Title Graphic

CHAPTER 13

THE MEDICAL SERVICE OF THE AAF

The story of the medical support of the Army Air Forces in World War I1 has been told elsewhere fully and competently.1 The present account, by contrast, makes no pretense at detailed coverage but attempts only to emphasize the unique problems that were encountered and the solutions that enabled the air arm to accomplish its war mission. The dominant feature of the program was the clear recognition of the central role of the individual flyer. The majority of line officers, responsible for the expansion of the Air Corps after 1939 and for its transformation into the Army Air Forces, were experienced flyers. During their years of training they had been intimately associated with the small group of medical officers who as pioneer flight surgeons were then creating the discipline of aviation medicine. In addition to a love of flying, these two groups had many common bonds, personal and professional, which were sources of mutual respect and strength. Regardless of how large the AAF became, its commanders rarely forgot that victory depended upon the individual fighter pilot and the small, interdependent aircrew of the bomber or other multiplace aircraft. As important as the machines were, they were obviously useless without the men to fly them courageously and effectively. The principal function of the medical service, therefore, was the care of the flyer.

No attempt will be made here to review what may be called the normal clinical activities of the physician in uniform. The personnel of the AAF benefited from all the advances in medical science that were contemporaneous with World War II: the sulfa drugs, penicillin, and more effective definitive surgery, to name only a few. In this general area the medical service of the AAF adopted two important

--365--


practices and demonstrated their value well in advance of the medical departments of the Army and Navy. These were the early ambulation of the postsurgical patient and the aggressive physical rehabilitation of the sick and wounded.2

These two clinical practices, plus a desire to retain administrative control over personnel who required special procedures in AAF hospitals, precipitated an administrative conflict between the Surgeon General of the Army (SG) and the chief medical officer of the AAF. Other conflicts with the SG concerned the need for a specialized medical service for flying personnel and the command relationship between the line and the medical service. These controversies which were carried on in the upper echelons of the military establishment will be described, briefly, below. It is enough to say at this point that the writer is convinced that the conditions of flying create a number of medical problems sufficiently important and sufficiently unique to justify the speciality career of flight surgeon and the discipline known as aviation medicine.

The Flight Surgeon

The term “flight surgeon” was coined in 1918 to designate those officers of the Medical Corps, United States Army, who had been trained in the Air Service Medical School and assigned to duty with Air Service units.” During the 1930% the rapid mechanical developments of aircraft, the increased knowledge of the physiological consequences of flight and air combat, and the prospects of mobilization resulted in frequent alterations in the type and extent of instruction and experience required for the rating of flight surgeon.3 After July 1940 the requirements and training were substantially the following: a desire, willingness, and aptitude to practice aviation medicine; an interest in aviation generally and a desire to participate regularly and frequently in aerial flight; graduation from a Class A medical school, followed by at least a one-year rotating internship; and completion of the approximately 300-hour course at the School of Aviation Medicine (SAM).

After graduation from SAM the medical officer qualified for the rating of Aviation Medical Examiner. After a year’s duty with the AM, and after having flown at least 50 hours in military aircraft, he was then eligible—if otherwise qualified—for the designation of flight


* See below, p. 376.

--366--


surgeon. The duties of the flight surgeon may be epitomized as follows:4

  1. To dispense routine medical services, including the management of traumatic injuries. 
  2. To select candidates for flying training, with special emphasis on the ophthalmological, cardiovascular, and neuropsychiatric phases of the examination. 
  3. To provide “care of the flyer,” i.e., to study the effect of flight on the pilot (and aircrewman), act as his confidant and adviser, and also to act as an intermediary in medical matters between the flyer, his commanding officer, and higher medical authority. 
  4. To investigate the effect of flight and seek remedies for those environmental conditions which may have an adverse, or a limiting, influence.

So cursory a description of the prescribed role of the flight surgeon in military aviation ignores perforce the’ many ambivalences in the three-way relationship of the doctor, the flyer, and the commander. Since most of the difficulties of the medical service were related directly to interpersonal problems, the actualities deserve some consideration.

As scientific investigators, flight surgeons studied exhaustively, and attempted to quantitate, the physical, physiological, and psychological stresses of flying. Such research enabled engineers to design equipment (e.g., oxygen-supply systems, instrument-training systems, and soundproofing) permitting men to fly the machines that were built. Equally important were the studies of survival in such circumstances as bail-outs at high altitude and high speed, ditching, air-sea rescue operations, and the like. Most experiments testing safety devices and survival procedures were carried out by flight surgeons themselves, nearly always at great personal hazard. Their willingness to risk their lives for the benefit of others and their ingenuity in reducing some of the perils of flight earned for the corps of flight surgeons the universal respect in which they are held by airmen. In contrast to this was the threatening aspect of the flight surgeon in the selection process and in the continuing evaluation which is comprehended by the term “the care of the flyer.” Here conflict was inevitable. On the one hand, the flyer grounded by the doctor’s decision had his career thwarted, his status altered, and his pay reduced. On the other hand, the doctor’s decision that he was fit to fly could send the combat aviator suffering from physical illness, anxiety, or fear of flying back to perils that were only too real or could force him to become insubordinate if he refused to fly.

--367--


At the squadron level the flight surgeon served the commander as personal adviser on the human factors in this small segment of a great weapons system. In this capacity it was his duty to keep as many men fit for flying as possible and to help the airmen under his care to function to the limit of their capacity. At the same time he was expected to be the confidant, adviser, and private physician to the individual flyer whom he was assigned to serve, A balanced discharge of these often mutually antagonistic responsibilities is called the art of aviation medicine. At the squadron (or unit) level, where personal contacts were closest, the art was practiced, in general, fairly well. But each higher echelon also had a flight surgeon, to whom the squadron doctor reported, who served as adviser on human factors to his commander. The senior physician dealt with the disposition of individual cases, with the combat capabilities of the subordinate commands, and with policy matters such as tours of duty, rotation, rest, and the like. On the one hand, the flight surgeon of the higher echelon attempted to interpret and justify to his commander the actions and recommendations of the unit physicians. On the other hand, the commander was under constant pressure from higher commands to keep as many men flying as possible. In turn, the medical officer was required to exert constant pressure on his medical subordinates for a course of action favorable to the war effort, even though it often appeared to him to be prejudicial to the flyers. It is not surprising that there was friction between the practitioners of the art of war and of the art of aviation medicine. Attempts to reduce this friction were legion, as evidenced by a steady stream of innovations, directives, and experimental procedures, but no perfect solution was possible.

Aviation Medicine

Aviation medicine began with the realization that individuals varied in their reactions to the circumstances of flight. Before World War I attention was directed principally to the physical fitness of the flyer, and the earliest work was concerned with the establishment of minimum physical standards. From the outset it was evident that the body’s capacity to adjust to the special conditions of flight was a limiting factor in the utilization of aircraft. The unusual stresses encountered in flying, which are the subject matter of aviation medicine, may be described as follows. 

--368--


  1. Physical. As we move from the earth’s surface into space, the atmosphere becomes less dense, and the temperature lower. At an altitude of about 10,000 feet symptoms develop, because of decreased oxygen in the blood; at 18,000–25,000 feet most individuals lose consciousness and are close to death. Using ordinary (i.e., non-pressurized) oxygen-supply systems, an altitude of 40,000–45,000 feet is barely tolerable. Using pressure oxygen systems, the limiting altitude is in the neighborhood of 90,000–100,000 feet.
  2. Gravitational. As aircraft were driven faster by improved engines, the typical maneuvers of flight (and particularly combat flight), such as acceleration, turns, dives, and the pull-outs from dives, generated centrifugal forces on the blood and tissues of the pilot, the magnitude of which is measured in G’s, or multiples of the force of gravity. The clinical significance of such gravitational stresses is related to the length of time over which they are sustained. Protective devices, known as anti-G suits, were devised which counteracted to a limited extent these powerful forces.
  3. Physiological. When the human body is exposed to physical and gravitational stresses, adaptive and compensatory physiological mechanisms come into action, and survival depends upon the adequacy of the response. A knowledge of the nature of these compensatory reactions is necessary in order to develop protective devices and to establish the limits within which the aviator can function. The stresses that the combat flyer encounters daily exist nowhere else, and the study of them requires such devices as low-pressure chambers and the giant human centrifuge as well as the usual equipment of the laboratory. 
  4. Psychological. Military and civil aviation ceased to be a daytime, fair-weather occupation during the 1920’s. The development of instrument flying grew out of psychological studies of the means by which man is able to orient, or fails to orient, himself in flight when all spatial reference points are absent.5 Likewise, the significance of other psychological attributes, such as depth perception, reaction time, and ability to tolerate rotary and confused motion, has a bearing on the capacity to fly safely. 
  5. Emotional. Even after years of study, the emotional aspects of flying are poorly understood. No one who has studied successful flyers will deny that their psychic constitutions are unique and that there is a fairly consistent configuration of their personality structure. The act of flying yields a distinct gratification, particularly to the pilot, and it appears that this libidinal devotion serves the airman as a powerful shield against the threat of failure and death. The existence of strong emotional currents in flyers, and the inadequate perception of their meaning by non-flyers, led inevitably to conflict at all levels where command or authority was shared by the two groups6 Such conflict was intensified by the mystical unity of the flyers against all others. This attitude was epitomized by Malraux when he said, “Aviation united them as childbirth makes all women one.”

--369--



These five areas, then, provide the subject matter for the specialty of aviation medicine. To a remarkable extent the medical scientist has been able to keep step with the aeronautical engineer, and the planes that have been produced can be flown safely. Long before Pearl Harbor, the leaders of the Air Corps recognized the need for collaboration between aviation medicine and aircraft design. This recognition came from realization of the discrepancy between aircraft performance and human tolerance and from realization that the human element was the weakest link in the air weapons system that the Air Corps was attempting to create in the 1930’s. At that time the medical research activities of the Air Corps were concentrated in the School of Aviation Medicine, being concerned primarily with selection procedures and physiological and psychological studies of individual flyers. The concept of a need for “human engineering” developed from the experiences of Lt. Col. Malcolm C. Grow, MC, who divided his time between air duties as flight surgeon at Patterson Field, Ohio, and as informal consultant to the Equipment Branch, Engineering Division, at Wright Field, Ohio. In 1934 he established the Laboratory of the Aero Medical Research Unit at Wright Field, with Capt. Harry G. Armstrong, MC, USA, as co-founder.* The broad mission of the unit was to investigate all medical problems with reference to Air Corps material, problems of flight in which tactical efficiency is correlated with the machine, medical problems arising from and related to engineering advances, and the effects of flight on man.

The laboratory expanded rapidly and to a remarkable degree accomplished its mission. Concurrently, the research program of SAM was accelerated, although the emphasis there continued to be directed to the investigation of psychophysiological problems.7 The American genius for improvisation, expansion, and improvement functioned in


* These two pioneers of aeromedical research carried heavy responsibilities throughout World War II. In 1946 Maj. Gen. M. C. Grow was appointed Air Surgeon and at the end of his term was succeeded by Maj. Gen. H. G. Armstrong.

--370--


its characteristic manner, and, when the United States entered the war, aviation medicine was full fledged, and the human factor was no longer the weakest link in military aviation.8

Administrative Problems

As a matter of expediency the Army Air Forces, in June 1941, wanted to accept as little immediate responsibility as possible for such services and housekeeping chores as were then adequately discharged by the Army’s Services of Supply. Among them was the medical service, which was provided in part by Army medical officers assigned to the Chief of the Medical Division, Office, Chief of Air Corps, and in part by hospitals and dispensaries ultimately responsible to the Surgeon General of the Army. There were enough problems involved in the expansion program to argue for deferment of some long-range objectives, but there can be no doubt that air force planners looked forward to the development of a fully integrated air weapons system. Implicit in the concept of a weapons system, whatever its mission was to become, was the need for organic control-if not of every element, at least of the key components. Since the establishment of the Aero Medical Research Unit (1934) the Air Corps had been committed, in doctrine as well as in practice, to the parity of the human factor and the “hardware.” It was inevitable that in time an unrelenting campaign would be waged for the establishment of an independent medical service responsible only to the Chief of the Army Air Forces.*

The unique emotional configuration of the flyer, the complexities of modern aircraft, and the exiguous nature of aerial warfare made it evident to the air staff that the expanding force must retain to the greatest extent possible the characteristics of an elite corps.† No one seriously challenged the air staff‘s decision not to lower intellectual and physical standards for aviation cadets. Hence there was no serious objection to the AAF’s requirement that only those enlistees and inductees


* The campaign for an organic medical service for the AAF really began when Col. David N. d. Grant, MC, was appointed Acting Chief of the Medical Division, WAC, on 12 October 1939. This able physician and administrator continued to serve as the chief medical officer of the air arm throughout the expansion period and the war. Frequent reorganization of the medical service was necessary to cope with the rapid development of the AAF, and on 30 October 1941 Colonel Grant was designated “The Air Surgeon.” Subsequently he was promoted to brigadier general and in 1943 to major general. He retired in 14 after twenty-nine years of service, fifteen of which were with the air force.

† It was not quite so straightforward as the following summary makes it seem. See Vol. VI, 537 ff.

--371--


whose AGCT score placed them in Classes I and II should be considered for pilot and aircrew training. It was only necessary to examine a contemporary bombardment plane like the B- I 7 to realize that the ground crewmen who serviced it needed to be far more dexterous and far better equipped intellectually than the men who serviced the ubiquitous jeep, for example. Serious resistance, however, was encountered to a corollary proposition that this fledgling force required its own medical service. As a matter of fact, the medical service of the AAF finally achieved about the same degree of virtual autonomy as did the air arm itself in June 1941, but the freedom gained involved a time-consuming and often acrimonious controversy between the medical officers assigned to the Office of the Air Surgeon and those in the Office of the Surgeon General of the Army.

The imaginative ones among the pioneers of military aviation and their medical colleagues, who were beginning to call themselves “flight surgeons,” insisted from the days of World War I that an effective air force should have an organic medical service responsible only to the chief of the force. In the years between 1917, when Lt. Col. Theodore C. Lyster, MC, first made the proposal, and 1947, when the United States Air Force was established, efforts to develop such a service varied greatly with respect to individual enthusiasm and official resistance or support. Inevitably, the long campaign was confused by recurring “battles of memos,” ad hoc committees, and compromises. Incompletely concealed by the verbiage that enshrouded the long struggle, there can be discerned two themes and a number of variations on them which are worthy of consideration.

The two themes were the revolutionary nature of air power and the equal importance of men and machines in an air weapons system. The variations can be abstracted most conveniently in the form of the following propositions.

The airplane is a revolutionary weapon that demands a tightly knit but flexible organization as modern as the instrument itself. The flyer must have a flight surgeon who understands his problems, who is responsive to his needs, who is able to participate in every phase of the development of the new air weapon, and who is under the authority of the same commander. The ideal flight surgeon must share the convictions of the flyer concerning the revolutionary nature of air power and should regard the challenge to participate in aviation medicine as equivalent to the challenge in other areas of medical research. The

--372--


leaders of military aviation had acquired an experimental attitude that stood in contrast to the intrenched conservatism of the General Staff. Flyers, including flight surgeons, should be free to develop American air power according to their own dreams, restricted only by the financial resources of the country and their own capabilities. The geographical limitations that provided a logical basis for the operational plans of the Army Medical Department were meaningless to an air force whose planes compressed time and distance. And, finally, since the human resources of the Air Force were considered equivalent in importance to the planes, and since the air arm provided all levels of maintenance for the latter, why should not the commander provide and control all levels of maintenance and repair (i.e., hospitalization) for the men without whom the planes were useless?

As a sort of counterpoint to these themes and variations one senses the unique personality of the airman-the visionary-who has rejected the good earth for the boundless air. One feels, rather than perceives directly, the spirit of defiance toward conventional attitudes and traditional authority. In spite of this, the flyers and their volunteer flight surgeons were realists enough to know that simply wanting a separate medical service would not achieve it. Such a service, like autonomy in any branch of the air arm, must be gained in a piecemeal manner, with the exertion of steady, opportunistic pressure, and in the end it was the demands of war rather than sheer logic that brought success.

In this context the first objective of the medical service of the AAF was to achieve an administrative situation where the chief of the medical service was responsible directly to, and only to, the chief of the air service (whatever his current designation might be).9 This was a unique concept for a military organization when it was first proposed in 1917, and in terms of management relationships it is still a unique concept. The theory behind the objective is very simple: in an air force-or in any other large enterprise, for that matter-the welfare of the human factor is as important as any other consideration which is the noimal concern of top management (e.g., raw materials and plans). Accordingly, the chief medical officer of the organization should be directly responsible to the chief executive; he should be a member of the top echelon of control, and he should not be required to present advice arid recommendations and receive directives on policy and/or operations through the medium of a non-medical administrator (e.g., a G-1 or G-4, or the Commanding General, Army

--373--


Service Forces, or the personnel manager). If the health and the welfare of manpower are important, the chief executive should have direct access to his chosen medical adviser, and vice versa.

To a physician, this proposition seems self-evident; but it is quite apparent that it is not, and has not been, equally evident to most military and civilian administrators. This staff relationship has been the normal procedure in the Air Corps, the Army Air Forces, and the present US. Air Force. Prior to the establishment of the USAF the relationship was not always unequivocal,10 but it was operationally effective, and it had the force of assuring that the medical needs of airmen were the direct concern of the highest echelon of command. In terms of human relationships, the devotion of AAF management to the philosophy of the parity of the human factor and the hardware, and the success with which it was implemented, represents a real contribution to the managerial aspect of our society.

The next objective-a medical service independent of the Surgeon General of the Army-was a logical consequence of the first, but its achievement was complicated by the traditional policies of the Medical Department. In the normal course of War Department operations it was customary for a Medical Corps officer to be assigned as surgeon to the staff of the commander of a major component such as a corps area, an army, or an overseas theater. This officer was directly responsible to his commanding officer, but he was also responsible to the Surgeon General for the execution of his military medical functions in compliance with the approved practices of the latter’s office. Professional standards, tables of organization and equipment, hospitalization procedures, disposition procedures, and research and development (to name only a few) were centralized functions controlled by policies established in the office of the SG. There was, therefore, no strain at all in assigning an officer as Chief, Medical Division, Office of the Chief of the Air Corps, and in stating, that he was responsible to the Chief; but the medical mission that he executed, and the manner in which he executed it, and the tools and personnel that he could requisition or develop remained to a very large extent within the control of the Surgeon General. Offsetting this limitation to some extent was the willingness of the Air Corps to use its own funds in support of medical projects peculiar to its own needs, as in the establishment of the School of Aviation Medicine in 1919 and the Aero Medical Research Unit in 1934. The failure of the SG to accept full responsibility

--374--


and the degree of independence for the Air Corps that came through financial control of such organizations represented significant steps toward a separate medical service for the air arm.

A military medical organization has three important components: a physical examination service; a field medical service, which includes the handling of battle casualties and provisions for ambulatory care (e.g., sick call); and a hospitalization service. In the agitation for a separate air medical service early in World War II one encounters little to indicate that the planners wanted separate air force hospitals under the same terms of control as for the physical examination and the field medical services. There were probably sound enough reasons for the failure to campaign for such hospitals early in the game. The Surgeon General may have been willing to delegate control of physical examinations (an unpleasant task at best) to the flight surgeons; but he resisted stoutly all attempts to relocate the field medical service until the pressures of expansion and the experiences of combat overrode the chronic objections. The fact that the Air Surgeon developed an effective hospital system around the stateside air-base station hospitals and the aviation medical dispensaries (i.e., the equivalent of a field medical service) did not weaken in the least the resolve of the SG to defend his general hospital system* to the limit of the patience of all concerned, including the Chief of Staff. The vast system of named general hospitals was one of the few military medical activities over which the Surgeon General had complete control. In actuality, the completeness of his control fluctuated as a result of organizational changes in the War Department, and there was a period subsequent to the March 1942 reorganization when the SG found himself receiving policy and other directives from a higher echelon, the Hospitalization and Evacuation Branch of the Special Staff of the Commanding General, Army Service Forces.11 In any case, it was evident that there would be no voluntary relinquishing of general hospitals on the


* In the nomenclature of the Medical Department, general hospitals were large establishments organized to render definitive medical service to any type of case, however com l a , and to determine eligibility for separation from the service on medical grounds. The general hospitals in the Zone of Interior were designated as named general hospitals (e.g., Walter Reed) and, as exempted stations of the War Department, were under the control of the SG rather than command of the military k i c t in which they were located. Overseas general hospitals in World War I1 were numbered, were zone-of-communications installations, and were under the control of the Commanding General, Army Service Forces.

--375--


part of the SG just because the Air Surgeon wanted to round out his medical service.

It is instructive to examine briefly the stepwise manner in which the air medical service emancipated itself from parental control, considering only what appear to be the critical phases of the separation process, with approximate dates and cursory comments.12

  1. Pilot selection and classification. The first physical examination requirement for flyers was prepared by the Surgeon General's office in 1912 at the request of the Aviation School, Signal Corps. In spite of its many revisions the physical examination test alone was an inadequate basis for selection when measured by the high fatality rate in trainees during World War I. On 19 January 1918, the Aviation Section, Signal Corps, established the Air Service Medical Research Laboratory at Mineola, New York, with Col. W. H. Wilmer, MC, as director, to study the factors responsible for pilot failure and thus to improve the selection process. From that time on the aviators and the flight surgeons retained the initiative in research and development of methods to reduce the loss in manpower and planes resulting from inadequate pilot selection and human failure, The impetus and the funds for these continuing studies came from the budget of the air arm.
  2. School of Aviation Medicine. The first school of aviation medicine was the School for Flight Surgeons established in 1918 in conjunction with the Air Service Medical Research Laboratory at Mineola, later moved to Mitchel Field, New York. The school taught the practical application of the research being done at the laboratory, particularly the performance of the new tests: the Altitude Classification Examination, the Personality Study, and the Physical Tests of Efficiency. In February 1921 the school was recognized by the War Department as a special service school. It thus became exempt from the jurisdiction of the corps area commander and was directly under the Chief of Air Service. In November 1922 its name was changed to the School of Aviation Medicine. Subsequently it was moved ( 1926) to Brooks Field, Texas, and then (193 I) to Randolph Field, Texas, its present location.
  3. Research laboratories. The first aviation medicine laboratory and the first school for flight surgeons became a single unit, concerned almost exclusively with the evaluation of the reactions of the individual aviator to the conditions of flight. As the aircraft development program progressed, the need of a laboratory for “human engineering” became apparent, and in 1934 the Air Corps authorized the Aero Medical Research Unit at Wright Field.* Its mission was to collaborate with aeronautical engineers on every aspect of military aircraft development that involved the human factor.

* See above, p. 370.

--376--


  1. Administration of aviation medicine. The medical unit responsible for pilot selection, the care of the flyer, and other matters related to aviation medicine has had many names and many organizational assignments. The first such unit was the Medical Department, Air Division, Signal Corps, activated 17 September 1917. This activity was returned to the Surgeon General’s control on 9 May I 91 8, presumably in connection with the creation of the Air Service on the 20th. The activity, including the same medical officer personnel, was then designated the Air Service Division, OSG. It remained in this administrative location until 14 March 1919, when the Surgeon General abolished the division and delegated its functions to the Chief Surgeon, Air Service. Operational control was never regained by the SG, and it appears that control of policy moved steadily away from the Army’s Medical Department from that time on.
  2. Procurement of aviation medical personnel. In the years between the two world wars, candidates for flight surgeon training and for careers in aviation medicine were members of the Medical Corps assigned to the School of Aviation Medicine at their own request. This system, which was adequate for peacetime, broke down completely in 1941. By the spring of 1942, the Surgeon General reported to the War Department that be had been unable to fill the 1,500 places for Medical Corps officers allotted to the AAF.13 A number of factors were responsible for this poor showing, chief of which were the temper of times, the unnecessarily complicated procurement procedure, and ineffective recruiting publicity. The Air Surgeon worked out an informal agreement with the SG, which was tantamount to permission to do his own recruiting, to process for the SG the paperwork of applicants who expressed a desire for service with the AAF. On this basis an aggressive and imaginative recruitment campaign was initiated, which included press releases in professional journals and regular news media, personal solicitation, and informational packets. In spite of the persistence of red tape in Washington, the Air Surgeon was able to fill his first procurement objective of 2,000 Medical Corps officers between 21 March 1942 and 1 July 1942. Similar techniques were applied to meet objectives for other specialized medical personnel. In terms of long-range objectives the Air Surgeon’s recruiting program brought into his medical service a high proportion of Board qualified specialists,* as well as a substantial number of Fellows of the American College of Surgeons and the American College of Physicians. These well-trained physicians were to play a key role in the hospitalization system of the AAF.
    * A number of quasi-official bodies have been organized (e.g., the American Board of Internal Medicine) to examine and certify physicians who wish to be designated as specialists because of advanced training and special interest. These boards specify minimum educational requirements and conduct written and oral examinations on which to base certification. Within the medical rofession, the term “specialist” is largely restricted to individuals certified by one o P nineteen specialty boards.

--377--


  1. Exemption of air-base installations. The revision of Army Regulation 95-5, 20 June 1941, established the Army Air Forces, and defined the status, function, and organization of the air arm. Among the provisions of AR 95-5 was the delegation to the Commanding General, Air Force Combat Command, of “command and control of all AFCC Stations [air bases] and all personnel, units, and installations thereon, including station complement personnel and activities.” Similar provisions applied to the Chief of the Air Corps with respect to Air Corps stations. As a result of this action, personnel at all air bases passed into the control of the AAF. In this way, an extensive system of station hospitals and aviation medical dispensaries was added to the responsibilities of the Air Surgeon.
  2. The convalescent centers. The medical service of the AAF, willing to benefit from the experience of its RAF counterpart with “flying fatigue,” “operational fatigue,” “staleness,” or whatever name was currently in vogue, began to plan for the reception of such cases well in advance of their appearance. In the European Theater of Operations rehabilitation centers were requested by the Surgeon, Eighth Air Force, in July 1942, were authorized by the Commanding General, ETOUSA, in August 1942, and were established forthwith.14 In the United States the Air Surgeon at the same time initiated requests for authority to operate comparable facilities for AAF personnel returned from overseas. The validity of the request and the proposal for AAF control were challenged by the SG, but ultimately the Chief of Staff, with the Secretary of War’s personal approval, authorized convalescent centers of the type desired. Approximately nine months after the Commanding General, AAF, asked permission to do so, the first eight centers were activated, and one-the station hospital at Coral Gables, Florida-was granted authority to function as a general hospital but only for the purpose of reclassifying officers for limited service and for appearance before retirement boards.15

--378--


  1. 8. Hospitalization. Throughout the war the problem of hospitalization of AAF personnel was never resolved to the satisfaction of anyone. In November 1943 the Air Surgeon controlled approximately 75,000 beds in about 350 station hospitals and dispensaries in the Zone of Interior.16 In the theaters the air forces controlled only the beds in their aviation medical dispensaries and in some rehabilitation centers. The philosophy of war, tradition, and prestige were inextricably involved in the controversy over hospitalization. Neither of the contending parties won, and in retrospect it is fair to say that the extreme attitudes of the partisans on either side reflected no credit on the medical profession.

By the end of the war the medical service of the AAF could review its accomplishments with justifiable pride. From the 800 Medical Corps officers on hand at the time of Pearl Harbor, it had expanded until, in November 1943, approximately 16,000 doctors were on duty in air stations throughout the world, providing superior medical care for the aircrewmen of 234 combat groups, 135 of which were overseas,* as well as for the noncombat personnel who made up 60-80 per cent of the global air force. Medical problems that were as revolutionary as the planes that generated them had to be faced and solved. In the absence of traditional solutions the air arm’s medical service had to improvise, experiment, and innovate on a grand scale. The youthful leadership of the service, and its close partnership with pioneering line and engineering officers, was equal to the challenge, and, although the administration was often severely strained, the mission was accomplished.

Operations

The operations of the air medical service in the field of aviation medicine is discussed here in a functional manner. Subdivision of the material on a geographical basis is neither feasible nor valid, for the speed of military aircraft in World War II reduced the significance


* See Vol. VI, 424.

--379--


of such terms as “zone of interior,” “zone of communications,” and the “front.”

In spite of the large numbers involved, the individual flyer continued to occupy the central position in aviation medicine and to provide the stimulus for aeromedical research. Every flight surgeon was a potential investigator, and the best of them contributed magnificently to our knowledge of men under stress. Moreover, it can be said truthfully that every aviator was a research problem, so little was known that needed to be understood. Thus for the leaders of aviation medicine each day’s problems, crises, and crashes led directly to experimental attempts to understand, solve, or avert them. Fortunately, the whole AAF operated pretty much on an experimental basis, so it was easy to obtain co-operation and support for any study that was stimulated by an obvious problem. Flight surgeons moved about rapidly among the special laboratories, the training stations, the schools, the proving grounds, and the theaters of operations. New ideas and new solutions were at a premium, and many projects were put into operation prematurely, to be withdrawn later when the validation study turned out to be negative. The entire air arm was composed of men in a hurry who knew where they wanted to go but had to learn how to get there.

Because it was easier to make changes in the procedures for men than to remodel the machines, one has the impression that the human factor was subjected to more experimentation than the hardware. Since it is not possible to review all the schemes that were tried and rejected, attention necessarily will be directed to the main currents and to the successful programs.

The strength of the AAF’s medical service rested on its strong orientation toward the welfare of the individual flyer. The fact that all the senior air commanders were successful aviators made them uniformly sympathetic to what may be considered the official attitude, However, as military commanders they had to subordinate concern for individuals to the tactical and strategic missions of their commands and to think of the maximum number of men and machines that were available each day. Bookkeeping on the human factor was necessary so that the rate of attrition of manpower did not exceed the rate of loss of planes. Sick and injured men were as easily understood as defective and damaged aircraft. Men who were unwilling to fly, or unable to fly, or who, when flying, were dangerous to others posed

--380--


an entirely different problem. An additional complication was the particularly poignant nature of the classical dilemma of the commander in the case of air combat units. It may be hard to think of a regiment of infantry or a battleship’s complement in terms of individuals, but it was not hard for the air group commander to think of the pilot officers in his fighter squadrons in this way. In spite of this inevitable personal identification, successful air commanders appear to have been as uncompromising in their demands on combat personnel as were the officers of the other arms. It is entirely possible that senior air officers, both line and medical, were able to repress their feelings of guilt by dependence upon “objective” assessments of the combat capability of their men. To this end a large number of “psychological tests” were devised, tested, and usually invalidated, “The remarkable pretense at prediction of success and failure in combat, common to [air] medical and line officers alike, suggests a widespread defense against the emotional impact of combat-the denial that fear of mutilation and death are in themselves strong enough to change a man, and the assertion that more important factors are whether he has wet his bed past the age of six or whether he can take orders or whether he is a competent flyer.”17’ The relevance of these remarks will become evident as the discussion progresses.

The reader is asked to bear in mind the fact that the medical service of the AAF was responsible not only for aviation medicine but also for the health of all air force personnel, except those admitted to hospitals outside the control of the Air Surgeon.

Selection and Classification of Aircrewmen

When the expansion of the Air Corps was authorized in 1938, the Medical Division had a well-established doctrine of pilot selection based on principles prescribed by the Air Service Medical Research Laboratory in 1918-r9 and elaborated over the succeeding years at the School of Aviation Medicine. In brief, the ideal pilot was preferably a graduate of the Military or Naval Academy who wanted to become a flyer, was a well-nigh perfect physical specimen of superior intelligence, and had scored in the upper deciles of tests of physical efficiency, altitude classification, co-ordination, and the like. The battery of tests to which the candidate was subjected varied from year to year depending on current medical thinking and on the attitudes of senior flight surgeons. The majority of the procedures had never

--381--


been submitted to a searching scrutiny by biostatistical techniques, since this science as it applied to test evaluation was just coming out of its infancy. Most of the tests were based on the concept that the stresses of flight were physical and that failure to adapt to such stresses was due to a substandard physiological constitution-a concept that was seldom criticized seriously at that time. The pilot-training program of the Air Corps before 1938 never graduated more than 250 flyers per year, so that there was plenty of time and personnel for an exhaustive study of the type of tests then in use. In 1939 the physical disqualification rate was 73 per cent of the applicants, and eliminations during training averaged around 40–50 per cent. In round numbers the Medical Division had to deal with no more than 1,800 candidates for pilot training each year.

The Air Corps expansion program* confronted the Medical Division with a new set of problems inherent in the mas production of aircrewmen. In June 1938 the strength of the Corps stood at 20,196, of which approximately 10 per cent were commissioned officers. Six years later the AAF would number 2,372,292, with 388,295 commissioned officers on duty. During the entire period of expansion and war, 194,000 young men successfully completed pilot training, and more than twice that number received their wings as aircrewmen (e.g., bombardiers, navigators, and gunners). There seems never to have been any question about the propriety of delegating the task of selection and classification to the medical service, and the successive procurement objectives did not alter the service's confidence in its ability to do the job. The projected work load of the flight surgeons and aviation medical examiners is shown in the following table:†


Program Date Formulated Annual Graduation Rate of Pilots Number of Cadets Entering Program* Number of Applicants Needed†
24-group Fall 1938 1,200 2,200 12,000
41-group Spring 1939 7,000 14,000 70,000
54-group Spring 1940 12,000 24,000 120,000
84-group Spring 1941 30,000 60,000 300,000

* Based on 50 percent elimination rate.

† Based on 80 percent disqualification rate.

This programing contained some slack, which was just as well, since no one could be sure that manpower and materiel procurement


* For a detailed account of the program, see Vol. VI, chap. 13.

† See also Vol. VI, 434.

--382--


would meet the ambitious schedule, The prediction of applicants needed was based on the round-number estimate that only one-fifth of the applicants could pass the aviation-cadet qualifying examinations. Actually, the rate of rejection in 1939 was 73.2 per cent, and realistic downgrading of the physical and mental qualifications reduced the reject rate to 50.3 per cent by the time the United States entered the war. Likewise, eliminations from pilot training for the whole six-year period turned out to be 39 per cent instead of the 50 per cent scheduled. The majority of the eliminees could be reclassified as aircrewmen, so that they were not entirely lost to the AAF. In any case, the magnitude of the task ahead suggested that the Medical Division had to streamline and facilitate its selection program. Two important actions were taken for this purpose.* First, a program was developed to predict the aptitudes of aviation cadets and to put the classification of aircrewmen on a positive basis. Second, in the selection process, the emphasis was changed from the pilot to the aircrewman (i.e., pilot, bombardier, navigator, and flight engineer, whether commissioned or not).

The impetus for these changes came from two directions. On the one hand, flight surgeons at SAM in the spring of 1941 obtained a grant of $600,000 for the development of aptitude tests that would indicate an applicant’s general potentialities, practical judgment, and capacity to absorb instruction. To implement this program, a psychology section was organized under Col. John C. Flanagan in the Medical Division, OCAC, and subsequently psychology units were established at SAM and at Maxwell Field and other preflight training centers. On the other hand, the Air Corps Technical Training Command (TTC) was seeking special tests to screen high-school graduates for training as bombardiers and navigators, a group that TTC‘s experts were convinced would afford better material than eliminees from pilot training, At the same time, because of concern for meeting training quotas, Brig. Gen. Carl Spaatz, Chief of Air Staff, became convinced that the AAF would have to adopt a revised testing program. Considering the existing system of educational requirements archaic because it placed “too much emphasis on formal education which may mean nothing and … no emphasis on native intelligence which may mean everything,” General Spaatz directed A-I to make a thorough renovation of regulations governing the requirements for


* Vol. VI, 489–91.

--383--


selecting flying cadets. This task was undertaken by the three OCAC divisions concerned–Personnel, Training and Operations, and Medical–at a series of conferences extending from 28 November to 3 December 1941. As a result it was recommended that thereafter all applicants for flying training, on passing an aviation-cadet qualifying examination (to be prepared by the Medical Division), should be qualified simply as aviation cadets (aircrew). Specific assignments for those thus qualified would then be determined by special classification tests administered at one of the three training centers. These tests were to be designed to measure the aptitude of each trainee for pilot, bombardier, and navigator training. To accomplish this latter objective, the research project of the Training Command was transferred to the Medical Division and combined with the pilot-selection project.

Although these actions were precipitated by the realities of preparation for total war, they were not unforeseen and represented, in fact, a steady drift of the thinking of aviation medicine with respect to the unsuccessful flyer. In World War I, failures were attributed to physical deficiencies: “chronic digestive disturbances, chronic constipation, or indigestion, or intestinal disorders tending to produce dizziness, headache or to impair vision.”18 The influence of physiologists after 1919 shifted the onus of failure to physiological mechanisms incapable of coping with reduced oxygen tension, cold, and gravitational forces. In the years before 1939, this concept was expanded, and to it was added the psychologists’ theory that failure also stemmed from inadequate psychomotor co-ordination and from inability to learn. At the time of the expansion program the technique employed to elicit disqualifying features other than physical and psychological ones was a biographical personality inventory called the Adaptability Rating for Military Aeronautics. The psychiatric phase of this rating was fairly primitive. In fact, prior to Pearl Harbor, psychiatry was not primarily concerned in the selection process, and instruction for flight surgeons was confined largely to the recognition of the major psychoses

The change in selection regulations was recommended just before the attack on Pearl Harbor, when the elaborate program of the psychologists was still in the stage of choosing and evaluating tests and of procuring test equipment. The declaration of war left the Air Surgeon no choice but to start processing applicants on the new basis and at once. From the outset there was insufficient time for the elaborate

--384--


battery of psychomotor and performance tests that had been projected, and simple, electrically scored paper-and-pencil tests had to be substituted wherever possible. The complex tests were carried out on samples of flying candidates to provide material for later validation. So far as the Air Surgeon’s office was concerned, the psychological tests turned out to be unsatisfactory predictors of failure, and in the fall of 1942 it was deemed necessary to reinstate a perfunctory neuropsychiatric examination which had been deleted in favor of certain attitude and aptitude tests.19 The details of the operation of the aircrew classification program are described elsewhere and need not be reviewed here.*

With the onset of hostilities the Medical Division was faced with the problem of processing a flood of aircrew candidates with a trickle of medical officers, who themselves required indoctrination and training. In February 1941 the War Department had authorized establishment of three Air Corps replacement training centers for classification and preflight instruction of candidates for pilot, bombardier, and navigator training. There was some realignment of the planning, and, finally, the classification centers of the Flying Training Command were established at Nashville, Tennessee, San Antonio, Texas, and Santa Ana, California.

The newly commissioned medical officers were assigned to these classification centers for a six-week practical training course. Initially, half their time was devoted to in-service training as members of the medical processing unit, which executed the medical portion of the cadet examination in production-line fashion. The balance of their time was scheduled for a variety of didactic exercises to familiarize them with medical administration and to introduce them to the problems and the philosophy of aviation medicine. There is probably no job in medicine more boring than to perform routine physical examinations day after day on healthy, willing recruits. In spite of this well-known fact, the rapid rotation of assignments in the processing unit, the excellent organization, and the enthusiastic co-operation of young physicians in a novel situation all resulted in a thoroughly


* See Vol. VI, 549–56, where General Arnold is quoted as saying: “The Aviation Psychology program paid off in time, lives, and money saved, and through its selection of the raw material has aided in the establishment of an effective air force. This has been done at a total cost of less than $5 per candidate tested.” Whatever the cost may have been, the air surgeons were less impressed with results than was General Arnold.

--385--


effective performance. From contemporary records there is no evidence that the medical processing units ever became bottlenecks in the classification program, nor is there any reason to believe that the high standards of the physical examination were seriously compromised. It was a remarkable achievement to adapt successfully production methods to a selection-classification process to which senior air officers, line and medical, attached so much significance.*

From the earliest days of military aviation, doctors and psychologists have served as selectors, and it is pertinent to compare the success of their efforts in two world wars, twenty-five years apart. In World War I the selection process was successful in 55 per cent of the candidates admitted to flying training; of 20,773 men who were passed by the selection boards, 11,438 completed the course.20 In World War II the selection classification was successful in 61 per cent; of 318,000 men who entered flight training, 193,400 graduated as pilots.† Since the prediction of success is only 10 per cent more reliable, it would appear that criticism of World War I standards as “based almost entirely on empirical grounds” could also apply to the standards used in World War II21 Regardless of this, it appears that responsible line officers of the AAF were well satisfied with the performance of the medical service in aircrew selection. It is entirely possible that this satisfaction was due to the not so obvious fact that this was an area of decision for which command was not responsible. Throughout the entire period of the wartime flight-training program there was increasing interest in the evaluation of the various


* In reflecting on this process, this writer has wondered why the responsibility for aircrew selection and classification should ever have been delegated to or assumed by the medical service. If success in military aviation (or any sort of flying for that matter) depended solely on physical fitness (theory of World War I), or on a combination of physical-psychological fitness and teachability (theory of the years between the wars), and not on something else, the job obviously belonged to the medical service. Moreover, medical educators, and graduate science educators (e.g., psychologists, physiologists, and the like), had always done a fine job of selecting candidates or advanced training in their own professions. In any good medical school elimnees should not exceed 10 per cent, and the same ought to be true for a major university's graduate school. But this degree of success in selecting for one’s own profession has no bearing on the ability to select for some other profession, such as flying. This raises, of course, the question of something else being involved in the makeup of the successful aviator in addition to the factors postulated by the medical service. It seems evident that the doctors and psychologists were failing to recognize some predictor of success or failure in flying that they were able to recognize intuitively in the candidates for their own profession. This is, of course, speculation, but the plain fact is that the selection process was not much more efficient in 1942 than it was in 1918.

† See Vol. VI, 577–78.

--386--


tests used. The large volume of recruits permitted rapid accumulation of sufficiently large samples of data for analysis. The AAF was statistically minded and, in addition to having business machines and computers, was able to call on biostatisticians and operations analysts for consultation. There was probably never a time when accepted medical procedures were subjected to so competent a scrutiny. Many were rejected entirely, and few of the elaborate routines escaped unscathed. A particularly striking example was the Schneider Index, a method of evaluating cardiovascular fitness developed by one of the fathers of aviation medicine. When the business machines got through with the index, it was evident that the only significant element was the differential between blood pressure measured in the reclining and the standing positions. This could be measured very simply and required less time and no need for consulting tables and summing-up scores. In the evaluation of susceptibility to motion sickness, the Barany-chair test was another casualty; it was replaced by a simple swing test. Most of the complex psychological tests of co-ordination and psychomotor function and the majority of the simple pencil-and-paper tests to evaluate personality and aptitude also failed to demonstrate validity when tested by modern methods. All these considerations end up in the same place: regardless of how carefully or how casually a group of men was selected for military flying, about 40–50 per cent washed out.

The Care of the Flyer: Training

The principal function of the medical service of the AAF is described by the term “the care of the flyer.” The concept of the flight surgeon and his role in the care of the flyer was originated during the first World War by Col. Theodore C. Lyster, MC, USA, and Maj. Isaac H. Jones, MC, USA, who proposed the organization of a Care of the Flyer Unit in June 1918. Although flight surgeons attached to such units were under the jurisdiction of the post surgeon, the latter was advised that “in all matters relating to the care of the flyer, the Flight Surgeon should be given a free hand and his advice will control.” The flight surgeon, on his part, was designated as the adviser to the commanding officer and the flight commander “in all question of fitness of aviators or aviation students to fly.”22 The term -the care of the flyer-was a durable one which is still in use, alrhough the concept of what it comprises has been expanded greatly.

--387--


In World War I1 the flight surgeon was necessarily concerned not only with the individual pilot but also with the aircrew of multiengined planes as individuals and as a combat team. The shift in emphasis from the single-seated fighter that dominated the air in the first war is demonstrated in the following table:*

Aircraft Acceptances by Type
1 July 1940–August 1945
Type Total Percent of Total Men per Plane (Approx.)
Fighter 99,950 34.3 5–2
Bomber 97,810 32.4 3–13
Trainer 57,623 19.3 1–2
Transport 23,929 8.9 2–6
Communication 13,643 4.6 2–4
Reconnaissance 3,918 1.3 1–4
Special purpose 2,420 0.8
Total 199,290 100.0

To man these aircraft in training and operations required about one-fourth of the strength of the AAF. The number of men who completed aircrew training between July 1939 and August 1945 is indicated below:†

Type Total Elimination Rate (Approx.) Percent
Pilots 193,400 40
Bombardiers 48,000 12
Navigators 50,000 20
Flexible Gunners 297,000 10
Flight Engineers 7,800 9
Radar Observers, bombers 7,600
Radar, night fighters 1,000
Radar, countermeasures 500

The grand total of better than 600,000, plus about another 125,000 eliminees, suggests the magnitude of the flight surgeons’ task in the provision of “care of the flyer.”

In functional terms this care consisted of the following: ( I ) to evaluate the influence of concurrent illness and injury on the ability to fly and to provide treatment for such disability; (2) to treat injuries and disorders attributable to flying; (3) to teach and to interpret the physiology of flight (in practice this meant altitude indoctrination and the use of oxygen equipment); (4) to teach the use of and to


* See Vol. VI, 352.

† Adapted from Vol. VI, chap. 17.

--388--


evaluate protective devices; ( 5 ) to diagnose as accurately as possible symptoms and disability due to emotional reactions; and (6) to help the airman recognize and deal with the tensions and anxieties generated by flight and combat, as well as the tensions and anxieties that may affect any man in the same age group or in the military service.* The first two items were well within the competence of the average physician who volunteered for medical service with the AAF, and there is every reason to believe that these duties were discharged enthusiastically and satisfactorily.

The next two items involved a specialized knowledge of physiology and modem air force equipment, which the ordinary doctor simply did not possess, The training provided by SAM was supposed to correct this deficiency, but over-all planning failed to the extent that two-thirds of the medical officers in the ETO at the beginning of operations there were not qualified to perform the essential duties of a flight surgeon.23 This regrettable situation resulted from a number of factors. Because of pressure to meet Eighth Air Force (and other air force) schedules, doctors were assigned overseas before they had received any special training in aviation medicine. Similarly, unit commanders tended to offer the less desirable medical officers when asked to contribute personnel for task forces. Most serious of all, the training then provided at SAM was obviously inadequate because of the large commitment of time to the “64”† (physical) examination and to aspects of military medicine of little use to the flight surgeon in a combat area. Training schedules for medical officers eventually were revamped to provide more tactical and physiological training before assignment overseas; and, in England, on-the-job training was supplied by the Eighth Air Force Provisional Medical Field Service School, Col. Harry G. Armstrong, commanding, which opened its doors on 10 August 1942.

The last two items on the list of “care of the flyer” functions constituted one of the most perplexing problems of military medicine not only in the AAF but also in the Army and the Navy. It was a bigger problem for the air medical service because its existence was recognized, even though there was never a clear scheme for dealing with it other than by the application of the art of aviation medicine. Any attempt to evaluate the extent to which the average flight surgeon


* Cf. statement of duties of a flight surgeon, above, p. 367.

† WD AGO Form 64, Physical Examination for Flying.

--389--


was successful in the discharge of these functions necessitates judgments contingent primarily on cultural factors: medical, social, and military. Since the flight surgeon was deeply involved in administrative procedures relating to the emotional reactions of aircrewmen, a brief digression is required to present the background of the problem.

When one explores the field currently defined as psychosomatic medicine, semantics becomes critical, and careful selection of terms is necessary, if the issues are to be understood at all. Instead of using the terms “psychological symptoms” or “psychiatric symptoms,” the writer prefers to speak of the role of emotional reactions in the production of symptoms and disability—or, more precisely, of inability to function at the expected level of performance. Contemporary physicians (1940–45) were aware of the fact that acute, overt emotional states (e.g., anger, fear) are accompanied by striking physiological activity (e.g., rapid heart beat, blood-pressure changes, disturbed gastrointestinal function), and the nature of these reactions was generally appreciated. There was considerably less agreement on the extent to which chronic, less obvious, emotional states (e.g., apprehension, anxiety, frustration, tension, desire, fatigue) were accompanied by physiological disturbances, and, if so, what these changes were and how they could be recognized. In an era of medicine when scientific research provided such certainties as the sulfa drugs and the electrocardiogram, it is not surprising that the average physician preferred to devote attention to these and tended to avoid the intellectual effort involved in analysis of so subtle and manifold a situation as the interaction of conflicting emotions and personality in complex present- day man. In addition to this, the relationship between these everyday emotional reactions and grosser disturbances of behavior–the psychoneuroses and psychoses-was not at all clear either to physicians or to psychiatrists. Competing schools of thought peddled conflicting doctrines, all of which lacked the substantial quality of the Law of the Heart or the explanation of the cause of diabetes, for example. It is fair to state that the seventy-odd medical schools of the country were relatively ineffective in ‘teaching this aspect of the practice of medicine. As recently as 1956,24 a study of general practitioners disclosed that no more than 15–20 per cent were able to deal intelligently and realistically with symptoms of emotional reactions. The average doctor not only is inept in this respect but also is aware of his ineptness, and the usual reaction on his part is indifference and/or hostility

--390--


to the patient who “has nothing wrong with him” as measured by a conventional physical examination and the usual laboratory tests.

The prevailing attitude of laymen—or of society—to such patients is not much different from that of the average physician. Family and acquaintances are usually aware of the stresses to which the invalid has been exposed, but, since they, and others, have endured comparable vicissitudes, the tendency is to attribute symptom formation and disability to an unrecognized disease, to a character defect, or to unwillingness to bear a fair share of the load, or to downright perversity. If a correct psychosomatic diagnosis is offered, the average layman tends to view it as a sentence, or an alibi, and not as a basis for corrective action. The normal sympathy for the sufferer from a “real disease” (e.g., tuberculosis or a stomach ulcer) is denied the one whose. troubles are “all in his head” or “imaginary.”

The reaction of the military to this realm of human behavior has always been more extreme than that of society or the medical profession. The deserter, the coward, the victim of the self-inflicted wound, and the “gold-brick,” having appeared in every war of which there is any record, were well known to commanders of all nations. The standing procedure for handling these types has varied according to the cultural level of the society and the personalities involved, but it has always been administrative: summary physical or capital punishment, imprisonment at hard labor, or discharge in disgrace. In the “old Army” and the “old Navy” there were no psychiatrists messing around with the men, acting as confidants and intermediaries, and inventing excuses for downright cowardice and insubordination. Senior air commanders, of course, had grown up with flight surgeons and remembered the value of their friendly counsel, and they recalled, the artful manner by which a sympathetic doctor could tide a fellow over a bad time. But the commander had made the grade because he had what it took, and these other fellows should be able to do the same if they had the guts and kept a stiff upper lip. Even so, the attitude of air commanders was a little more humane and a little less regimental than that of other military men. This may explain in part why the air force fought so hard for its own medical service and why the Air Surgeon was able to retain direct access to the Commanding General, AAF. The handling of the situation was complicated in the overseas air forces because hospitalization and (to a large extent originally, at least) disposition was a function of the Army Medical Department,

--391--


which was under the strict control of the line with respect to standing operating procedures for such laggards. The military attitude is essentially a no-nonsense one, which may be suitable for an infantryman, or an AB seaman, or a stevedore in a port battalion, although some doctors challenged this view before the war was over. In the case of the highly trained, almost irreplaceable aircrewman a somewhat more flexible, less arbitrary form of treatment was obviously in order.

These attitudes, which can be interpreted as evidence of a culture lag, had a profound influence on the complex function of the doctor assigned to a military unit. War is a remarkable laboratory, and perceptive physicians learned fast, not only from their own personal reactions to deprivation, ‘hardship, and combat, but also from their patients. Repeated efforts were made by command to establish simple categories and specifications for what were essentially dynamic personality reactions of the greatest complexity.

The foregoing are the elements, greatly simplified, of the dilemma that confronted the flight surgeon who conscientiously tried to discharge the duties implicit in the last two items on the list of “care of the flyer” functions. There was further complication of the deceptively simple statement of the surgeon’s duties: to act as confidant and adviser to the airman and also to act as an intermediary in medical matters between the flyer, his commanding officer, and higher medical authority.* Small wonder that those who knew the business best believed that it required at least three years of close contact with airmen and their problems to become adept in the art of aviation medicine! It is not surprising that the newly recruited and superficially trained flight surgeons had difficulties. The remarkable fact is how well they did in this relatively uncharted area of medicine, guided only by their professional idealism and the experience of the few seasoned flight surgeons who were available in any command. The learning process was difficult and the level of service uneven, but somehow the doctors kept the men flying.

The basic function of the flight surgeon at the combat squadron or group level was to determine whether a man was fit to fly. It was the prerogative of command to determine what sort of aircraft he should fly and what mission he should be assigned. This separation of roles seemed reasonable enough in peacetime and apparently never led to any serious difficulty then or during wartime training. But in combat



* See above, pp. 366-68.

--392--


zones conflict developed when a man was judged able to fly but not to fly a combat mission. The background of this problem and its ramifications will become evident.

During individual flying training crowded schedules left little time for establishment of a close confidant-adviser relationship between the flyer and the doctor. Moreover, it was evident to everyone that assignment to combat crews would involve a different physician, so that a cadet seldom bothered to make the emotional investment of becoming intimate with a flight surgeon. Serious emotional reactions that could not be handled by the cadet himself were likely to result in his being promptly washed out by a hard-boiled instructor or through a serious or fatal accident. Cadet elimination boards adopted a strict, no-nonsense attitude and were accustomed to depend on the subjective judgments of the flight instructors, whose advice was seldom questioned so long as the elimination rate remained in the 4-60 per cent range. Although flight surgeons sat with these boards, they did not act as intermediaries between the cadet and command; indeed, their primary duty was to help in the cadet’s next assignment. Flight training is necessarily ruthless, and the men who survived it had been through a selection process far more rigorous and realistic than anything the psychologists could devise.

Having completed individual training and received his wings, the typical airman was assigned to an operational or replacement training unit at one of the combat crew training stations (CCTS). Here, all the elements of a combat unit, including medical personnel, were assembled for training as a team prior to assignment to operational duties. “When the individual pilot, gunner, or other flying specialist arrived at an OTU or RTU station, his main concern was the character of his crew [or, in the case of the fighter pilot, his squadron]. The crew was the family circle of an air force; each member knew that long hours of work, play, anxiety, and danger would be shared. Naturally, each man hoped to be assigned to a crew [or a squadron] in whose members he had confidence and with whom he would be congenial.”* Here also began the unique patient-physician relationship which the flight surgeon (the family doctor) had to develop to serve effectively his men and his commander. The time together prior to combat varied from a few months to a year, and in that time every aspect of the team relationship had to be consolidated. The elimination


* Vol. VI, 606.

--393--


rate had decreased with each step in the training program, and at CCTS the unit flight surgeon was intimately involved in cases submitted to the flying evaluation board. By this time the AAF had invested eight to ten months of expensive training in each flyer, and serious consideration was necessarily given to all recommendations or requests for elimination on whatever grounds. In most cases, flying personnel now had their first experience with high-performance military aircraft, and this required training in the use of oxygen equipment and protective devices.

Responsibility with respect to oxygen equipment was twofold. First, each unit commander was responsible for oxygen discipline in his command, and he was required to designate an oxygen equipment officer, usually the assistant operations, officer25 who had received training through a unit oxygen officers’ course given either at SAM or overseas, as at the Eighth Air Force Provisional Medical Field Service School. Second, the medical service was responsible through SAM for altitude (and oxygen) indoctrination of aircrewmen and, through the Aero Medical Research Laboratory, for the development of oxygen equipment and the conduct of investigations to ascertain the physiological requirements of oxygen equipment. A formal procedure to accomplish this, the High-Altitude Indoctrination and Classification Program, was established by an AAF directive, 19 March 1942.26This provided for preliminary instruction on altitude flying and oxygen discipline at preflight and flexible-gunnery schools and advanced indoctrination and classification for high-altitude tolerance at CCTS. To implement the program, low-pressure chambers were installed at the three cadet training centers, the seven flexible-gunnery schools, and at various stations of the four continental air forces. Personnel to man these units were trained in SAM’S aviation physiology course, attendance at which was required of all flight surgeons. At a typical CCTS each aircrewman received instruction covering the effects of altitude on bodily functions (anoxia, aero-embolism, gastrointestinal cramping, aero-otitis, and effects of cold) and the proper use of his mask and the plane’s oxygen system. In addition, each man (in groups of about twenty, under the supervision of a flight surgeon and an aviation physiologist) experienced a 3–4½ hour chamber “flight” to 35,000–40,000 feet . During this flight the symptoms of anoxia were demonstrated, the fitting and use of the face mask was checked, and confidence in the oxygen system was established.

--394--


Early experience in the ETO with flyers who had not received such indoctrination was so unsatisfactory that the program was accorded high priority and implemented with great diligence. In the AAF Training Command more than 42,000 separate chamber flights were made to train over 620,000 different individuals.27

The usefulness of the unit’s surgeon at this and later stages in his military career owed much to the special training he had received through a program conducted by the School of Aviation Medicine under the able leadership of its wartime commandant, Col. Eugene G. Reinartz, MC. Between Pearl Harbor and V-J Day, a total of 4,3 65 physicians completed the aviation medical examiners’ course or the flight surgeons’ course. (During the same period the failures totaled only 146.)28 At least an equal number of medical officers and other personnel attended short courses of specialized instruction at SAM. In addition, a variety of special-purpose training was offered for medical officers at the School of Applied Tactics, the Emergency Rescue School, and the School of Air Evacuation, to name only three. The SAM commandant and his staff were kept informed of conditions in the theaters and of apparent deficiencies in the training of medical officers. In general, they were unselfishly responsive to criticisms and suggestions, and the curriculum was revised almost constantly as the war progressed.

Care of the Flyer: Combat

Training accomplished, the combat unit and its flight surgeon moved overseas to the ETO, or to the Mediterranean or the Pacific, or to the China-Burma-India theater, where in each there were unique medical problems as well as those common to the whole AAF. But it is from the experience of the Eighth Air Force, based in England, where combat conditions were the most arduous, that the problems of aviation medicine can be separated with fair confidence from the unfavorable environmental and sanitation conditions that existed in other air theaters. The emphasis on the experience of the Eighth is not intended to minimize the accomplishments of medical personnel elsewhere. It is chosen as an illustrative case simply because the Eighth had the longest experience, the highest casualty rates, and the most reliable statistics.

The war mission of the Eighth Air Force was offensive: to drop hundreds of thousands of tons of high explosives on Hitler’s Europe

--395--


by high-altitude, daylight bombing. The Eighth was the proving agency for the AAF’s doctrine of air power implemented by an air weapons system. In Europe the AAF had two excellent heavy bombers- the B-17 and the B-q-in friendly competition with the heavies of the RAF. Opposing these two air forces were the still mighty Luftwaffe and the powerful antiaircraft defenses of the Reich with its excellent guns and rapidly developing air-warning system, which always seemed good enough to the Allied flyers but actually was inferior to the Allied radar. It was most important for American airmen that the Eighth Air Force succeed and to do as well or preferably better than the battle-tested RAF. Command was acutely conscious of all these considerations, and so-to a large extent-were the men. It is within this frame of reference, and with the knowledge that the Eighth was expanding rapidly at the end of its 3,500-mile supply line, that one should examine the care of the flyer program and other aspects of the AAF’s medical service. Motivation was very strong, and whether it involved the will to win or the will to outperform the RAF is immaterial; the result was excellent morale in the whole force. It was predictable that the commanding general would expect maximum effort from the two components of his weapons system: the human resources and the materiel. It was also predictable that anyone who interfered with his attempt to squeeze the last bit of service out of his men and planes was in for a fight. It was up to the medical service to assure the maximum availability of manpower.

Headquarters, Eighth Air Force was established 19 May 1942, and Maj. Gen. Carl Spaatz assumed command 18 June. Between that date and the initial all-out strike of the 1st Bombardment Wing on 9 October 1942,” General Spaatz approved most of the recommendations of the Eighth Air Force surgeon that involved care of the flyer, but his failure to support two others were to have a serious effect on the originally high morale of the airmen. One, ‘relating to an unsatisfactory situation in hospitalization and disposition, will be described later.) The other was a request for a decision on the length of the tour of duty. It was obvious to experienced flight surgeons that combat crews and individual fighter pilots could not long tolerate the combined stresses of combat and the anticipated attrition rate if the only limit to their tour of operational duty was personal survival. Based on a “conservative” estimate of 5 per cent loss per mission,


* See Vol. II, 220.

† See below, pp. 407-12.

--396--


combat crews with little regard for mathematical accuracy realized that they could be wiped out, theoretically, by 20 missions.* As early as the fall of 1942, the Eighth Air Force surgeon, Colonel Grow, urged that combat crews be relieved from operational duty after 15 missions. Flight surgeons watched morale sink during the winter of 1942-43, as the squadrons were depleted more rapidly than the replacements dribbled in. In March 1943 the Eighth Air Force Central Medical Establishment† prepared a study of the consequences of this lack of policy, “Morale in Air Crew Members, Eighth Bomber Command,”29 and recommended a definite and fixed combat tour. Finally, some seven months after the start of the bomber offensive, Maj. Gen. Ira C. Eaker, then commanding the Eighth Air Force, announced that the tour of duty for bomber crews would be a minimum of 25 missions, and for fighter pilots, 150 missions or zoo operational hours of flying. This decision, combined with a well-balanced leave policy and the use of rest homes and rehabilitation centers, had a favorable effect on morale. Comparable decisions regarding the combat tour were not made in the other air forces until they were forced on command by the pressure of circumstances.

As the offensive of the Eighth Air Force got under way in 1942, flight surgeons encountered five problems in aviation medicine which remained major concerns until the end of hostilities. They were: anoxia, frostbite, aero-otitis, battle wounds, and stress. Attempts to minimize and control these problems became the concern of the school system and the research units of the medical service, and the time and effort devoted to them are incalculable. It is fair to say that each problem had been anticipated to some extent, but actual combat was necessary to underline its urgency and define its scope.‡


* Actually, a loss rate of 5 per cent per mission works out to 35 per cent surviving 20 missions. This amendment of the odds could not have afforded much satisfaction men to the most unsophisticated.

† First established 24 July 1942 at PINETREE, England, as Eighth Air Force Provisional Medical Field Service School. It was renamed Eighth Air Force Central Medical Establishment on 9 November 1943 and became the First Central Medical Establishment (CME) in August 1944 (Link and Coleman, Medical Support of AAF in WW ZZ, p. 551). Other numbered air forces organized similar establishments.

‡ The medical statistics of the AAF were presented as follows: ( I ) occupational disorders peculiar to flying, i.e., anoxia, frostbite, aero-otitis; (2) non-occupational disorders, i.e., respiratory disease, venereal disease, neuropsychiatric disorders, injuries; and (3) battle casualties, i.e., wounded or injured in action, killed in action, missing in action. These were reported on the Care of the Flyer Reports, AF Form 203, which included mean strength and individual data on each casualty.

--397--


  1. Anoxia. Combat missions of the Eighth were normally executed at altitudes of 22,000-25,000 feet, so that an adequate continuous supply of oxygen was mandatory. As soon as operations began, the number of reports of fatal and non-fatal anoxia incidents far exceeded the most pessimistic predictions.30 In non-fatal cases reduced combat efficiency was evident, and on many occasions a mission aborted because of failure of the oxygen system or the appearance of anoxia in a crewman. Fatal cases occasionally occurred without any clear evidence of defect in the equipment. A study by the Eighth Air Force Central Medical Establishment showed that anoxia cases were caused by battle damage to the oxygen system, failure of the quick-disconnect, freezing of the mask, personal errors in the use of the system and ignorance of proper oxygen discipline, and failure of the regulators.
The two obvious remedies were better training and better equipment. In England the Eighth Air Force Provisional Medical Field Service School stepped up its program of training flight surgeons and unit oxygen officers and attempted to provide low-pressure chamber indoctrination for all aircrewmen who had missed it during flight training. A comparable increase in emphasis on high-altitude training at all levels was ordered at SAM and in the Training Command. The equipment problem had been practically overcome at the Aero Medical Research Laboratory in 1941, when captured samples of German demand systems were used as models for a completely new demand system to replace unsatisfactory continuous-flow units. Production and installation of the new system got sidetracked somewhere, and it was not until the spring of 1943 that the new equipment arrived in England in sufficient quantities for installation in all operational aircraft. There were still a few bugs in the masks and valves and the “walk-around” bottles, but the people at Central Medical Establishment soon overcame them. By November 1943 the problem was coming under control, and one year later the Air Surgeon could report that the anoxia incident rate among heavy-bomber crews had dropped from 115.5 per 100,000 man-missions (November 1943) to 23.4 in November 1944. This 80 per cent decrease in incidents was accompanied by a 68 per cent reduction in fatalities, whose rate decreased from 21.6 to 7 . 1 per 100,000 man-missions over the same period of time. 
  1. Frostbite. At the maximum altitudes flown in the ETO, the air

--398--


temperature ranged from -50° to -60° F. Inside bomber and fighter aircraft, temperatures of 0° to -10° F. were the rule except ;It open gunports in the waist and the tail, where the temperature approximated that outside. In belated anticipation of these conditions the Aero Medical Research Laboratory established a clothing-test unit in the Biophysics Branch early in 1942 to develop individually heated garments for aircrewmen. In spite of the late date of starting, it appears that prototype electrically heated garments were produced in time for issue to waist and tail gunners in the VIII Bomber Command in the fall of 1942. These suits, boots, and gloves were poorly designed and susceptible to electrical failure. Better models came into production after October 1943, and eventually enough were on hand to help control the frostbite problem.
In addition to the equipment deficiency, the aircrews lacked proper indoctrination in the prevention and emergency treatment of frostbite and in the proper use of such protective equipment that was on hand. An energetic training program and advanced instruction of unit equipment officers by the Central Medical Establishment were helpful. Finally, the American genius for improvisation in the field resulted in inclosures for the waist and tail guns, with obvious benefit to the gunners. The magnitude of the frostbite problem was evident from the fact that more than one-half of the casualties (excluding accidents on returning from missions and missing in action) between August 1942 and January 1944 were due to frostbite. Twelve per cent of these were attributed to lack of equipment and 24 per cent to defective equipment. The heavy toll of 19.7 cold injuries per 1,000 manmissions in February 1943 was finally reduced to 0.03 in August I 944. Over the entire period of air operations in the ETO, frostbite was responsible for 3,452 removals from flying status, 35 of which were permanent.31
  1. Aero-otitis. This is an acute or chronic disorder of the middle ear caused initially by inflammation and obstruction of the Eustachian tube, particularly at its entrance into the nasopharynx. In healthy individuals this passage is open, permitting equalization of the air pressure on both sides of the eardrum and free movement of secretions into the nasopharynx. When the upper respiratory passages are inflamed for any reason, air-pressure adjustment fails to occur during ascent, causing pain and hearing loss. At altitude, adjustment eventually occurs, but during descent the external pressure increase is not

--399--


balanced, and pain and deafness return. The victim can inflate his middle ears by a forced expiration with the nose and mouth held shut, but this maneuver carries infected secretions into the middle ear. Because of the abnormal conditions resulting from the blocked Eustachian tube, an inflammatory or suppurative otitis media develops. The acute process runs a course of a few days to a few weeks, but in susceptible individuals recurrences are common or a state of chronic infection may develop. When the infection is due to pyogenic bacteria (e.g., streptococci), sulfa drugs and penicillin control the attack promptly. Since most cases are related to a viral infection, drug therapy is useless. Before the development of cabin pressurization, aero-otitis was cornmon, and the disability and discomfort associated with it was a significant factor in the adoption of pressurized cabins in commercial aircraft. In the continental air forces, aero-otitis was the commonest disorder attributed to flying. Factors that favor its development, in addition to respiratory-tract infection, are long exposure to high altitude and gradual ascent and descent. The incidence was twice as great in heavy-bomber crews as in mediums and four times as great in heavies as in fighters because of the difference in rate of climb.
Among the occupational disorders of the Eighth‘s aircrewmen aero-otitis was the most important, accounting for two-thirds of the temporary removals from flying status. During the whole period of operations there were 8,345 removals for this reason, and, of these, 52 were permanent. The average number of days lost per attack of otitis was eight. Of the non-fatal afflictions of flyers, only battle injuries were more numerous. A great deal of effort was devoted to this problem by a variety of medical specialists, with surprisingly little in the way of significant results. The most popular form of treatment was the destruction of lymphoid tissue at the entrance of the Eustachian tube by means of radium applicators. No well-controlled study of this prophylactic procedure to justify its use has come to the writer’s attention. The situation in England was particularly favorable to the development of aero-otitis, because of the high “normal” rate of respiratory infection, the crowded living quarters, and the rapid turnover of personnel. The flight surgeons did all the conventional things-and some unconventional ones-to cope with this problem but were no more successful than anyone else.32
  1. Battle casualties. Casualties* from enemy action were of course

* In military medicine “casualties” is the general term for those killed in action (KIA) and those dying of wounds, which together equals total killed; those wounded in action (WIA); and those missing in action (MIA). The latter category is subject to adjustment later, when all the returns are in.

--400--


anticipated by the medical service, but no one knew when the air war got under way what the final reports would look like. RAF experience, so valuable in many areas, was of little aid here, since British bombers operated at night, the AAF by day, Two aspects of battle casualties deserve comment: first, the influence of the casualty rate on morale33 and, second, the usefulness of protective armor. In this new type of warfare, the majority of casualties were the crews of the planes that never returned. The empty bunks and the new replacements told the story more bitterly than the steady disappearance of familiar aircraft from the hardstands.
The problem is illustrated graphically in the following chart, where the numbers of survivors and the numbers of those killed and missing in action out of a group of 2,051 heavy-bomber crewmen are plotted against the number of operational missions.34 The risk rate per mission is also shown.* 
ATTRITION OF HEAVY-BOMBER AIRCREWMEN

* This graph is constructed from data collected in a study of the attrition rate for heavy-bomber crews in the ETO. The 2,051 flying personnel used in the study were members of the 91st, 94th, 305th, 306th, 381st, and 384th Bombardment Groups. The total survivors are the aircrewmen available for subsequent missions. In addition to the 1,295 airmen killed and missing in action, 197 were lost from the original number for a variety of reasons, including battle wounds. The broken curve indicates the percentage of the survivors killed and missing in action per mission. These data apply to '943-44.

--401--


The average aircrewman may have been handy with dice or cards, but he never understood statistics. The way he interpreted it, the rising curve for the percentage of the group killed and missing in action spelled a steady decrease in his personal chance of survival. He never understood the significance of the broken line showing the risk rate per mission, which became increasingly more favorable as the 25-mission tour progressed. The net result was that the old soldier’s protection against anxiety, the delusion that “nothing can happen to me,” was replaced by the morale-destroying fixation that “something disastrous must happen to me.” There was nothing definite that the flight surgeon could do about this, except talk to the ones that had it worst, prescribe phenobarbital and benzedrine, arrange for a rest leave, and hope for the best.
When the aircrewman who flew against the Nazis said that things were really tough in the ETO and the MTO but everyone else had it pretty good, he was absolutely right, as can be seen in the final tabulation of AAF casualties:
AAF Casualties in All Theaters December 1941–August 1945*
Theater Total Casualties Percent Total of Grand Total Killed Wounded Missing Strength†
ETO 63,410 52.0 19,876 8,413 35,121 610,000
MTO 31,155 25.6 10,223 4,947 15,985 ……
FEAF 17,237 14.2 6,594 3,005 7,638 ……
20th AF 3,415 2.8 536 433 1,406 ……
CBI 3,332 2.7 1,263 494 1,575 ……
POA 2,476 2.0 926 882 668 440,000
Alaska 682 0.6 451 53 168 ……
Other 160 0.1 152 1 7 ……
Grand total 121,867 100.0 40,451 18,238 63,568

* AAF Statistical Digest, Dec. 1945, pp. 49-59.

† Total strength deployed against Germany and Japan, respectively (Vol VI, 32).


The decision to supply aircrewmen with body armor may seem anachronistic, but it was based on careful studies of wound ballistics initiated by the Surgeon, Eighth Air Force.35 Colonel Grow was aware of British studies of the wounds received by men engaged in desert warfare: 40–70 per cent of the wounds were caused by low-velocity missiles (i.e., shell fragments, ricochets, and grenade fragments), capable of being intercepted by armored vests and properly

--402--


designed helmets. Because of the similarity of these missiles to flak, a study of air force battle casualties was ordered in October 1942. The incidence of wounds due to low-velocity missiles in a good sampling was 70 per cent. The Central Medical Establishment then designed and ordered armored vests, half-vests, and sporrans for field trial. Delivery began in March 1943, and, by January 1944, 13,500 flak suits were on hand. Crews resisted the use of the armor at first, but an energetic demonstration campaign and the obvious protection afforded converted the majority of airmen. In addition to the flak suits, seats were armored, and flak screens and flak pads resistant to low-velocity missiles were installed in most planes. The results are seen in the following table:
Effect of Body Armor on Casualty Rates

* In ETO.

† This figure is included to indicate the comparable intensity of enemy resistance during the early part of the campaign, when aircrewmen were unarmored, and the latter part, when armor was generally used.


  1. Stress. When stress and its sequelae come up for consideration, the comfortable realm of definite clinical entities and reliable statistics is left behind. There is only a wasteland in which to wander, filled with shadows of theories, dusty slogans, and dire predictions. Everyone knew that military service, particularly combat, was bound to be rugged. The stresses to which men would be subjected were many, and they could occur singly or in any conceivable combination. In a preceding section" attention was directed to the contemporary attitude of physicians and others to emotional reactions to stresses as the basis for symptom formation and disability. Experienced physicians have no idea how to predict how much stress a given person can tolerate, nor are they at all certain that exposure to stress to the limit of tolerance is intrinsically harmful. If the medical service had any common tacit policy in this respect, it was to help the men carry on to the limit of their capacity, and then perhaps fly a few more missions. As an official policy spelled out in directives, such a plan would

* See above, pp 390–92.

--403--


have been futile at best and destructive of morale at worst. As implemented by sympathetic, perceptive flight surgeons, responsive to the high goals of command and eager to help their charges conduct themselves as men, the unwritten plan worked magnificently. Psychologists and psychiatrists presented arguments, proposals, nomenclatures, and warnings which only served to confuse the issue. Twelve years after the end of the war one fails to see the grave psychic consequences of pushing men to-and beyond-what many then considered the breaking point. By the pragmatic test of war, the airman tolerated magnificently all the stresses that he encountered. No one knows the extent or the variety of the symptom-producing emotional reactions that occurred along the way, but remarkably few men permitted these reactions to produce disability. Statistics are meaningless on the various emotional states: anxiety reaction, fatigue, fear of flying, aeroneurosis, or what-not. The figures that count are the temporary removals from flying status-of which there were only 3,067 for the entire war period in the ETO. In addition, there were only 1,042 permanent removals from flying status for anxiety reactions; and if one adds other probably related entities, such as insubordination, the total is only 1,576, or less than 1.5 per cent of the combat force.36 This force had been badly mauled by the Luftwaffe and the inclement weather of northern Europe-to the extent that its casualties numbered 63,000, while some 60,000 aircrewmen successfully completed the prescribed tour of duty.37 The flyers in the other theaters did just about as well.
It is quite evident that the morale of the men who finished their combat tours had been exceptionally well sustained and that the effort devoted to the care of the flyer had paid off handsomely.

A Day in the Life of a Flight Surgeon

The complex duties of the flight surgeon assigned to a heavy-bomber squadron are illustrated by the following “log” of a typical bad day. This is what it was like in England, or Guadalcanal, or Nadzab, or Tunisia. The composite presented derives from many sources:

0400 Up early for briefing at Group—coffee and crackers there. This will be another maximum effort strike for which we have 53 planes available, but only 50 crews. Weather foul—a twelve hour trip. After briefing, checked oxygen equipment myself for the 2 new crews. . . .
 

--404--


0500 In the ambulance on the line for takeoff. There are only 2 of us on duty—another is off at school somewhere and the group surgeon is at a meeting.
0510 Called to sick bay. Lt. … carried in by his crewmen, too weak to climb into the aircraft-Diarrhea all night-Bad chow? -Too much whiskey? -Or nerves? He’s stayed in his hut smoking and drinking since the last strike when his buddy got a direct hit and exploded. Crew looked relieved when I grounded him, and the sergeant made out the hospital ticket.
0540 One of ours-Capt. … lost power on takeoff-crashed into the Channelburned- Poor devils! Air-sea got there quick but no survivors.
05550 One of the new crews lost an engine half-way down the field-skidded off the runway and nosed over gently. No one hurt but the waist gunner who broke an arm when he jumped out—sergeant puts a temporary splint on him; and I take the pilot who’s shaking bad to my quarters for a few stiff drinks—When he relaxes, I give him a seconal and my driver takes him to his hut. Lucky!
0630 Everyone airborne—to breakfast.
0700 Sick call: 2 or 3 men with bronchitis (or malaria, or diarrhea) to overcrowd the already full dispensary. Couple of fellows getting e