments to overseas installations were made during 1943 and 1944; consequently, only small quantities of instruments protected by the new process were sent abroad before the end of the war.

Results of Research and Development

The Medical Department's experience with the protection of surgical instruments clearly demonstrated that the entire packing and packaging program in the depots should be subjected to central control. At the beginning of the war, the depot commanders were allowed to operate without interference in the handling of outgoing shipments. This encouraged ingenuity and local initiative, which produced many important advances in packing techniques.

11Hornbacher, Arthur: Surgical Instruments: Difficulties Due to Corrosion and Methods Taken to Combat Them. [Official record.]
12See footnote 11, above.


126

Unfortunately, this system also had the disadvantages usually associated with local independence. Some depot commanders, possessing imagination and energy, applied themselves to the task of adapting their packing methods to wartime conditions; but others were slow to change their methods even though the need for haste was the theme of all reports received from overseas. Depot inspections could not correct these deficiencies; by the time the inspections were made, much of the damage had been done, and poorly packed supplies were deteriorating in every theater.

Packing methods which were developed in the depots, and the advances which research produced, were standardized by the Medical Department for use in all depots. Precise packing specifications were prepared, which described the materials and methods to use in packing the more important and easily damaged medical items. Manuals were published and directives were issued. Training films were made and exhibited to the appropriate personnel of all depots. At packing and packaging conferences (at Toledo, Ohio, St. Louis, and New York, N. Y.), attended by supply officers from the various depots, new processes were explained and enthusiasm for better work was generated. In other words, strong and continuous efforts were made to develop and maintain an "export consciousness," to instill the belief that supplies must be so packed that they would be usable to combat areas. The extent to which this attitude was built up is indicated by the remark of a depot commander in 1945, who declared that he "would not quibble about spending $50 to insure the arrival of a single package of blood plasma to the battle front in good condition." To enforce the directives and to assess the value of this widespread training program, inspecting officers from ASF Headquarters and from the Supply Service of the Surgeon General's Office, made frequent visits to the packing rooms of the depots. These manifold efforts bore a rich harvest. By spring 1945, the Medical Department was reported to have climbed from the bottom rung of the ladder to a place near the top, in comparison with other technical services, in the protection and packing of supplies.13

This judgment, rendered by inspecting officials in the the Zone of Interior, was confirmed by reports from overseas. Supply officers in the Southwest Pacific declared that the supplies received during the period from 1 July 1944 to 1 April 1945 showed a "100 per cent improvement" in packing. The waterproof case liners and the nailed wooden boxes were hailed as the most satisfactory packing materials used. The only persistent and important complaints received from this area in 1945 were that fragile items should be more carefully cushioned and that large pieces of equipment with projecting parts should be disassembled before shipment.14

By the spring of 1945, all the more serious packing and packaging problems had been solved. The early and laborious efforts of the depots, the research and experimentation in the laboratories, and the developments in manufacturers' plants culminated in a series of joint Army-Navy packing specifica-

13See footnotes 1 and 2, p. 119.
14See footnote 2, p. 119.


127

tions, which replaced the ASF Manual 406 and a multitude of tentative specifications. The Joint Army-Navy Packaging Board, established in 1945, coordinated the work of subsidiary groups and issued specifications to all branches of the Armed Forces. The work of the Packaging and Packing Section, Army Medical Purchasing Office, resulted in the preparation of a "Master Preservation Packaging and Packing Listing," which described in detail a method of processing and packing for every item of the Medical Department catalog.15 If an invasion of Japan had been necessary, the medical supplies thrown upon the shores of that country would have shown the great improvements in packing techniques which had been achieved since the landings on Guadalcanal.

STORAGE OF MEDICAL SUPPLIES

The functions of storage and distribution are closely linked in many ways. For a large part of the war, they were supervised by a single division of the Supply Service, and throughout the conflict both were carried out by the Medical Department's farflung depot system. But, however linked they were, the functions of storage and distribution were essentially different. In the purposes they were intended to accomplish and in the problems encountered, they found little in common.

Increased Depot Activities

At the outset of World War II, the Medical Department was responsible for procurement, storage, and issue of approximately 4,500 items. By 1942, the number of items under medical cognizance had jumped to 6,000, and another 1,000 items were added by 1943. During mid-1942, some 700 contractors were serving the Medical Department, but within a year's time, this had jumped to 2,500 contractors and the number of contracts had reached 25,000.16

Furthermore, until early 1944, contracts were F.O.B. destination, which meant that items received from contractors could not be picked up on stock records and made available for issue until they were formally accepted. Some deliveries from procurement to depots were piecemeal, delayed, lost, or damaged in transit. Often, stocks arrived before receipt of specifications or copies of the contracts. These documents were necessary to permit identification, inspection, and acceptance. In the event of deficiencies, stocks upon arrival had to be segregated and withheld from issue pending acceptance, or refusal and disposition instructions.

Aggregating more than 5.4 million square feet by July 1941, medical supply depot space continued to expand after entry of the United States into the war. A new branch depot was established in Kansas City, with Lt. Col. Revel E. Hewitt, MC, as commanding officer; and medical sections were added in general depots at Seattle, Wash., Atlanta, Ga., and Richmond, Va., so that in

15See footnote 3, p. 120.
16(1) Annual Report, Finance and Supply Services, OTSG, fiscal year 1942, and attachment "Office diary." (2) Annual Report, Supply Service, OTSG, fiscal year 1943.


128

July 1942, the space available amounted to 7 million square feet. Additional space acquisitions increased storage facilities still further during the next 6 months; in July 1943, the peak of 13 million square feet was reached. From this time until the end of the war, the trend was reversed. Space in depots and medical sections was sharply reduced, and a number of installations were inactivated as the demand for storage area was diminished. Twenty depots and medical sections had been occupied in July 1943. This number dropped to 17 in July 1944, and to 14 in July 1945. During the same period, the number of square feet occupied fell to 10,348,000 in 1944, and to 9,127,000 in 1945.17

The number of military and civilian personnel employed in the depots showed a steady climb to the middle of 1943 and a similar reduction after that year. A few months before Pearl Harbor, fewer than a score of trained supply officers were available for depot operations. This meager pool of military personnel was supplemented by granting commissions to individuals with appropriate civilian experience, calling to active duty a number who held Reserve commissions in the Medical Administrative Corps and the Sanitary Corps, and by training newly commissioned graduates of the Medical Administrative Corps officer candidate schools. These young officers, directly after receiving their commissions, entered upon a period of supply training. The number of officers on duty in the depots increased from 171 in December 1941 to 465 in December 1942, and to 511 in June 1943.18

Despite difficult problems in recruitment, including a relatively low salary scale, the number of civilian employees increased at an impressive rate (fig. 29). When the United States entered the war, there were approximately 2,600 civilian employees in medical depots. This number was increased to 5,700 in July 1942, and to 14,100 in July 1943. As in storage space, this was the peak period. Employment declined to approximately 9,400 in July 1944, and 6,800 in July 1945.19 It should not be assumed, however, that this decrease in civilian personnel indicated a diminution of activity in the depots. Quite the contrary is true, for the workload of the depots showed a distinct increase during the latter part of the war. This striking conservation of manpower was made possible by the decrease in storage space, by the increased use of materials-handling equipment, by work simplification, and by better training and control of employees.

Operation of the Depot System

Medical depots were able to survive the onslaught of work and confusion that flashed into being during the first years of the emergency and war. By June 1943, they were beginning to reap the gains of experience. From then

17(1) See footnote 16, p. 127. (2) Annual Report, Storage and Maintenance Division, OTSG, fiscal year 1945.
18(1) See footnote 16(2), p. 127. (2) Report on Administrative Developments, Office of The Surgeon General, 1 Dec. 1942. [Official record.]
19(1) See footnotes 16(1), p. 127, and 17(2), above. (2) Memorandum, The Surgeon General for the Commanding General, ASF, 29 June 1945, subject: Report, Pursuant to Directive of 1 June 1945, Submitting Additional Material for Annual Report of ASF.


129

FIGURE 29.-Window showing job openings at San Francisco Medical Depot, San Francisco, Calif.

on, even increased demands placed on depots seemed more reasonable in view of their extended capabilities, thus swelling their production without an increase in manpower.

In December 1941, however, the depot system itself was rudimentary, with specialization only just begun. The medical sections at New York, San Antonio, Tex., and San Francisco, Calif., distributed stocks to their respective distribution areas and to ports of embarkation, while the branch depots at St. Louis and Savannah, Ga., performed similar functions. The medical sections at Schenectady, N.Y., Columbus, Ohio, and New Cumberland, Pa., were used for storage of the War Reserve. The branch depot at Toledo constructed hospital assemblies. This was the full extent of specialization, but wartime demands soon proved too heavy for the existing framework.

One of the earliest difficulties arose from the scarcity of certain items. The old system under which stocks had been divided more or less impartially among the depots left no facility with sufficient scarce items to satisfy its needs. The solution was the "key depot system" set up in 1942. In each of three


130

main geographical regions, one depot was designated to receive and store stocks of these items.20

By summer 1943, the depot system was substantially in final form. Storage facilities were divided then into five categories, each with its specialized function-distribution depots, assembly depots, port filler depots, reserve depots, and holding and reconsignment points. In each category, the depot type determined to considerable degree the variety and quantity of medical supplies sent to it.

Depot administrative organization, originally conditioned by local needs and the wishes of individual commanders, was brought into conformity with a general pattern in 1943, the pattern being laid down by the Storage Division, ASF. The basic divisions were Administration, Transportation, Stock Control, Personnel, and Storage.21 The storage divisions were usually composed of Inventory, Storekeeping, and Labor and Equipment Pool Branches, and required the largest number of military and civilian supervisors because of the variety of functions for which they were responsible. Receiving and inspection were the first duties of the Storage Division. Inspection extended to quantity, condition, and packaging, but not to actual testing for conformity to specifications of drugs, chemicals, and biologicals. This latter function was performed by the Army Medical Purchasing Office and the U.S. Food and Drug Administration.

Movement of supplies within the individual depots was often severely handicapped by poor elevators. The construction of single floor warehouses by the Army helped solve this problem.

Before the war, medical supplies were stored, to a great extent, in "item sequence"-that is, all quantities of each item were stored in one place and, so far as practicable, all item numbers were stored adjacently and in sequence. The huge procurement program of 1942-43 forced expansion in depots, and item sequence storage could be maintained only by building bigger warehouses and rewarehousing. Because of this complication, most depots which were activated in 1941 and 1942 never employed the item sequence method, and those which antedated the war were compelled to abandon this method. Under the new system, the location of each medical item was determined by the amount of storage space it required, appropriate storage conditions (such as load limits on floors), and the speed with which the item was used or requisitioned. The experience of the Toledo Medical Depot suggested that fast-moving items, such as beds and mattresses, should be stored on the first floor. Slower-moving items and bulky hospital equipment and supplies should be placed on the top floors, while surgical dressings, instruments, laboratory equipment, dental equipment, and X-ray equipment should be stored near the packing room.22

20(1) See footnotes 16(1), p. 127; and 18(2), p. 128. (2) Hangen, Herman C.: Key Depot System, in Program of Port and Assembly Depot Conference, SGO, 22 Jan. 1943.
21History and Procedure Manual, Toledo Medical Depot, 1941-1945. [Official record.] Some of the larger depots (for example, the St. Louis Medical Depot) established additional divisions.
22See footnote 21, above.


131

When the item sequence method of storage was abandoned, or when a new depot was established which did not employ it, a card locator system was absolutely essential. At first, in most depots, the cards for all items were assembled at one place, so that through an examination of the cards in one centralized unit, the selectors could determine the location of the stock on every floor of all warehouses. In the early summer of 1944, a decentralized stock locator system was established in all depots, remaining in effect until the end of the war. This system established a small locator unit on each warehouse floor. A locator card for each item stored on that floor showed: (1) the location, (2) number of original packages, (3) number of units in each original package, and (4) the condition of the packing. This new method increased the efficiency of the stock selectors and, at the same time, provided sufficient information for depot stock records.23

Need for Periodic Inventories

In October 1942, the Surgeon General's Office directed the medical depots to make a physical inventory of all stock in storage and to reconcile the balances on the stock records with the actual physical count. In addition, this directive required that each accountable item be inventoried at least every 6 months. Thus originated the "cycle inventory," which continued throughout the war and which acted as a continuous corrective of the stock records. A Cycle Inventory Branch was established in each depot, and an inventory schedule was developed which made possible the count of each item every 6 months. Additional inventories were made upon special requests. These regular and special inventories provided valuable information for both the storage and stock control officers.

At the same time, a simplified inventory adjustment procedure giving greater latitude to post, camp, and station commanders was substituted for the rigid property accountability of the peacetime army.24

Another matter, more directly connected with storage functions of depots, was the layout of storage areas in the warehouses. All floors were divided into sections and designated by letter of the alphabet. Many factors, such as local conditions, floor space, and volume of supplies, determined the size of the sections. These sections, in turn divided into bays by supporting columns, were numbered consecutively. The number of aisles varied and the height to which supplies were stacked depended upon the load limit of the floor, the location of the sprinkler system, and the type of supplies stored.

Use of Materials-Handling Equipment

When the heavy procurement program of 1942 and 1943 began to fill the depots with unprecedented quantities of supplies and equipment, the increased

23(1) History of the St. Louis Medical Depot, 7 Dec. 1943-7 Dec. 1944. [Official record.] (2) See footnote 21, p. 130.
24(1) See footnote 23, above. (2) War Department Circular No. 101, 12 Apr. 1943, Section IV: Simplified Inventory Adjustment Procedure (AR 35-6640).


132

workload rendered materials-handling equipment necessary, and the abundance of funds made its acquisition possible. Forklift trucks, tractors, and trailers became standard equipment in the depots for moving and storing nearly all supplies. The widespread use of this equipment was rendered more practicable by the adoption of a simple but ingenious aid-the wooden pallet. Supplies were unloaded on pallets at the receiving platforms and were then moved by trailers or forklift trucks to the inspection area. Still remaining on the pallets, the supplies were tallied-in, inspected, and conveyed to the storage area, where they were stacked by forklift trucks. Under the new system, the fork of the forklift trucks was inserted into the pallet, and a large number of original boxes were thus moved and stacked by a single operation. Stacks in the warehouses could be erected to greater heights, with a consequent saving of space, because the pallets provided both secure platforms upon which to store the supplies and open spaces for free circulation of air. After supplies were unloaded from freight cars and placed on pallets, they received no more manual handling until they were withdrawn for shipment (fig. 30).25

Work Measurement System

During the last 18 months of the war, another factor made important contributions to the efficient operation of the Medical Department depot. Early in 1944, a "work measurement system" was installed, which involved a close study of each piece of work performed in a depot. Records were maintained on the methods employed in performing each task and on the amount of time and personnel required. By comparing records of the various depots, supervising officers of the Surgeon General's Office could discover weak spots in the operation of a depot and could point out, with great particularity, the specific tasks which were being inefficiently performed. Better methods which had been devised and adopted by other depots could be introduced wherever they were needed, with a consequent saving in time, personnel, and materials. At regular intervals, the records of the work measurement system were brought to the attention of all depots, so that each could determine its efficiency in comparison with the others. This produced a spirit of competition and rivalry among the depots which still further increased their efficiency.26

DISTRIBUTION OF MEDICAL SUPPLIES TO ZONE OF INTERIOR INSTALLATIONS

The nature of the war which the United States entered in 1941 made it clear that in the Zone of Interior there would be two major requirements for large quantities of medical supplies. One concerned the training of more than

25The extent to which materials-handling equipment was used is indicated by the fact that at the St. Louis Medical Depot, the number of forklift trucks increased from 7 in 1942 to 29 in 1943 and to 40 in 1944. Pallets, which were not used in 1942, increased to 23,390 in 1943 and to 51,250 in 1944. See History of the St. Louis Medical Depot, 1941-1944. [Official record.] See also footnote 21, p. 130.
26See footnote 17(2), p. 128.


133

FIGURE 30.-Use of pallets in warehouses.

10 million men and women of the Army. The great variety of medical care and the large number of troops involved made inevitable the need for immense quantities of supplies. The second requirement was the provision of supplies for the named general hospitals, which provided definitive treatment for all American soldiers and especially for those evacuated from theaters of operations. These general hospitals were the fifth and final echelon of medical support; and, as such, they required the most elaborate equipment and a steady stream of supplies.

On each major Army installation, a medical supply officer was responsible for receipt, storage, and issue of all medical supplies. This officer sent periodic requisitions to his distribution depot, stored the supplies as they arrived, and filled the requisitions of the station hospitals, dispensaries, and other medical units on the post. Before January 1942, all requisitions from posts, camps, and hospitals were first edited by the corps area surgeons, who compared the requisitions with appropriate allowance tables and stock levels. If supplies in excess of the allowances were requisitioned or if nonstandard medical equipment was required, the corps area surgeon obtained the approval of The Sur-


134

geon General before forwarding the requisition to the distribution depot. The final step in this supply chain was the medical depot which handled the inspection, storage, and distribution by requisition of medical supplies to the training camps and general hospitals.

Use of Medical Unit Assemblies

Large quantities of medical supplies were issued in the form of unit assemblies. All the supplies and equipment needed to establish a medical unit (whether a 50-bed station hospital or a 1,000-bed general hospital) were assembled, packed together, and clearly labeled. When supplies for a particular medical unit were requisitioned, the depot simply added the deteriorating items and shipped a unit which had been previously assembled and packed. Although there were unanticipated difficulties, the advantages of the unit assembly as a vehicle for issuing supplies were so pronounced that it continued to be used throughout World War II. The assemblies were especially valuable in the activation of station hospitals in Zone of Interior posts. As new training camps sprang up all over the country, station hospitals opened rapidly. Many hospitals were commanded and manned by Reserve officers and Army of the United States officers who were unacquainted with tables of equipment and could not anticipate their supply needs. Time was saved and efficiency was advanced by the system which made it possible for them to requisition a station hospital, a regimental dispensary, or any other appropriate unit. When the depot system expanded with mobilization, the St. Louis Medical Depot, commanded by Col. Royal K. Stacey, MC, was responsible for construction of assemblies; and until 1943, this depot devoted a large part of its space and personnel to the assembly program. Assembly depots were also located at Toledo (hospitals); Atlanta (hospitals); Kansas City (kits and chests); and Columbus (civilian aid program).27

In the construction of a hospital assembly, much "paperwork" was required. The basic equipment list, of the items and the quantities of each to be included in the assembly, was reproduced on punched cards in the electrical accounting machine section, and then run through the machine to determine if sufficient stock was on hand to construct the assembly. In 1941-42, while the procurement program was getting underway, stock was extremely short. Consequently, the first "run" of the cards usually accounted for only 60 to 70 percent of the items needed. When speed was essential, the assemblies were shipped incomplete, and the receiving agencies were authorized to requisition the missing items at a later time. During this early period, the shortage of "housekeeping" items created an especially difficult problem in Zone of Interior medical installations.28

27(1) History of the St. Louis Medical Depot, 7 Dec. 1941-7 Dec. 1942. (2) See footnote 16(2), p. 127.
28Memorandum, Lt. Col. R. L. Black, MSC, to The Historical Division, SGO, 16 Nov. 1944, subject: Supply Depot Historical Highlights.


135

Many medical items were in chronically short supply until summer 1943, necessitating back orders and extracts to other depots. The delays thus occasioned in constructing the assemblies still further aggravated the scarcities; supplies available when the first accounting machine run was made were obligated and, consequently, could not be used for any other purpose. The result was that, for periods as long as 6 months, scarce supplies lay unused in the depots, because they were being held to build assemblies. Requisitions to other services were necessary, and these requisitions also frequently resulted in an almost interminable process of back orders and extracts. For example, the Medical Department was dependent upon other technical services for procurement of web equipment, electric motors, mattresses, and other nonmedical supplies. Sometimes, the supplies were not placed in procurement until shortages were revealed by the effort to build a unit assembly. Even after the supplies were procured and shipped by the other services, there still remained the problem of combining them with the medical items in the assemblies. If the assembly was to be shipped complete, this process was accomplished at the medical depot; but frequently, to save time and to prevent crosshauling, the "marrying-up" process was performed at the Zone of Interior installation which received the assembly or at the port of embarkation to which it was shipped.29 Assemblies were held for weeks and sometimes months, awaiting the arrival of missing items, and many units were shipped incomplete. The mere process of packing and storing hospital assemblies, pending requisitions for them, also resulted in immobilizing large quantities of critically needed medical supplies.

Another problem arose when basic equipment lists were changed or when packing instructions were altered after an assembly was packed, labeled, and stored. Such changes made it necessary that depot personnel remove the assembly for storage, make the indicated alterations, and repack it-work which involved large quantities of packing supplies and many hours of labor. Some depots tried to solve this problem by building only a limited number of assemblies, which were held for emergency requisitions, and by maintaining a sufficient quantity of stock to build any additional assemblies that might be required. When medical supplies became comparatively plentiful, this solution was quite practicable, for a large assembly could be constructed within 2 weeks.30

While the assembly concept had definite advantages, execution of the concept caused many serious problems for the Medical Supply Service during World War II. Tremendous major assembly requirements were relatively predictable, unlike those for minor assemblies. The lateral transfer of kits and chests among units was necessary because of volume, movement, and changes in priority of tactical units; this made it impossible to determine total assets as they pertained to material in the hands of troops. Major assemblies when issued were more stable and controllable, but had an irrepressible tendency to

29See footnote 27(1), p.134.
30See footnote 21, p. 130.


136

FIGURE 31.-Hospital assembly, ready for overseas shipment.

fly apart in transit because of their size. For example, complete table-of-organization equipment for a 1,000-bed general hospital comprised one assembly of more than 3,000 items. It weighed over 600,000 pounds and required approximately 20 freight cars for shipment. When one of these assemblies was shipped to a Zone of Interior hospital, it was relatively unimportant if the 20 freight cars arrived at different days provided the last one arrived on time. For an assembly destined for use in a general hospital overseas, the situation was entirely different. If the whole assembly did not arrive as a unit, the port was faced with the almost impossible job of reassembling it (fig. 31).

Regular and Emergency Requisitions

The building and shipment of hospital assemblies was only one method by which medical supplies were distributed to Zone of Interior installations. The other, and more important, method of accomplishing the task was the filling of regular and emergency requisitions initiated by the medical supply officers.

After Pearl Harbor, speed became more essential. In February 1942, the medical supply officers began to send their requisitions directly to the distribution depot, which was empowered to approve all requisitions except for controlled items and quantities in excess of authorized allowances. Any requisition on which the depot lacked authority to approve and fill was forwarded to the Supply Service for a final decision.

These forwarded requisitions called for quantities in excess of allowance, for nonstandard supplies, or for unauthorized equipment. As the war progressed, the number of requisitions forwarded for the approval of the Surgeon


137

General's Office steadily mounted; before the conflict ended, disposition of these requisitions became the most time-consuming duty of the Issue Division, Supply Service. This work grew in volume, despite the many efforts to decentralize, so far as possible, all phases of the distribution process. It was quite necessary, however, for the Surgeon General's Office to exert firm supervision over the issue of controlled items and quantities of supplies in excess of authorized allowances, for only in this manner could procurement and distribution be coordinated.

The depots' work in the distribution of medical supplies may be divided into three parts: receiving and editing the requisition; accomplishing the preliminary paperwork; and selecting, packing, and shipping the supplies. The editing process determined that the items were properly identified, were authorized for the station which had requisitioned them, and were not requested in quantities exceeding allowances. International Business Machines were used to ascertain if the items were in stock, to obligate the stock, and to print shipping tickets. The tickets were transmitted to the issue room, the stock was withdrawn by the selectors, and the items were packed and made ready for shipment. After "tally-outs" and inspection, the papers were transmitted to the transportation department and the supplies were shipped.31

The unpreparedness of industry, the production timelag, the scarcity of certain raw materials, and the administrative friction of a great buying machine all contributed to delays in placing orders and to delays in the manufacture of medical supplies and their shipment to depots. The simple result was the inability of the depots to fill many of the requisitions they received. When stock was not available, but was due in from procurement, the requisition was placed on "back order," a procedure which obligated the soon-to-be-received supplies to the filling of these requisitions. The number of items on back order, therefore, is some indication of the extent of shortages. In May 1942, on back order at the St. Louis depot were approximately 3,700 medical items, the most important of which were sterilizers, rubber goods, generators, anesthesia apparatus, litters, and X-ray machines. This large number of back orders was gradually reduced, but it is significant that, as late as May 1945, a total of 1,250 items were on back order at this depot.32

In the emergency and early war period, a depot unable to fill a requisition for urgently needed supplies extracted the requisition to the Surgeon General's Office. After consulting the consolidated stock report, supply officers in Washington, D. C., sent the requisition to the depot which had a supply of the required items. The system broke down when shortages of many items became nationwide. The consolidated stock report, moreover, was not an accurate record of stock location during most of 1942 and the early months of 1943. So many requisitions were received and filled after the depots' "cutoff date" and before the stock report could be compiled that the report was out of date,

31See footnote 27(1), p. 134.
32(1) History of the St. Louis Medical Depot, 7 Dec. 1942-7 Dec. 1943. (2) See footnote 27(1), p. 134. (3) History of the St. Louis Medical Depot, 7 Dec. 1944-8 May 1945.


138

for many items, on the day it was printed. The practice of extracting requisitions from one depot to Washington and thence to another depot nevertheless continued unchanged throughout 1942, with most unhappy results for the posts needing the supplies. Extracts of requisitions moved futilely from one depot to another, via Washington, to a third, fourth, or even a fifth depot.

Before the procurement program could be expected to make up all deficiencies, partial remedies were developed. The most outstanding and successful of these remedies was the establishment of the key depot system late in 1942. The distribution depots were "keyed" to receive, store, and issue certain classes of items in short supply. When a depot received a requisition for key items which were not assigned to it, an extract was forwarded to the key depot which stocked the items. Important advantages resulted from this system. During the first 6 months of 1943, the time required to process requisitions through depots was reduced by 50 percent. Many man-hours were saved by the elimination of fruitless extracts, and the small stocks of scarce items were less dispersed and their issue more strictly controlled.33

Central Stock Control

The establishment of a more efficient central stock control system produced distinct improvements in the distribution of medical supplies. The installation of electric accounting machines in the depots and in the Surgeon General's Office in 1941 was followed by the establishment of a new system of stock records, which by 1943 was in successful operation. Under this system, each depot submitted periodic reports to the central stock control point, located at first in Washington and later in New York. The principal information carried on these cards, for each item of medical supply, was the quantity on hand, quantity on back order, quantity due in from procurement and transfers, and the quantity issued. The central stock control point sorted the punched cards and printed periodic stock reports, which showed the information of each depot and a total for all depots.

The preparation of a consolidated report a few days after the cutoff date made possible an efficient system of centralized stock control. Using the consolidated stock report, the Surgeon General's Office controlled procurement and distribution which was impossible in peacetime. It became practicable to compute short-term procurement requirements and to direct shipments from manufacturers to the proper depots. More important for distribution, the central stock control point was able to transfer stock between depots and to send requisitions or extracts to the depots which had the needed stock.34

The technique of ordering medical supplies was also changed in the interest of conservation. Throughout 1942, medical supply officers of training camps and general hospitals submitted to their distribution depots three types of requisitions: Semiannual, quarterly (for deteriorating items), and emergency

33See footnote 16(2), p. 127.
34Material submitted informally by Col. S. B. Hays, MC, Supply Service, 13 May 1946.


139

requisitions. Shortly after the attack on Pearl Harbor, special requisitions were added, differing from the emergency type in that they were produced by the activation and expansion of training camps, and thus were intended to fill urgent needs which could be anticipated. In January 1943, a thoroughgoing change was made. From that date, all requisitions were submitted monthly and were divided into three new categories according to the type of supplies required: standard expendable supplies, standard nonexpendable supplies, and nonstandard supplies. In addition, a staggered schedule was arranged by each distribution depot, so that the flow of requisitions from the posts would be evenly spaced over all the days of the month. This was a pronounced improvement over the system which it succeeded. Serious shortages of medical supplies had been aggravated by allowing the posts to hold a quantity sufficient for 6 months. The institution of monthly requisitions was an attempt to get the greatest use possible from the insufficient supplies then available.35

Although this change in requisitioning procedure produced good results, it was soon obvious that more heroic measures were necessary. As the number of training camps and general hospitals increased during 1942-43, the quantity of medical supplies held in storage at these posts proportionately increased. And as shortages became more acute, medical supply officers were tempted to hoard against possible future needs. Even under normal circumstances, a large quantity of medical supplies were, from necessity, unavailable for immediate use. The distribution "pipeline" remained full, and a considerable quantity was in storage. This meant, specifically, that large amounts of medical supplies were always in transit and that another quantity remained in storage at the factory, medical depot, and the warehouses of the post. It became essential, therefore, to reduce these idle supplies to the smallest amount commensurate with efficient operations. Immediate shipment by the manufacturer, elimination of delays in transit, and speedy filling of requisitions submitted to depots offered a partial solution to the problem.

These factors made a tight stock control system absolutely essential to accomplish a fair and economical distribution of medical supplies. For many years, the control of stocks at posts and general hospitals had been inadequately administered. Hospitals were allowed to carry a year's stock of non-deteriorating items and a 6-month supply of deteriorating items. In addition, no accurate due-in records were kept. As hospitals grew in number and size and as requisitions were submitted with increasing frequency, it became impossible for supply officers to maintain an accurate knowledge of what was on order. In the fall of 1942, therefore, the Surgeon General's Office devised a new stock record card for posts and general hospitals which showed a stock level for each item, receipts, issues, transfers, stock on hand, and stock due in. The stock level, as originally established, was sufficient to care for a post's needs for 60 days, calculated from actual issues made during the previous 90-day period. In the spring of 1944, when the demand for supplies in  theaters

35See footnotes 18(2), p. 128; and 27(1), p. 134.


140

of operations had mounted to unanticipated heights, the level of stock authorized for posts was reduced to a 45-day period. The stock level for nonexpendable Medical Department items was reduced to the actual amount of the items on memorandum receipt at the posts, plus the necessary quantity on hand for the replacement of damaged or wornout equipment. At the same time, the Medical Department depots were authorized to maintain a stock level of only 90 days of anticipated issues. In September 1944, the stock level of depots was reduced to 60 days. This resulted in such a serious increase in out-of-stock items that, in February 1945, medical depots were authorized to return to the 90-day level for expendable items.36

Hoarding in Zone of Interior Installations

Post medical supply officers were expected to abide by authorized stock levels, to requisition no more than they needed, and to return to the distribution depot any excesses that developed. Each month, they submitted, to the distribution depot, reports which were supposed to reveal any excess supplies on hand. However, the experience of 1942 indicated rather clearly that stock levels must be policed by the distribution depot. Accordingly, in 1943, liaison sections were established in medical depots and staffed with personnel trained in stock control procedures. These liaison officers made quarterly visits to posts and general hospitals, examined the stocks on hand, and declared excess all supplies above the authorized levels. These excess supplies were returned to the distribution depot. At many training camps, the liaison officers discovered tremendous excesses in many items.

By summer 1944, liaison officers had reduced the more easily discovered excesses to such a point that their operations became routine in nature. Time was available, also, for the officers to discuss and offer suggestions on major supply problems which troubled post medical supply officers. During this period, moreover, substandard and obsolete surgical instruments were removed from the posts, and the inspection of these instruments became a duty of the liaison officers.37

These efforts to police stock levels were not altogether successful. Medical supply officers of training camps and general hospitals naturally considered that their primary job was to maintain sufficient supplies for their installations. If the medical supply officer hoarded his excesses, his immediate superiors were not inclined to censure him. But, if he promptly returned all excess stocks and then, at a later period, was unable to supply the needs of his units, his reputation as a prudent and foresighted supply officer would suffer. In fact, a division of power and responsibility, and a divergence of interests between the service commands and the Medical Department depot system

36(1) See footnotes 16(2), p. 127; 27(1), p. 134; and 34, p. 138. (2) Annual Report, Station Section, Issue Branch, Distribution and Requirements Division, Supply Service, OTSG, fiscal year 1944. (3) Notes on Supply Service Staff Meeting, 14 Dec. 1944. (4) Annual Report, Stock Control Division, Supply Service, fiscal year 1945.
37See footnote 23(1), p. 131.


141

made it difficult to police the stock levels. These two authorities, it is true, were subject to the same overall command in the ASF Headquarters; but the actual work of stock control was not done at this high level. It was done in the field, where divided responsibilities and clashing interests were most evident.38

From the viewpoint of post medical supply officers, some circumstances justified exceeding authorized stock levels. These levels, it will be recalled, were based upon previous consumption. Yet, when there had been no stocks of certain scarce items for many months, there was no issue experience upon which a stock level could be based. In many other instances, previous issues had been small because the stock was chronically low. The real need for an item, therefore, was not always indicated by the authorized stock level. Delays in the filling of requisitions created shortages at the posts and (because these shortages reduced issues) led to lower authorized levels in the future. In addition, some medical supply officers wished to retain excess supplies for they had good reason to believe that the patient census of their hospitals would soon increase. The service command surgeons were unwilling to declare any supplies as surplus for they feared a large influx of patients would result from the bitter fighting then in progress in Germany. These fears were well founded. In the late winter of 1944 and the early spring of 1945, Zone of Interior hospitals became crowded with overseas casualties.39

It became clear, during the last year of the war, that large quantities of excess supplies had been issued to, and were being held by, hospital pharmacies, operating rooms, and dental clinics. No surpluses appeared on the books of the medical supply officers or in the warehouses; for all practical purposes, the excesses were hidden away in the using installations. In January and February 1945, approximately 1,250,000 artificial teeth were recovered from dental clinics-a windfall which, together with quantities already on hand, was estimated to be sufficient for all needs during 1945 and 1946 and made possible the cancellation of several procurement contracts. In a survey of general hospitals by the chief of the Issue Division, Supply Service, excessively large quantities of quinine and dental burs were discovered and returned to distribution depots. In the summer of 1945, when medical installations began to close all over the country, even larger excesses were unearthed. In one general hospital an entire year's supply of Pentothal sodium (thiopental sodium) was located in the surgical service. Quite obviously, therefore, this type of hoarding not only created scarcities in less fortunate hospitals, but also led the Medical Department to purchase great quantities of unneeded supplies. Procure-

38During October and November 1944, when heavy fighting in Europe caused shortages in the Zone of Interior, service command surgeons were taking action contradictory to Medical Department policies by holding on to medical supplies above authorized stock levels. At least a part of this was caused by failure of the Surgeon General's Office properly to inform the service command surgeons, some of whom were not familiar with Medical Department policies. See Notes on Supply Service Staff Meeting, 5 Dec. 1944.
39(1) Annual Report, Station Hospital, Laredo Army Air Field, Laredo, Tex., 1944. (2) Notes on Supply Service Staff Meeting, 28 Nov. 1944. (3) Notes on Supply Service Staff Meeting, 23 Feb. 1945.


142

ment was based upon issues, and purchasing officers were unable to distinguish between issues for hoarding and issues for use.40

To wipe out the scarcities caused by hoarding, inspecting officers visited dental clinics, station hospitals, and general hospitals; but this was a remedy which took effect only after the disease had caused much damage. A revision of the Stock Control Manual for Stations sought to prevent the evil by extending stock control to hospital pharmacies, dental clinics, and other using agencies.41 This, also, came too late for, by the time these new orders were issued (May 1945), Germany had collapsed and the entire world conflict was drawing to a close. Quite probably, many scarcities of medical supplies, which were so serious in 1942-43, were caused not by overall shortages, but by maldistribution of the quantities procured. And the large excesses recovered in 1944-45 clearly indicate that hoarding was partly responsible for this maldistribution.

From 1943 until the end of the war, an unremitting effort was made to operate medical depots more efficiently. Training programs for employees, work measurement studies, improved methods of packing and labeling, and use of materials-handling equipment were only the most outstanding methods employed in the pursuit of efficiency. The results were closely connected with the speedier distribution of medical supplies to training camps and general hospitals. During 1942-43, many requisitions remained in the depots for 4 to 6 weeks before they were filled; by the early summer of 1944, the usual period required was 10 to 14 days. The increasing abundance of medical supplies during the third year of the war was very influential, but administrative improvements within the depots had a considerable share, in producing this result.42

Central Service System

In the station and general hospitals, a noteworthy economy in the use of equipment was obtained through the establishment and operation of the central service system. During 1943, a number of hospitals inaugurated this system which centralized the storage, care, and issue of supplies and equipment used in certain diagnostic and therapeutic procedures. These items were highly specialized and could be used for any patient, but only as the occasion demanded. Their constant presence in each ward was unnecessary and entailed the expenditure of unreasonably large quantities of scarce medical equipment. The establishment of a central agency permitted a greater utilization of available equipment and also assured better care and longer life to critical materials. This innovation produced such good results during the latter part of 1943 that, early in the following year, a directive was issued, requiring all station hospitals of 750 beds or larger and all named general hospitals to

40(1) Notes on Supply Service Staff Meeting, 6 Mar. 1945. (2) Address, Brig. Gen. Edward Reynolds to Medical Department officers assembled at Walter Reed General Hospital, 19 Sept. 1945, subject: Medical Supply Problems of World War II. [Official record.] 
41War Department Technical Manual (TM) 38-220, Stock Control Manual for Stations, May 1945.
42See footnote 36(2), p. 140.


143

establish the central service system.43 Obviously, the widespread adoption of this procedure relieved the shortages in essential equipment and aided the Supply Service in solving its procurement and distribution problems.

War Department Shipping Documents

Possibly the most extensive standardization in the supply system during the war was the War Department Shipping Document. First introduced on a trial basis in the summer of 1943, it became a permanent fixture in January 1944.44 From the master copy, four variations were reproduced: order copy, property copy, overseas copy, and price copy.

The order copy was used by the consignor as a shipping order to the Storage Division which prepared the freight for shipment; as a packing list; as a basis for preparing bills of lading; as a basis for completing the property, overseas, and price copies of the shipping document; as a notice of availability to ports, when required; and, as a back order or extract form. Property copies were used by the consignor for domestic shipments to stations, depots, ports, holding and reconsignment points, and similar recipients; and, by the consignee, to tally-in shipments and as a basis for the stock record account. The overseas copies were used for shipments passing through water and aerial ports of embarkation and debarkation, holding and reconsignment points, and air in-transit depots. Price copies were used in instances where reimbursement or pricing in terms of unit cost was involved, such as lend-lease shipments.

The Army Service Forces extended the principles of the War Department shipping document to procurement activities with the publication in May 1944 of a vendor's shipping document-a combination form that standardized and simplified procedures for accepting, shipping, receiving, and invoicing shipments from vendors. This document expedited supply action and satisfied back orders before filling current requisitions with newly arrived stock. Its uniformity also was an outstanding factor in its use. However, its intrinsic value was never fully realized because the size of the unit assembled required a giant-sized shipping document to move it. The volume and length of the shipping document invited errors and misinterpretation, and much training of depot personnel in its use was necessary.45

DISTRIBUTION OF MEDICAL SUPPLIES TO THEATERS OF OPERATIONS

Responsibility for Distribution of Supplies

The responsibility of the Medical Department for distribution of its supplies to overseas commands was limited. The ports of embarkation through which the supplies moved and the vessels and aircraft which conveyed them

43War Department Memorandum No. W40-44, 12 Apr. 1944, subject: Central Service System in Army Hospitals.
44Army Service Forces Manual M401, War Department Shipping Document, 25 Jan. 1944.
45Army Service Forces Manual M410, Vendor's Shipping Document, 5 May 1944.


144

abroad were not under the Medical Department's jurisdiction. Once overseas, the supplies were transported, stored, and issued under the supervision of the theater commanders, who were completely independent of the technical services. Yet, in the first stages of overseas distribution, the Medical Department had important responsibilities, the discharge of which placed the supplies on board the ships and consigned them to using installations.

The depot system was employed for both Zone of Interior and overseas distribution. Port filler depots were the most important installations for the supply of overseas commands. Located at strategic spots some distance from the seaboard, these depots had, as one of their most important missions, the responsibility of receiving medical supplies of all classes, storing these supplies in warehouses, and shipping them to ports of embarkation. At Toledo and Atlanta, assembly depots packed the hospital assemblies, and shipped them to the ports when needed. In addition, many depots of the Medical Department were keyed to receive and store certain scarce items; and to those depots, ports of embarkation sent extracts of requisitions. Finally, holding and reconsignment points, operated by the Transportation Corps, were used to hold completed hospital assemblies so that requisitions from ports could be speedily filled. Since these holding and reconsignment points were located close to the ports, the assemblies could be moved quickly to meet ship sailings on short notice.46

Ports of Embarkation

At the apex of this system stood the ports of embarkation, located at Boston, Mass., New York (fig. 32), Hampton Roads, Va., Charleston, S. C., New Orleans, La., Los Angeles, Calif., San Francisco, and Seattle. Through these ports, troop units and replacements moved to overseas stations, carrying with them their initial allowances of supplies and equipment; and, through them, vast quantities of maintenance supplies were funneled to all fighting fronts. Administered at first by the Quartermaster Corps and during the greater part of the war by the Transportation Corps, the ports of embarkation were nonetheless important parts of the Medical Department's supply system.

Each port had a Medical Supply Division which was headed by a port medical supply officer. This officer was on the staff of the port commander, functioning directly under him, and was the technical agent of The Surgeon General in supply matters. The port medical supply officer's duties and responsibilities are difficult to describe for he was both a staff officer and an operating officer. His duties included advising the port commander on matters pertaining to medical supply, maintaining shipment status reports, following up all requisitions scheduled for overseas shipment, checking on serviceability of equipment of all units moving through the port, and purchasing medical supplies needed in emergency to supply outgoing forces. The port medical supply officer also maintained port stocks of deteriorating items by placing delivery

46See footnote 16(2), p. 127.


145

FIGURE 32.-Portion of New York Port of Embarkation, heavily populated with famed World War II Victory ships and Liberty ships, 1943.

orders against open contracts, furnished medical equipment and supplies to Army transports and hospital ships, furnished emergency supplies to port terminals and staging areas, and exercised staff supervision over stock control in the separate commands of the port.47

Under the plan inaugurated in March 1942, each port of embarkation supplied an assigned overseas area. For example, the New York port, with Lt. Col. Theodore M. Carow, MC, as medical supply officer, was responsible for supply in the European theater, the Mediterranean theater, and the Azores; the Boston port, of which Maj. William A. Bell, MAC, was medical supply officer, served U.S. garrisons in Greenland and Newfoundland; and the Seattle port, whose medical supply officer was Maj. Joseph B. Kingsley, SnC, furnished supplies to Alaska and the Aleutian Islands. Close liaison was maintained between the port and its overseas area by survey trips, cable, and ordinary correspondence.

As overseas commands and combat areas developed and port activities surged beyond capacity, supplies were moved from ports as rapidly as possible. Additionally, because primary ports were not physically capable of

47(1) Memorandum, Brig. Gen. C. P. Gross, Chief of Transportation Service, to Commanding General, New York Port of Embarkation, 2 May 1942, subject: Port Medical Supply Officers. (2) Training Kit of the Port Medical Supply Division, New York Port of Embarkation, 22 July 1944.


146

transshipping all supplies required by the larger and more active theaters, and for economy reasons, primary ports could direct that some cargo be loaded at other ports known as outports. Primary ports, however, retained the responsibility for control and timely delivery of material to their designated consignees. In practice, a part of the port medical supply officer's mission was absorbed by the Oversea Supply Division of his port, which was staffed with representatives of all technical services and served as a clearing house and control center for overseas supply actions.

The port medical supply officer carried stocks of biologicals, antimalarial drugs, and other items needed to fill last minute shortages of outgoing troops, and emergency requisitions from overseas. To meet such requirements, it was often necessary to resort to local off-the-shelf procurement. Port stockage was contrary to basic ASF policy and was a subject of controversy between ASF and The Surgeon General's staff, but was condoned because of the urgency of the need. Early in 1945, the medical local procurement function was absorbed by a newly established Port Control Procurement Division.

Medical Maintenance Units

Shortly after the United States entered the War, the acute need for a uniform method of automatic supply of medical items to overseas commands became apparent. Directives of the War Department originating with the Assistant Chief of Staff, G-4, called for immediate action. As a result of concerted effort by Mr. Mead M. Messick, civilian consultant to the chief of the Storage and Distribution Division of the Surgeon General's Office, a medical maintenance unit was developed, which provided great quantities of medical supplies for U.S. soldiers in all parts of the world. Each unit consisted of 700 to 900 medical items and was designed to supply 10,000 men for 30 days. The entire unit weighed 15 tons, occupied 1,500 cubic feet of space, and was valued at approximately $10,000.48 To each major troop unit stationed overseas, a number of medical maintenance units was shipped which was sufficient to provide the prescribed level of supply. This level varied from time to time during the war, but it never fell below 60 days as a minimum nor rose above 180 days as a maximum. As additional troop units moved overseas, they were provided with the requisite number of maintenance units; and, after the arrival of the troops, other units were shipped to maintain the level of supply.

Instructions governing the medical units made the port medical supply officers responsible for insuring timely delivery. This included recommending to the Surgeon General's Office the number of such units to be placed to the port's credit in the designated filler depot. Originally, the port filler depots established credits upon which the ports of embarkation drew whenever it became necessary to ship maintenance units overseas; but, beginning in 1943, they were shipped from port stocks. During a large part of the war, however,

48Letter, Lt. Col. S. B. Hays, MC, to Medical Supply Officer, New York Port of Embarkation, 19 Mar. 1942, subject: Medical Maintenance Unit.


147

the port medical supply officers were responsible for requisitioning or shipping sufficient medical maintenance units to maintain the supply in the overseas theaters at the prescribed level.

Supply officers in the Zone of Interior looked upon the medical maintenance unit as a temporary expedient, designed to provide medical supplies to overseas bases only until the bases accumulated the issue experience to guide them in requisitioning the items needed. Before going on a requisitioning basis, each base was authorized to inform its port of deficiencies in the automatic supply system. It could, for example, request that certain items be deleted from subsequent shipments, that other items be added, or that the prescribed quantities be reduced or increased. This flexibility, it was thought, would enable the port to adapt the maintenance units to the needs of the various troop units and would provide information leading to revision of the standard medical maintenance unit. Numerous valuable suggestions were indeed received, but some overseas supply officers were content to take these units just as they were sent. They were inclined, moreover, to remain on this automatic basis of supply for protracted periods. The resulting imbalance was a natural one and could have been predicted by any supply officer familiar with the variety of conditions under which American soldiers lived and fought. For example, the quantities of quinine in the maintenance unit resulted in large surpluses in Alaska and in acute shortages in the South Pacific. The consumption of many other items varied from place to place, with the result that enormous excesses were built up in some parts of the world while soldiers in other areas did not receive their minimum needs.

To overcome this problem, a Balanced Medical Depot Stock listing was developed early in 1943. The new listing was formulated by supplementing most items on the 1,000-bed general hospital list with an estimated 90 days' supply of all items not found in the 1,000-bed assembly, but included in other selected Medical Department standard unit assembly lists, plus 30 medical maintenance units. Certain items were added or deleted by professional personnel to conform to possible needs and to complement the peculiarities of the geographic area.49

Final Reserve Units

American experience in the Bataan campaign seems to indicate that troops should be provided with a quantity of medical supplies to be used only when they were besieged. To satisfy this presumed need, a Final Reserve Unit was devised, which consisted of 200 highly necessary medical items in quantities sufficient for 10,000 men for 30 days. This unit was approximately one-third the size of the medical maintenance unit and had a monetary value of $5,000. Each overseas base was required to have on hand a 90-day supply of final reserve units-three units for each 10,000 men-to be provided by the

49(1) See footnotes 16(2), p. 127; and 48, p. 146. (2) Freedman, Abraham: Overseas Supply, 22 Nov. 1944. [Official record.]


148

port medical supply officer when the troops embarked. Deteriorating items were to be rotated, and each box in the unit was marked: Final Reserve-Medical Supplies-Not for Routine Use. When and if these supplies were consumed, the overseas base was expected to notify its port, so that additional units could be shipped.50

Several factors tarnished the repute of this final reserve. Instructions governing its use were issued under a classification of Secret so that, in many instances, the personnel actually receiving and handling the supplies were never told how they were to be handled. This resulted in considerable confusion and disturbed the morale of the forces concerned. Keeping these supplies separate from other stocks, even though the items were the same as those on hand, created a variety of problems in areas where mobility was of the essence and adequate storage facilities were scarce or nonexistent.

Transportation Problems

Requisitions were prepared by medical supply officers of the theater surgeon's staff and were transmitted by radio, cable, or airmail to the appropriate port of embarkation. Here, they were received by the Oversea Supply Division, and then submitted to the port medical supply officer for editing. All controlled items, all items in excess of allowances, and all nonstandard items were referred to the Distribution Division, ASF, for approval, the latter agency basing its decision upon information received from the Surgeon General's Office. Early requisitions called for amounts far in excess of those authorized by consumption tables because of the use of a projected troop strength of which the ports were unaware. Later, theater troop strengths were announced in tables published by the Oversea Supply Divisions of the ports, and thus requisitions came to be submitted and edited on the same basis. After editing, the requisitions were returned to the Oversea Supply Division, where extracts were prepared and sent to the appropriate port filler depot. The port medical supply officer maintained close liaison with the port filler depot, to assure that the supplies were available within the convoy period for which they were planned.

To get the supplies to the theater in the required time, a Cargo Priority System was inaugurated in 1944. Upon request of the theater, the Oversea Supply Division was authorized to apply priority 1 to any item on a requisition, priority 2 on any special requisition, or priority 3 to all other requisitions. The port medical supply officer was responsible for expediting priority 1 items into the port for loading as soon as possible. Priority 2 items were given attention to insure shipment within the scheduled convoy period. Priority 3 items were not expedited, but were followed up routinely to see that shipments were made. When the depot made a shipment to the port, advance copies of the War Department Shipping Document were sent for the use of the Port Transportation Division and the port medical supply officer. Upon receipt

50See footnote 49, p. 147.


149

of shipments at the port, tally-in copies of the shipping document were furnished to the port medical supply officer. And, when the supplies were loaded aboard the ship, he received "floated" copies of the hatch tally. Thus, the port medical supply officer received and maintained records on the progress made with each requisition, and was able to check on, and expedite the filling of, requisitions.51

Considerable delay and difficulty were caused by the failure of overseas commands to prepare and submit requisitions as authorized. Sometimes requisitions for badly needed supplies were sent directly to the Surgeon General's Office. Instead of hastening the arrival of the supplies, this procedure delayed them; such requisitions were routinely referred to the ports of embarkation, to which they should have been addressed in the first instance. Frequently, the requisitions did not give sufficient information. These omissions occasioned serious delays in filling the requisitions for editing authorities were compelled to query the theater and obtain the missing data.52

Equipping Tactical Units

In addition to providing for automatic supply and the filling of itemized requisitions, the Medical Department supply system had important responsibilities in equipping all tactical units of the Army with organizational equipment before overseas movement. In 1942, a Field Equipment Subdivision was established in the Finance and Supply Division of the Surgeon General's Office to discharge this duty. Tactical units customarily received their organizational equipment through the port medical supply officer, who drew upon his distribution depot. During most of the war, however, and because of shortages, this equipment could be supplied only through the aid of the Surgeon General's Office. Reports of shortages were transmitted to the Field Equipment Subdivision, which consulted stock reports from depots and ordered shipment of the needed equipment. So far as possible, during 1942-43, the tactical units were completely equipped at their home stations, and any remaining shortages were supplied by shipment to the port of embarkation from which the unit was scheduled to depart. Occasionally, units left for overseas stations before their equipment could be furnished; in such instances, the equipment was shipped to the port and followed the units overseas. These belated shipments became so numerous, and in so many instances never reached the troop unit to which they were directed, that in the spring of 1945 a new procedure was adopted. Thereafter, when the equipment could not reach the home station by the required date, the unit was so informed and the requisi-

51For full discussion of procedures employed in filling requisitions at the New York port, see footnote 49(2), p. 147.
52(1) The original source for this paragraph was "Charleston Port of Embarkation, Overseas Medical Supply," an official record used by Capt. Richard E. Yates, MAC, in preparing the first draft of this chapter. The document has since disappeared, but the practice of sending requisitions directly to the Surgeon General's Office is verified by (2) Circular Letter No. 36 [(Supply No. 6), OTSG, 5 Feb. 1943, subject: Overseas Supply], which officially terminates it.


150

tions were canceled. The missing items were supplied from port stocks or, if not available at the port, were issued at the overseas destination.53

Priority System for Medical Supplies

In the meantime, the available organizational equipment was too limited in quantity to supply all units moving overseas in 1944. To equip the units scheduled to participate in the European campaign, the Red List procedure was initiated in June of that year. It was stipulated that all units on the list must be fully equipped before overseas movement and that the troops and their equipment were to be combat loaded. This plan required special procedures by the Supply Service, the medical depots, and the units themselves. The units on the list were notified early of the pending movement so that local supply officers could make a final effort to complete their equipment. Shortages were promptly reported to the Surgeon General's Office, which issued top priority requisitions to the depots. When time was not available for this direct shipment, the equipment was sent to the holding and reconsignment point at Elmira, N.Y., where shortages for each unit were segregated and assembled. Then, equipment was shipped to the proper port of embarkation and thus was available when the troops arrived.

In the execution of Red List procedures, several problems developed. Frequent transfers of units within the Zone of Interior resulted in much cross-hauling, lost shipments, and duplicate shipments. The misinterpretation of directives regarding equipment which should be sent to the home station and that which should go to Elmira resulted in duplicate shipments and excesses at Elmira. At length, the holding and reconsignment point became so swamped with freight that it was impossible, within the time available, to sort and mark the equipment. This produced numerous shortages, especially in hospital assemblies, that had to be filled from port stocks.

Despite these difficulties, the achievements produced by the Red List procedure were impressive. The list included 100 separate movement orders, directing the overseas movement of approximately 725,000 men and their equipment. In discharging its supply responsibility, the Medical Department provided the appropriate organizational equipment for 20 infantry divisions; 8 armored divisions; 1 airborne division; 42 general hospitals; 14 field hospitals; 22 evacuation hospitals (400-bed); 1 evacuation hospital (750-bed); 17 hospital trains; and 2 medical laboratories.54

Preshipment of Supplies

In 1943, large quantities of medical items were shipped to the British Isles in anticipation of heavy troop movements to follow. This preshipment plan

53(1) See footnote 16(1), p. 127. (2) Memorandum, Maj. R. L. Parker, MAC, to The Historical Division (attention: Capt. R. E. Yates), 6 Mar. 1946, subject: Supplementary Material on History of Supply Service Not Previously Covered.
54(1) See footnote 53(2), above. (2) Annual Report, Equipment Branch, Issue Division, Supply Service, OTSG, fiscal year 1945.


151

was based on the knowledge that the excess shipping space then available would be transformed into a deficit when the movement of troops reached its peak. The decision was made, therefore, to take advantage of the available shipping space and to build up a stock of medical equipment and supplies which would partially support the large scale campaigns in prospect.

The first shipments under this plan, made in April 1943, contained specific organizational equipment for the troops plus 45 days of maintenance supplies. Units included in the preshipment plan returned their organizational equipment to local supply officers. All outstanding requisitions were canceled, and any subsequent ones were returned without action. The troops carried a minimum of essential equipment, referred to as TAT (To Accompany Troops), including individual medical kits and Medical Department chests Nos. 1 and 2. The kits proved to be readily available and very practical in providing medical care en route, but the chests, packed in the hold of the ship, were not accessible to the using organization during the entire trip.

Before the troops left their home stations, the Supply Service studied the appropriate tables of organization and equipment and calculated the quantities which would be required for the units. Shipping orders for these quantities were then sent to the appropriate depots. All shipments of this equipment moved through the New York and Boston ports: 75 percent through New York and 25 percent through Boston. The packing cases were marked "ADV" to identify them as advance supplies and additional markings ("SOXO" and "GLUE") represented the destination ports in the United Kingdom. Having arrived in the British Isles, the supplies were conveyed to a designated key depot and then were transported to a depot near the troop unit's permanent camp. Poor transportation facilities and pilfering caused the last movement to be accompanied by considerable losses, and in March 1944, Medical Department units were authorized to move into the key depot and pick up their equipment with their own transportation.

The advantages of preshipment were numerous and important. It allowed the shipment of supplies in bulk and eliminated the losses and damage experienced when organizational equipment accompanied troops. It permitted the distribution of critical items within the theater according to the tactical priority of units. And it made possible the modification of equipment in bulk.

There were, however, two distinct disadvantages to the plan. Throughout the period, troop lifts were subject to frequent amendments, making it difficult for the Medical Department to plan its shipments. In addition, numerous changes in tables of organization and equipment lists were made after the publication of a troop lift and before the movement of troops. This caused units to requisition new items before the items were available in the theater, and necessitated the cancellation of requisitions and the augmentation of previously calculated requirements and shipments. This latter disadvantage very probably is inseparably connected with all supply operations in a lengthy war,


152

and can be eliminated only by foregoing the advantages which accrue from the improvement of equipment lists.55

Shipment of Penicillin and Blood

Throughout the war, special procedures were adopted in the shipment of medical supplies whenever the tactical situation or the nature of particular supplies required a departure from routine operations. The bulk of the supplies, of course, moved through ports of embarkation and was conveyed overseas by surface ships; but, from 1943 until the end of the war, two important medical items-penicillin and whole blood-used facilities of the Air Transport Command for speedy distribution to theaters of operations. Air shipment was rendered necessary by the perishability of the items and by the pressing needs of overseas installations.

Routine air priorities were established, the commercial laboratories which produced penicillin rushed the drug to aerial ports of embarkation, and planes of the Air Transport Command carried increasing quantities of the item to American troops on all continents. Penicillin ceased to be an allocated item in 1945, and the quantities shipped depended upon the expressed needs of overseas commands. In addition, surface vessels began to carry a portion of this cargo late in the war. Despite these changes, however, the distribution of penicillin was never characterized by the routine procedures which were used in shipping more stable and more plentiful medical supplies.56

Experience gained in the air shipment of penicillin proved to be valuable in the distribution of whole blood, an even more perishable item. Fortunately, the need for whole blood, first demonstrated by the North African campaign, had been anticipated by the Supply Service and most essential items of equipment had already been developed, such as anticoagulant solutions, donor sets, and recipient sets. The farflung service of the Red Cross, established to procure donations for blood plasma, was available to furnish the type "O" whole blood which was needed at the battlefronts. Using the facilities of the Air Transport Command, whole-blood shipments to Europe were started on 21 August 1944, within a few days after the request for them was received by The Surgeon General.

In the beginning, the shipments were not refrigerated for it was assumed that the relatively high altitudes maintained by the planes would keep the blood sufficiently cool. The bottles were chilled before and after the blood was drawn; and, when ready for shipment, they were packed in cardboard boxes wrapped in heavy paper. It was discovered, however, that refrigeration of the blood en route was desirable. In the spring of 1945, the Technical Division of the Surgeon General's Office developed a special shipping container, which consisted of an insulated refrigerator holding a can of wet ice. The refrigerator weighed 35 pounds empty and 104 pounds when fully packed; it held 24 bot-

55See footnote 53(2), p. 150.
56See footnotes 36(2), p. 140; and 40(2), p. 142.


153

tles of 600 cc. capacity, a can with 19 pounds of ice, and 24 recipient sets. Temperature of the whole blood was maintained at less than 5 C. during 24 hours of summer weather. The plan for shipping blood to the Pacific theaters was similar to the procedures established for Europe, except that it was Navy-operated.57

Editing Requisitions

As the war progressed, the problems of overseas distribution were rendered more acute by the excessively large requisitions transmitted to the ports of embarkation. Supply officers in the theaters were authorized to maintain levels of supply sufficient for a designated number of days. The quantity of each item stocked depended upon the days of supply authorized, the number of troops in the theater, and the maintenance or replenishment rates. It was expected that the maintenance factor would be largely based upon issue experience, but the uncertainties of war rendered it necessary that allowance be made for unexpected and unprecedented needs which only the future could fully disclose.

The elasticity of this maintenance factor produced requisitions for excessively large quantities of medical supplies; and these requisitions, in turn, created serious problems in the ports of embarkation and in the Surgeon General's Office. Requisitions for unusually large quantities were edited by these agencies, but there was a disposition to be lenient in the editing and thus allow the theaters to have what they wanted, so far as the availability of the supplies and equipment permitted.58 As an inevitable result, inequities and maldistribution resulted.

By December 1944, Supply Service officers concluded that the policy of lenient editing must be abandoned. So many large requisitions had been received recently from the Pacific that strict editing would be necessary if other theaters were to have their minimum needs supplied.59 A large part of this difficulty apparently was caused by poor stock control procedures in the theaters, the natural tendency to hoard, and by failure to base requisitions upon issue experience. Continued use of medical maintenance units also perpetuated the basic error of automatic supply which produced some shortages and great surpluses.

Extremely large requisitions from the European theater placed a burden upon ports of embarkation and medical depots. A 90-day stock level for depots, based upon previous issues, was adopted on 1 July 1944. During the 3 months which followed, the Medical Department learned that this stock level was unequal to the huge quantities of medical supplies used in mechanized warfare. After beachheads were established on the Normandy coast and requisitions were received for direct shipment to the Continent, it became apparent

57Medical Department, United States Army. Blood Program in World War II. Washington: U.S. Government Printing Office, 1964, pp. 206-215.
58Notes on Supply Service Staff Meeting, 13 Oct. 1944.
59Notes on Supply Service Staff Meeting, 22 Dec. 1944.


154

that a quantity of many items sufficient to last 90 days before the invasion was insufficient to meet a single overseas requisition. Stocks at Binghamton, the port filler depot which served New York, were soon exhausted; and extracts were rushed to the eastern and central depots in a frantic effort to fill the requisitions. Despite new procurement and heavy interdepot transfers, the port filler depot continued to be burdened beyond its capacity until V-E Day, in May 1945, brought relief.60

The foregoing experience clearly indicated the necessity for accurate, up-to-date maintenance rates. In April 1945, a special board was established by the Stock Control Division, Supply Service, to review maintenance issue experience for the period 1 January 1944 to 31 March 1945, and to compute maintenance rates on the basis of that experience. Near the end of the war, therefore, the Medical Department developed and put into use maintenance rates which reflected its experience in preparing for combat, stockpiling in theaters, and actual expenditures of supplies and equipment under combat conditions.61

60See footnote 36(4), p. 140.
61See footnote 36(4), p.140.

RETURN TO TABLE OF CONTENTS