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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
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.
surgeon. The duties of the flight surgeon may be epitomized as follows:4
- To dispense routine medical services, including the management of traumatic injuries.
- To select candidates for flying training, with special emphasis on the ophthalmological, cardiovascular, and neuropsychiatric phases of the examination.
- 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.
- 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.
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.
- 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.
- 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.
- 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.
- 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.
- 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."
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.
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.
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
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
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
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.
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
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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
- 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.
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.
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
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
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.
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.
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
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.
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.
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.
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.
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.
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
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,
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.
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.
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.
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
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.
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.
- 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.
Frostbite. At the maximum altitudes flown in the ETO, the air
- 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
- 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
- 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
- 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.
- 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.*
* 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.
- 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
- 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.
- 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.
- 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. . . .
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 edgy—headaches—dizzy spells: gave them appointments to come back later for a little quiet talk. Usual dressings—all o.k. Sergeant and I work on the reports—Reports! 0930 The other flight surgeon and I flip to see who will stick around for the cripples and the aborts so my driver and I start off for rounds in the hospitals. Raining. 1000 … Station Hospital men in surgery doing fine, except Lt. … who has minor flak w e abdomen-says he can't eat. Talked with him for half hour or -his crew has ditched twice and somebody has been hurt on every one of their 10 missions—I think he's had it and suggested to the ward officer that he'd do better in the general hospital—he won't be fit to fly for months. 1100 The colonel called me to his office and raised hell about one of our men who went AWOL during the night-the kid is a tail gunner that I sent in with acute amebic dysentery-we're not permitted to treat it in dispensary now! I'd seen the kid on the flight line this morning and wondered how he got out so soon. Some guys …. 1200 Lunch at the hospital. Picked up some stuff from the pharmacy and from medical supply-very generous fellows …. 1300 … General Hospital. Several of our mob got in here when they got lost in the fog and crashed nearby. Doctor on the officer's ward wanted to talk to me about the pilot, Capt. … , who it seems is very morose, won't talk about the war, his family, or anything else for that matter. His broken ribs and chest injuries are doing all right, but the doc has requested a psychiatric consultation. I told him to forget it—B's always quiet, and of course he feels bad about smashing up his plane—she'd always been lucky until that trip—he only thinks about planes and women and won't talk much about either of them—He's an iron man and his crew idolizes him—he.needs a psychiatrist like I do—The young doctor is not convinced and we have quite a debate—says he knows when a man is cracking up. I say wait a bit, let me talk to B. I'll manage to get B out before they do anything drastic….
1400 Sat in on a Disposition Board involving some of our men—what a riot! One of our mechanics with headaches that they said was due to hostility to his lieutenant—they think he better be sent back. I know better: his headaches are hangovers from the rotten moonshine he and his pals are making somewhere on the base-we'll probably lose him even though he's a good mechanic, overhung or not…. 1430 On the way back to the field passed our ambulance—stopped—four of our men with fairly serious injuries from flak and a crash when their cripple came in-not too bad, but too much for our sick bay to handle … 1500 Talked with men with nerves-one had a "Dear John" letter which I had to read—-the other just needed some one to talk to—They'll be all right with some phenobarb and a little more rest-twelve hours a day, seven days a week in the shops can get a little rugged for some of the boys—The last man, a navigator is worried about his ability to do his job-he's loused up a couple of trips and they only got back because of plain dumb luck- I can't make out whether he's stupid, or beginning to crack up-we'll talk some more tomorrow.… 1610 Back in the ambulance on the line, "sweating out" the returns as the fog begins to roll in. … Our radio brings us all the chatter between the tower and the planes. … Priority in landing goes to the planes with wounded men aboard-there are only 2 this time-one gets down safely-moderate flak and machine gun wounds which can be patched up when we get all the planes in-The other couldn't get its wheels down so we all raced over to the crash strip, and ran along with her as she came in—a messy landing—cartwheeled— then caught on fire. The crash crew got there first and had foam on her and we got all the men but the copilot who was pinned in the debris. We were working on him when the gun belts started to go, and then the fire started again in the cabin so we couldn't get back—the radioman said he died on the way in, and that's the way it looked to me, the few seconds I had to see him. Two other planes missing—one was seen going down over the target—no one knew what happened to the other. According to my form card this is a little worse than average for a tough mission—but not bad considering.… 1700 Helped serve at the aircrew bar aker interrogation—all who feel the need of medicinal whiskey get it courtesy of the Air Surgeon—bless him! No one very edgy, except Lt. …, who has just lost the second roommate in a fortnight as our Allies say—Later at the club, I played gin rummy with him and we philosophized about luck and life and things.… 1730 Dinner—the mess is getting worse—food too greasy—mess attendants not too clean-the kitchen will get a thorough inspection and the mess sergeant will get chewed tomorrow.… 1830 Made rounds in the dispensary with my partner—everyone doing well, thanks to sulfa, paregoric and phenobarb—Only a few men for evening sick call—a special one that I run for the men who are too busy on the line for the regular one—Sergeant and I worked up the reports on the day's casualties—Crash crew brought in the body from the burned plane—described the wounds—he may not have been dead when they crashed—made out the report, tagged the body and sent it off to the Graves people.… 1930 Back to the … General Hospital for a medical meeting—the Wing Surgeon thinks we should all be there—and attendance is taken—one goes—Not
a bad clinic on hepatitis and frostbite-some good ideas-there was a social hour afterwards and I ran into a classmate that just came over.… 2300 Back home-and to bed-too tired to write home. 0200 Sergeant wakened me-one of the armorers has DT's and is sitting in his hut shooting the snakes with his 45. I took the gun away from him, and we got him to the sick bay where some IV amytal finally put him out and so to bed again.
The hospital care of AAF personnel was the basis for a dispute that began with the expansion program and continued to V-J Day. The details of the controversy are given exhaustively elsewhere.38 The problem of command control and the prerogatives of the Surgeon General of the Army and of the Air Surgeon, respectively, loom large in the voluminous official correspondence on the subject. As is often the case, the fundamental issues were relatively simple, and they can be understood best by briefly describing the system as it operated during the war years and by considering the personnel procedures involved in the hospitalization of a typical infantryman and a typical aircrewman.
In the Zone of the Interior (ZI) a recruit, or an officer, assigned to infantry received his training in one of the four continental army areas. When sick or injured, he was sent to a post station hospital under the control of the Army Service Forces or, in the case of a special school, under the control of the Surgeon, Army Ground Forces. If the condition requiring hospitalization was minor (directives specified cases properly treated in station hospitals), the infantryman remained on the rolls of his company and on discharge returned to it. For a major condition, or if apparently unfit for further military service, the soldier was transferred to a named general hospital and dropped from the rolls of his company, which could now requisition a replacement with the appropriate military occupational specialty (MOS) . In the general hospital the soldier was picked up on the morning report of the detachment of patients. After receiving maximum benefit from this hospitalization, if fit for duty, he was shipped to a replacement depot for assignment on the basis of his MOS, but there was almost no likelihood that he would return to his original unit. If he was not fit for duty, the hospital disposition board recommended the appropriate type of separation from the service.
In a theater of operations the wounded, sick, or injured infantryman moved backward along a medical evacuation chain. So long as the
reason for hospitalization did not require him to move farther to the rear than the field medical service of the division or corps (medical battalion installations and evacuation hospital), he remained under the control of the army commander but was not necessarily returned to his own company. He was sent, usually through a replacement unit, to some understrength company. If the disability was more severe, he entered the numbered station and general hospital system of the zone of communications which was under the control of the theater Services of Supply. From there on procedures paralleled those in the ZI.
In theory, then, the soldier was an interchangeable part of the war machine, whose assignment depended upon his MOS. The system was designed to keep ground-force units up to combat strength, utilizing the table of organization and the MOS as the basis for assignment from a replacement unit.
Procedures within the AAF were conditioned by a different attitude toward the airman. During individual flying training, and in the preliminary training of ground-duty personnel, the practice with respect to hospitalization was similar to that of the Army except that the station hospitals of air bases and other air installations were under the command of the AAF and, therefore, under control of the Air Surgeon. Transfer of a patient to a named general hospital was seldom ordered, except when disposition as unfit for further duty was contemplated, for the station hospitals as a rule were exceptionally competent professionally. Even at this early level of training the AAF tended to consider its human resources not so much as interchangeable parts but rather as members of individual teams, whose esprit de corps was a vital element. When aircrewmen were assigned to a combat crew training station, this official attitude became an increasingly important consideration with respect to hospitalization. As members of an aircrew or a fighter squadron, the flyers and ground-duty personnel rapidly developed into a team that required mutual interdependence, mutual responsibility, and mutual loyalty. Under these circumstances it was of the utmost importance that the man who had to be hospitalized for a tolerably brief period should return to his own unit and that he should get back as promptly as possible. The AAF accelerated station hospital care to the maximum extent possible, and this helped the individual to retain his allegiance to his unit and his group. An airman who got into a named general hospital was lost not
only to his squadron, but the operations of ASF replacement centers were such that he could also be lost to the AAF, although this latter possibility was corrected eventually by War Department directive.
Overseas the problem was serious, for the AAF did not have a field medical service comparable to the medical battalion and the evacuation hospital, except for the z 5-bed aviation medical dispensaries. In most theaters, men on sick report could be retained in dispensaries for a limited time only: 96 hours to a week was the rule. The numbered station hospitals on or adjacent to the large air bases and the numbered general hospitals were controlled, as were the bases, by the Services of Supply, responsible to the theater commander. As zone-of-communications installations supporting a combat force, these hospitals were supposed to return to their units battle casualties and the sick and injured who were hospitalized 30 days or less. If released from a hospital after more than 30 days, airmen were sent to an air force replacement depot. In theory there was no assurance that an airman would ever return to his own unit, although in practice most of them did as a result of informal agreements in the various theaters. Where the station hospital staff thought it desirable or when theater medical directives so specified, long-term patients and those requiring disposition were transferred to numbered general hospitals, whose disposition boards tended not to consult the flight surgeons of the airman's unit. To correct this, theater directives usually prohibited disposition of flying personnel, since assignment to flying duty was a prerogative of air command, even though determination of fitness to fly was a medical responsibility.
The difference in the attitude of the Army and the AAF toward their respective human resources is abundantly clear in the medical operations of the ZI and of the theaters. In the complex team activities of an air combat unit, the individual had to be paramount, since personality and group experience were important. Small wonder that flight surgeons complained bitterly about protracted hospitalizations and time-consuming administrative procedures over which they had no control.
In the United States the air-base station hospitals were developed professionally to an extent that provoked frequent complaints from the Surgeon General. The violent nature of aircraft accidents demanded prompt and skilful surgical care which the medical service of the AAF was able to supply as a result of the ambitious physician recruitment
program undertaken in 1942, largely by default. Of the 9,000 doctors who volunteered for service with the AAF, 4,000 ranked as specialists, and, by the winter of 1943, the staffing capability of air-base station hospitals was such that approximately 60 per cent of the 239 then in operation were approved for residency training by the American Medical Association and accredited by the American College of Surgeons.39 Many of these functioned as general hospitals, medically, although they could not perform the administrative functions of disposition.
As a result of a number of factors, including complaints to President Roosevelt about hospital treatment of airmen overseas, the rapidly increasing load of casualties, and exacerbation of the conflict between the Surgeon General of the Army and the Air Surgeon, the regional hospital system was established in April 1944 by WD Circular 140. The provisions of this circular were as follows:
- The flow of general-hospital-type patients to ZI installations was split so that battle casualties were sent to the named general hospitals and trainee patients to the nearest regional hospital, regardless of command relationships.
- The Air Surgeon and the Surgeon General each designated 30 of the 21 station hospitals to be under his control as regional hospitals, chosen to serve non-overlapping areas.
- The regional hospitals were staffed to provide definitive care (except for patients requiring specialized treatment at certain named general hospitals, e.g., paraplegics at Lawson General Hospital) and to operate disposition, physical reclassification, and retirement boards.
- No airman could be separated from the AAF by an Army Service Forces board without the concurrence of the Commanding General, AAF, or his representative.
- Patients from overseas or from the ZI requiring convalescent care were sent to separate Army or AAF convalescent hospitals, depending on the service to which they belonged.
- Commanding General, AAF, was charged with the responsibility for air transportation of patients and their medical service in transit.
This adjustment improved and clarified the situation in the United States, but it had no influence overseas. The theater hospitalization problem was never resolved in spite of many memoranda, letters, expressions of opinion, conferences, and plans. Two factors seem to have been responsible for the air staff's lack of willingness to press the issue. In the first place, the current structure of theater command was working well, as measured by the success of combat operations. A drastic revision of the plan for medical support had to be thoroughly justified, and the staff doubted that the situation was quite as intolerable
as the medical service kept insisting. Estimates by command flight surgeons of excessive man-days lost due to failure of the AAF to control overseas hospitalization ran as high as 30 percent;40 opinions as to the effect of Army doctors on airmen's morale made discouraging reading-almost too discouraging. In the second place, such factual evidence as could be collected did not support these claims. The air staff was statistically minded, and management of the human resources could be handled the same way as aircraft maintenance. Studies were made in the Eighth Air Force which indicated that about 1,000 mandays per month were lost because of the existing system of hospitalization .41 This worked out to a loss of only a few per cent in the availability of flying personnel and was obviously not sufficiently serious to justify an overhaul of the command structure in the theaters.42
Actually it does not appear that the medical care of airmen was inadequate in any important respect: either because they had to be sent to SOS hospitals or because they were retained and cared for illegally in aviation dispensaries. The young doctors who staffed either type of installation had the same basic medical background and approximately the same tools to work with. It is true that the 25-bed aviation medical dispensaries were often overcrowded, and it is also true that the equipment authorized for them was far less adequate than existed in a 250- or 500-bed numbered hospital. But the flight surgeons were energetic and rapidly developed skills in organizing that were not taught in medical school. Commanders of medical supply depots tended to disregard regulations, and highly efficient supply pipelines were developed for items "peculiar to the AAF" that often included medical equipment. In fact, the informal development of medical facilities for the Eighth Air Force was so effective that the theater surgeon, Brig. Gen. Paul Hawley, wrote to TSG, in July 1943, as follows: "I am so fed up with the ability of the Air Forces to obtain in profusion critical items of medical equipment through their own channels, which I am unable to obtain for other components of the Army, that I am resisting strenuously any move to give the Air Force a separate medical service or separate medical supply."43 The flight surgeons in the other theaters did just about as well.
The Surgeon General and the War Department were not able to prevent the medical corps of the AAF from providing the sort of medical service they wanted their men to have, but it was possible for the SG and those in sympathy with his views to exact a sorry retribution.
The victims of official policy were not the sick and wounded but the doctors and the enlisted medical personnel allotted to the AAF. Failure to revise manning tables and failure to recognize the de facto conditions retarded promotions and kept the unofficial field medical service of the AAF seriously understaffed and underrated. In spite of this unpleasant situation, and although overworked and inadequately housed, the unit surgeons took excellent care of the men who needed hospitalization of the sort they were able to provide.
Disposition and Tour of Duty
The major responsibility of the medical service was to enable command to get the maximum effort out of flying personnel. A realistic concept of an air weapons system in action required that every resource be utilized to the limit of its capability. In the case of the plane the limit was obvious: when it could no longer fly, a replacement was provided, and the remains were cannibalized or simply shoved aside to be junked later. In the case of the human resources, this realistic practice was not feasible for utilitarian and humanitarian reasons, some of which have a bearing on the disposition procedures of the AAF. In the discussion that follows, attention will be confined to the disposition of the airman considered incapable of further combat flying, regardless of whether the judgment was made by himself, his flight surgeon, his unit commander, or any combination of the three. Certain general comments are necessary to establish a proper perspective for consideration of the ways in which the AAF dealt with the problem.
At the outset of every bitterly contested campaign in World War II there were combat units that dubbed themselves-often with considerable justice-expendables. As a campaign progressed, sound military doctrine provided a system of reserves so that it was possible to rotate the forces in actual contact with the enemy. The theater commander was clearly responsible for the decision to develop and implement such plans depending upon his mission, the extent of enemy resistance, the forces at his disposal, and his estimate of the situation. The disastrous effect on morale of a policy that provided relief only for casualties was recognized, but no one had a clear, quantitative basis for relating attrition to morale, least of all American air commanders who were aggressively using their new weapons for which there was no sufficient background of combat experience. Army and Navy commsander
had some (usually) vicarious experience from other wars, but this was relatively useless to the air arm, since the official attitude toward the individual soldier or sailor was simply not comparable to the flyer-centered orientation of the AAF. Each overseas air force, then, had to develop its own policies of relief, rotation, and disposition; and, even when official AAF directives on disposition appeared in 1944, each theater air commander continued to follow, primarily, the patterns that had been evolved to meet the problems peculiar to his own force. It seems obvious that any fair policy with respect to disposition had to be contingent upon and reasonably consistent with the policies establishing tours of combat duty and rotation between combat and rest areas. Unfortunately, in all the overseas air forces, the problem of disposition arose with the onset of hostilities and increased rapidly, whereas directives regarding tours of duty and rotation either were never issued, were late in appearing, or were variable because of delegation of authority to subordinate commanders.
The fundamental problem of disposition of aircrewmen is stated succinctly in the official medical history:
There were two methods of removing aircrew personnel from flying status. One was administrative and the other was medical. Unfortunately, medical disposition was easier to accomplish and was likely to have less repercussion than administrative disposal. For this reason, line officers took advantage of medical disposition to remove many aircrew personnel which rightly should have been done by administrative measures. This practice placed tremendous responsibility upon the [unit] flight surgeon, and led eventually to the establishment of flying evaluation boards.
There was often a conflict between the medical condition and needs of the individual on the one hand and the tactical situation on the other which demanded full aircrews. This conflict was not easily resolved by the flight surgeon. Each case Presented a unique problem. Along with the flyers whose ailments were magnified by their own fatigue were those with prohibitive conditions who wanted to resume flying status in order to serve with their crews. There were occasions, it was believed, where the flight surgeon's opinion was influenced by the necessity of continuing on good terms with his unit commander. Problems posed in the disposition of flying personnel were important because of the potential effects upon the fighting ability of an air force, and hence had to be dealt with in the light of operational experience.
Policies for the disposition of aircrew personnel who developed anxiety reactions* had to be established as the need arose. Throughout the war there was never complete agreement between the line officers, the medical officers and the psychiatrists about the disposition of such personnel, which testifies to the complicated nature of the problem posed by personnel suffering from emotional disturbances.
* The terminology used in this chapter would be: ". , , who developed emotional reactions due to stress."
In many of the anxiety reaction cases there was no clear-cut distinction which would indicate either medical or administrative aspects. Moreover, after a medical diagnosis was made, the administrative disposition of the individual would determine, in many instances, whether the individual could be salvaged for further.44
The paramount consideration was the great complexity of military aircraft and the nature of air combat, both of which required that the human component of the weapons system be composed-to the greatest extent possible-of "professional" fighting men. There was really no place in the combat force for the militia-type soldier, the ninety-day wonder, or the citizen-in-arms. The specialized training, the high degree of integration necessary for successful air operations, and the great burden placed on the individual aircrewman in combat all demanded a policy of conservation of manpower. The force, to be effective, had to be an elite force and one that was committed for the duration of hostilities. In this sense the aircrewman could not be considered expendable or replaceable to the same extent as the aircraft, even though the field commander had to be prepared to expend both of them to accomplish his mission. From this standpoint, the utilitarian aspect of unfitness for combat flying, from whatever cause, can be summarized as follows:
- The man who considers himself unfit for combat flying or who is considered unfit by the flight surgeon or the unit commander is obviously inefficient, and he is thus potentially dangerous to the safety of others, as well as to himself.
- Men inefficient in one area (e.g., combat) may have considerable efficiency in another assignment.
- An inefficient man who is capable of endangering another's life arouses in the latter a fierce resentment.
- A man declared medically unfit for flying has the basis for a future claim against the government for compensation.
- The medical determination "unfit for flying" precluded disciplinary administrative action, although reassignment was possible.
- It was manifestly unfair to courageous, highly motivated men when a weakling or a coward was relieved from combat flying solely on medical grounds.45
Finally, it is necessary to recall the traditional air force policy mentioned earlier: the flight surgeon determines only fitness for flying, but command determines the type of duty to which a flyer shall be assigned.
Consideration of the human factors in the disposition problem involves both the art of aviation medicine and the art of war. The problem here, in terms of the individual flyer, is the amount of combat he can tolerate and the extent to which his efficiency can be impaired
before he is useless or dangerous to his combat unit. Even if the AAF administration had tried to establish a uniform policy for the tolerance of the human factor, it would have been a failure for two reasons: biological variability and the dissimilar nature of the stresses to which flyers were exposed in the various overseas theaters. The greatest difficulties that were encountered by command in the determination of policy regarding fitness to fly have been summarized by Douglas D. Bond in The Love and Fear of Flying. They were, first, the openly expressed fear of combat flying, or fear of flying a particular aircraft, or fear of night flying; second, that the severest symptoms of fear of flying were seldom detectable on the ground or seldom persisted for very long after grounding; third, the enormous value placed on physical symptoms by doctors and line officers; and, finally, the ambivalent attitudes on the part of those doing evaluation.
The problem that confronted the medical service and command can be appreciated most readily in terms of stress and strain. These words are used here approximately in their engineering sense, where stress refers to any sort of adverse influence exerted on a structure (or a person), and where strain implies the deformation or disturbance of the individual resulting from the forces applied. When the strain becomes sufficiently great, failure occurs. In the case of the airman, failure is his inability to fly or his refusal to fly.
Strain may be manifest in a variety of ways: by fatigue, staleness, headache, insomnia, gastrointestinal disturbances, anxiety states, phobic reactions, or regressive reactions (i.e., psychoses), to name only a few. In some cases strain is apparent on the physical examination (e.g., increased pulse rate, tremor, and abnormal breathing). In other cases, strain appears as "psychosomatic" symptoms, with no abnormal physical signs (eg., vomiting, headache, and dizzy spells). In still others, strain manifests itself as disturbances in behavior (e.g., insubordination, excessive drinking, and inability to concentrate). Presumably, the nature of the strain will depend more upon the constitution and the personality of the individual than upon the sort and the intensity of the stresses that are responsible. Skilful physicians recognize strain intuitively and quantitate it in the same fashion.
Stress is a composite term for all the pressures exerted on the combat flyer in addition to the ordinary vicissitudes of life. It refers to the physical fatigue of long missions at high altitude in the cramped confines of military aircraft; harrowing experiences, such as heavy flak
or gunfire damage, ditching, crashes in hostile territory or in remote regions; minor wounds; infections and parasitic disease; unappetizing meals; enervating climate; fear; and a host of other elements, none of which can be quantitated either singly or in combination. Quite obviously, the problem is that of dealing intelligently and realistically with symptoms due to emotional reactions, symptoms due to environmental factors and disease, and the reaction of the total personality to the stresses incurred. As indicated above, not all physicians are able to deal with such problems as effectively as they should. But it seems obvious that intelligent, perceptive doctors should be better qualified to evaluate intuitively such a manifold problem than any layman or board of line officers regardless of their military rank or experience with troops.
The administration of the AAF believed otherwise, and the prerogative of command to determine the disposition of the individual flyer was never relinquished, unless a disqualifying medical diagnosis was made and sustained by a review board, such as those authorized in the several central medical establishments. It is fair to say that throughout the war the attitude of administration toward the ineffective flyer was much more consistent than the attitude of the doctors. Professional differences of opinion are no novelty, and they are particularly common when the problem is the interpretation of emotional reactions as a cause of symptoms and disability. Calling a psychiatrist into consultation often adds to the confusion, and such was the case during the war. The consultants of the Neuropsychiatric Division introduced new terms and new concepts that were no more useful as guidelines in the administration of the disposition process than the ones the flight surgeons had been using all along. In fact, the attitude of the average psychiatrist toward a man with "flying fatigue'' was a great deal more permissive than that of the average flight surgeon, who usually knew the man pretty well and had "sweated out" some bad times with him before
At the start of hostilities there were few precedents and no clear policy for handling men who were to fail because of strain. The man who refused to fly because of openly expressed fear was given a Standard Form 64 examination to determine whether or not he was "medically fit to fly." In the absence of disqualifying physical findings, he was seen by a psychiatrist, and, if his finding was "abnormal fear of flying, no psychoneurosis or psychosis found," the aircrewman
was ordered to appear before a flying evaluation board convened by command. This board could recommend reassignment to other flying duties, or to non-flying duty, or it could recommend a court-martial at which the flyer could lose his wings, be demoted and reassigned to ground duty in the theater, or be subjected to even more severe disciplinary action. If the finding was "psychoneurosis," the case was handled through medical channels. If fear was not openly expressed but the flight surgeon believed that the "anxiety" was incapacitating, he could disqualify the flyer on the medical examination (e.g., manifested by rapid heart rate). Under these circumstances, no disciplinary action was taken, but the man was reassigned, and the diagnosis was accepted by the commander as an excuse for the man's failure, as well as an explanation of it. Such grounded men stayed on duty with their group and, because of shortages of qualified ground-duty personnel, often were advanced in rank more rapidly than their squadron mates who remained on flying status, The effect on morale was obvious, and in 1944 command ruled.46 that the doctors could not disqualify'a flyer on medical grounds if any administrative action was contemplated, such as reassignment to other flying or to non-flying duty.
At this point the flight surgeons lost the privilege of grounding a man for anything except symptomatic medical conditions or well-established neuropsychiatric disorders: psychoneuroses and psychoses. The large number of flyers who showed evidence of strain between these extremes had to be referred to a central medical establishment for evaluation on a complex basis prescribed by the AAF. When the administration took a hand in diagnosis, the sensitive care of the flyer relationship was compromised, and this led inevitably to degradation in diagnosis and disordered medical statistics. All the problem cases had to be fitted into one or two categories, whose components were vulnerable to criticism because of the lack of quantitative criteria for stress and predisposition.
The first category was secondary flying fatigue (also called "operational exhaustion," "combat stress reaction," and other terms), Anxiety had developed, physical signs were evident, creditable amount of emotional trauma (i.e., stress) had been sustained, and there was no neurotic predisposition. In such a case no disciplinary action was proposed, and the airman was reassigned to noncombat duty. The second category was lack of moral fiber (also called "fear reaction" and "temperamentally unsuited for flying"). In this condition anxiety had
developed, but there had been too little trauma (ie., stress), and there was no neurotic predisposition. In such a case a man was considered medically qualified for flying, and disciplinary action was required (i.e., demotion, loss of wings, or other action). The boards that made these determinations included senior flight surgeons, but the authority of the board remained vested in the line-officer members.
The flight surgeon retained the right to recognize simple or primary flying fatigue and could authorize rest leave, subject to constantly changing theater directives. It should be evident that, when the theater had no official policy regarding the length of the tour of duty or the rotation of combat crews, the judicious use of rest leaves was a powerful instrument for the maintenance of morale and combat effectiveness. Just the fact that rest areas existed to which a man could retreat for a week or two helped him to cope with the hopeless feeling that he was expendable. Where the attrition rate was heaviest, it helped him to suppress the feeling that his number had to come up sooner or later; and, most of all, it provided an opportunity to convalesce from minor occupational incidents, such as aero-otitis, aero-sinusitis, malaria, or superficial flak wounds, away from the petty annoyances of a service hospital. Happily, the red tape involved in ordering rest leave was kept at a minimum, and, in most commands, the judgment of ,the unit surgeon was final.
The policy of rest leave originated in World War I and was abundantly justified then and in the second war. For many flyers one of the few pleasant memories was a rest leave in some lovely resort town or in a charming, private country home. Whether in England, or the Mediterranean, or Australia, or the Vale of Kashmir, the AAF found places where the tired flyer could discard his uniform, sleep as long as he wanted, and spend idle, pleasant days while the mysterious "healing force of nature" accomplished what no schedule of rehabilitation could ever do. Weight was gained, tension relaxed, self-confidence restored; and, even if the venereal disease rate for a month at a place like Ifrane (in Morocco) got as high as 1,400 per 1,000 per annum,47 it was worthwhile. This was an exceptional situation, however, and VD was never a serious medical problem because of the remarkable effectiveness of sulfadiazine and penicillin. The real benefits of rest leave were derived from the friendly folk who took care of the men and from the restoration of the flyer's belief in the continued existence
of a peaceful, orderly world where death and destruction were not the principal goals.
There was never an AAF-wide policy on thec granting of such leaves. In England, where the facilities were the most abundant, some heavy-bomber crews began to take rest leave after the third or fourth mission, with most of them going off between the tenth and eighteenth, when they had been on station for two to five months.48 After a serious crash or an exceptionally harrowing mission, it was customary for the flight surgeon to give the survivors a leave. In the MTO comparable practices prevailed, although an abundance of close-by rest areas was not available until the ground campaign moved into northern Italy. In the Fifth and Thirteenth Air Forces it was the policy to give rest leaves approximately every three months, and the entire flying personnel of a unit might go en masse to Australia or New Zealand. This practice, in combination with the rotation of duty policy of these air forces, yielded excellent results in the maintenance of the health and morale of men operating in an enervating and malarious tropical theater.49
Where the rest centers were remote from the combat bases, which was the usual condition everywhere but England, it was necessary to establish air force medical facilities, with skilled flight surgeons in attendance, to supervise the centers. When the SOS hospital system of a theater lacked a convalescent care or rehabilitation program-as was the rule during much of the war in the Pacific-the rest areas functioned as convalescent centers, and flying personnel were ordered to rest leave, when indicated, immediately after discharge from a station or general hospital. As the war progressed, each rest area developed in its own fashion, uniquely adapted to local circumstances. Since no provision had been made for rest-rehabilitation-convalescent facilities in tables of organization and manning tables, staffing of the centers was accomplished on a temporary basis usually under the supervision of the "care of the flyer" section of the central medical establishments. The latter units provided a remarkable degree of flexibility in coping with problems that developed in a theater which had not been-and usually could not have been-anticipated. It is not easy to evaluate with any degree of confidence the contribution of the rest-leave facilities to the success of the war mission of the AAF. As an extension of the "care of the flyer" program it is fair to say that it was one of the most important and successful activities of the medical service.
A brief discussion of policies and practices relating to the length of the tour of combat duty and rotation* in the several air theaters is necessary. The basic problem here is the same as the one mentioned above: the utilization of the human resources to the limit of their capability. The limiting factors were interrelated—fatigue and morale—and had no particular relation to casualty rates. As an elite, professional fighting force, the AAF expected to use its highly trained aircrewmen for the duration of hostilities, however long that might be. When the first listless, dejected airmen of the Eighth, the Fifth, and the Thirteenth returned to the United States as a result of medical disposition, command was presented with grave prognoses and dire predictions by some of the physicians and psychiatrists who attended them. Few of these doctors had field experience with professional fighting men, but they knew a beaten man when they saw one. If this was a sample of what aerial combat could do, there was bound to be trouble ahead. Strenuous attempts were made to rehabilitate these men, but the early results were not encouraging.† Actually, the men who appeared in stateside rehabilitation centers in 1943 were a very small fraction of flying personnel overseas, and these had been thoroughly screened in the disposition process. They were anything but representative of the men who were able to carry on. The majority of the aircrewmen who completed prescribed tours of duty or who returned to the United States on orders to training units were in much better condition even though the occurrence of fatigue states-not diagnosed as such on medical records-was high. Of these, the consulting psychiatrist of the Office of the Air Surgeon said in July 1944:50
At Redistribution Stations routine examination of returnees sent back on rotation policy after completion of prescribed tours of operational missions indicates that such a policy is absolutely essential for maintenance of flying personnel in the theaters. This examination shows that sometimes as high as 30 per cent of returnees are suffering from operational fatigue, moderate or severe.
* Rotation, as used here, refers to the alternation of assignment to combat and noncombat duty in the course of a tour of duty in a theater of operations. This is not to be confused with rotation between a theater and continental United States.
† In the case of flying personnel returned from the Southwest Pacific Area for medical reasons, only 5 per cent were rehabilitated sufficiently to return to flying status. In contrast to this, 60 per cent of men from all other theaters passing through rehabilitation centres were able to return to flying duty. The personnel polices of SWPA were exceptionally severe for all hands, and approximately the same salvage reports occurred in the case of Army combat personnel. Ask any man who was out there!
The remaining 70 per cent are usually badly played out even if they are not demonstrating actual symptoms.*
Throughout the war, in every air force, there was constant pressure by command surgeons for a fixed tour of duty and some sort of rotational plan. The resistance of theater air commanders to the establishment of a fixed tour of duty is understandable only from the point of view that the AAF was on its mettle and was willing to go all out to demonstrate the correctness of its theory of air power.
Prescribed tours of duty were the rule in the Navy and the Fleet Marine Force, not only for regular personnel but also for airmen. Years of experience with overseas service, isolated stations, and sea duty (a major warship is not so different from an air combat group, when you think about it) formed the basis for a policy to which there were very few exceptions: eighteen months' service outside the continental United States for the Navy, fourteen months for the Marine Corps. Moreover, in naval combat operations the imperative need to service the ships-even during an aggressive, sustained campaign-led to the establishment of a sort of two-platoon system. A destroyer squadron (or cruiser division) would slug it out in the Slot or the North Atlantic for two or three months and then be relieved by a fresh squadron, while it went to a naval base for repairs and refitting. It is true that some of the advanced bases were pretty dull ports (e.g., Espiritu Santo), but at least there was a break in the sea routine. More often than not, some major repair job required a run to Pearl Harbor, or Sydney, or Norfolk, where a decent liberty was possible for all hands.
The Army never worked out a satisfactory policy for its overseas tour of duty; in fact, most of the troops assigned to a theater were there for the duration, and return to the United States (TUS, the orders said) other than as a casualty, or for other medical reasons, was the exception. In combat, rotation of troop units in contact with the enemy was a standing operating procedure, and this practice was obviously related to the necessity of having a substantial fraction (say one-third) of any force in reserve. The length of time in the line (i.e., in actual contact with enemy troops) varied from army to army, depending on local circumstances and the attitude of the commanding
* Apparently the consultant believed that a report of 100 per cent incidence of fatigue would force the air staff to "do something." Air staff, presumably with the concurrence of the Air Surgeon, thought otherwise.
general. In some theaters (SWPA was the most extreme case) there were campaigns where the reserves were committed early, and the foot soldier had to take it on the same terms as the airman. For the personnel of the Army Service Forces overseas, there was no policy on tour of duty, no rotation, and almost no rest leave until 1944-45, when the unpopular adjusted service rating (ASR) scheme was instituted.
To describe in simple fashion the situation in the AAF, the following tabulation is offered. Where tours of duty and rotation policies were sufficiently well defined, they are stated, along with summary remarks about the unusual stresses encountered in the particular theater.
Tour of Duty: 25–30 missions for heavies and 200+ hours for fighters.
Rotation: None prescribed
Special Stresses: Very high attrition rate; many casualties due to intense antiaircraft defense and the Luftwaffe; high incidence of respiratory disease and its complications.
Tour of Duty: Based on an elaborate sortie credit system, related to the probability of completing a tour-averaged 50–60 missions for heavies and 300+ hours far fighters.
Rotation: None prescribed.
Special Stresses: Moderate opposition by Luftwaffe; poor subtropical and desert environmental sanitation, resulting in hepatitis, malaria, and dysentery.
Tour of Duty: Not definite; around 500 hours for heavies and 500–600 hours for fighters.
Rotation: Well-enforced policy of 6 weeks of combat, 2 weeks of rest, and 4 weeks of rear-area operational training.
Special Stresses: Missions over water or inaccessible terrain; initially moderately severe but decreasing opposition by Japanese air; poor tropical environmental sanitation, resulting in malaria, scrub typhus, dysentery, and heat
Tour of Duty: None prescribed.
Rotation: None prescribed.
Special Stresses: Missions over inaccessible terrain—Himalayas, jungles, China; poor subtropical environmental sanitation, resulting in dysentery and malaria.
Tour of Duty: 8–11 months, 400–1,000 hours.
Rotation: None prescribed.
Special Stresses: Very long missions over water to Japan and fear of capture; repeated maximum effort strikes ordered by CG to force surrender without necessity of invasion of the home islands; higher operational than combat loss.
In summary, a fair evaluation of the conflict over the disposition process requires serious criticism of the medical service, particularly the lower echelons-the unit and group flight surgeons. The attitude toward ineffectives on the part of Headquarters, AAF, 2nd air force commanders was much more consistent than that of the doctors. As members of senior staffs, the Air Surgeon and the force surgeons shared the views of the line, and they generally worked in harmony with command to establish medical policies compatible with the AAF's concept of air power. The difficulty was almost entirely with the unit flight surgeons and the psychiatrists. As air force officers and physicians, their position was potentially ambiguous, but their sympathies were clearly with the flyers. As average products of American medical education, their ability to evaluate stress and strain was uneven, often inconsistent, and highly personal; and, as physicians, they were resentful when their judgments and diagnoses were challenged. Had the doctors been united, or even consistent, as to diagnosis and as to their responsibility to the AAF, there might have been relatively little trouble with administration. As it was-and whether he liked it or not-the physician was the subordinate of command and was expected to play on the team at all times. Highly qualified and experienced senior flight surgeons worked with command to develop policies for the medical and administrative treatment and for the further use of men incompetent as a result of illness or failure, and to do this command had to be concerned with diagnosis. The fact that the problems of individual flyers were complex and often unique was insufficient justification for resistance to, and resentment of, an over-all policy.
Comparable comments may be made about the issues involving the tour of duty and rotation. The lower echelons of the medical service were seldom in sympathy with official policy as they perceived it. It is certain, however, from the position of the Air Surgeon in relation to the Commanding General, AAF, and the Air Staff that serious, continuing consideration was given to the medical requirements of flying personnel. Regardless of how the tough policies were formulated and implemented, they can only be measured by the pragmatic test of war. The simple fact is that the policies were sound, and the fraction of aircrewmen who were permanently removed from flying status because they could no longer take it did not exceed a few per cent for the whole period of hostilities. Finally, this writer is not aware of any
significant number of ex-airmen who are now disabled because they were driven so hard.
Human Engineering
The concept of human engineering had exerted an increasingly important influence on aircraft design since the establishment of the Aero Medical Research Laboratory at Wright Field in 1934.* During the war years the AAF was able to recruit a great number of physicians and biologists qualified to participate in research involving every aspect of flight. The combined research program of the medical and engineering division had many ramifications, too numerous to describe in detail. The scope of the research is clearly shown in the figure below, a diagram prepared to illustrate the human factors in aircraft design.51
* See above, p. 370.
Fundamentally, flight surgeons were involved in two types of research; an example of each will be discussed briefly. The first type included problems suggested by investigations of serious accidents and incidents during routine, experimental, or combat flying (e.g., freezing of oxygen masks, failure of protective equipment, and death or injury while bailing out). The second consisted of problems presented by the design of aircraft with higher performance characteristics than standard models (e.g., anti-G suits to compensate for gravitational forces developed during high-speed combat maneuvers, survival at altitudes in excess of 40,000 feet, and supersonic flight).
In the first category, an example is the development of the ejection seat to facilitate escape from damaged aircraft. The Flying Safety Branch, AC/AS-3, established in 1942, received reports of all flying accidents. Detailed analyses of crashes led to recommendations for revised training, procedures, and materiel. In I 942, pathologists at SAM began studies of the types of injuries sustained in fatal and nonfatal crashes with the objective of recommending changes in the design of aircraft and of safety devices to improve the chances of survival. A medical division was organized in the Office of Flying Safety (1943) to work with the pathologists and to study the nature of pilot error or pilot failure when it occurred. A problem of particular interest was the reason for failure to use parachutes in cases involving spin or dive crashes. Associated with this problem were the many fatal accidents where the flyer was killed or rendered incapable of using his parachute as a result of colliding with the aircraft while bailing out. The obvious solution was a combination of a seat that could be ejected automatically to throw the flyer clear and a parachute that could be opened automatically if for any reason the man could not operate it. The latter device had been developed at the Aero Medical Research Laboratory as a result of studies of free falls from extreme altitude. A free fall, say, from 35,000 feet to about 15,000 feet, was desirable to get the flyer rapidly down to altitudes where emergency oxygen was not required and where the air temperature was more tolerable. All the problems associated with free falls had been solved: the emergency oxygen unit, parachutes and harnesses to withstand any opening shock that a man could tolerate, and the pressure-sensitive device to open the parachute if the flyer was unable to do so. It was apparent that an ejection device to throw a man clear of a wildly spinning plane had to impart a high initial velocity to the seat and had to be failure-proof.
The human tolerances for acceleration had been worked out in the big human centrifuges as a part of the anti-G suit program, and certainty of function could be assured by using an explosive charge to fire the seat and its occupant out of the plane. The various components of the system were fabricated and assembled, and, as was customary, the critical tests of vertical acceleration and the operation of the entire unit in flight were made by flight surgeon volunteers. The value of the ejection seat was obvious, and ultimately it became standard equipment in certain types of military aircraft.
In the second category, the example to be presented involves the problem of flight at altitudes in excess of 40,000 feet. Aeronautical engineers had solved the problem of engine design to permit flight at 50,000 feet or higher long before aviation medical researchers worked out the human equation to everyone's satisfaction. In the case of the aircraft, the superchargers required to supply enough thin air for the motors could also compress air for the cabin, and cabin pressurization was well established before the war to provide greater comfort and safety for civilian transport planes. It was no problem at all to build a plane to withstand a pressure differential of more than 7 pounds per square inch (psi), and, when fully pressurized, the "altitude" inside the cabin would be about 14,000 feet when the plane itself was at 50,000 feet. For military aircraft, cabin pressurization presented two problems: first, the weight of the compressors and the extra weight of the air frame reduced the aircraft's effective bombload; second (more serious), enemy action was sure to damage the fuselage, resulting in a sudden loss of cabin pressure which exposed the crew to the triple hazards of anoxia, aero-embolism, and explosive decompression.
The first of these hazards had been studied exhaustively at the Aero Medical Laboratory, and it was known that the standard demand mask, delivering 100 per cent oxygen, could not keep the blood fully oxygenated above 35,000 feet and that the absolute limit for the demand system was a bit over 40,000 feet. For flights at higher altitudes pressure-breathing systems were developed, and these extended the limit for adequate oxygenation from 35,000 to around 50,000 feet. Pressure-breathing systems were well enough developed by the winter of 1943 /44 that they could be used in photo-reconnaissance planes. (The first such missions were flown over Berlin, February 1944, by the 14th Photo Reconnaissance Squadron, using Spitfires.) The new system created a number of problems and required special indoctrination
of the crews, since rapid changes of altitude or rapid changes in the mask pressure could lead to aero-embolism, which was a real hazard in any case above about 45,000 feet.
The second hazard, aero-embolism, is similar to the bends, the caisson-worker's disease, which affects people exposed to a rapid drop in atmospheric pressure. The flight surgeons and the naval medical research people worked together on a problem as serious for divers and submariners as for flyers. What happens in aero-embolism is exactly what happens when a bottle of champagne is opened: there is a rapid drop in the pressure within the bottle, and the gas in the wine expands rapidly, forming bubbles and shooting out the cork. When the pressure surrounding a man drops suddenly, the gas dissolved in the fluids of the body—in this case, nitrogen—expands to form bubbles which obstruct the tiny capillaries that supply oxygen to the tissues. The result is aero-embolism, the predominant symptoms of which are pain in nerves and bone and which, if long continued, may be fatal. It is obvious that the crewman of a pressurized plane were liable to aero-embolism in the event of battle damage to the cabin. The effect on the flyers would be equivalent to a very rapid ascent to the altitude at which the plane was hit. In the case of the flyers, aero-embolism could be minimized by proper use of the pressure-breathing system.
There remained the third hazard—explosive decompression. The human body contains a considerable volume of gas in the lungs and the gastrointestinal system, in addition to the dissolved nitrogen in the blood. The pressure difference between sea level and 40,000 feet will expand this volume of gas 7.6 times. If the expansion (or the ascent) occurs slowly, the increase in volume can be exhaled or expelled without difficulty. However, if the pressure change is instantaneous, there is a real possibility that lung tissue would be damaged or a hollow organ like the stomach ruptured. Studies made before the war suggested that decompression at a rate greater than 5,000 feet per second was hazardous, and rates in excess of this were considered explosive. The. urgent need for high-altitude aircraft (to get above the Luftwaffe) was so pressing that further studies were made to set realistic limits of tolerance for rapid decompression. Flight surgeons, using each other as subjects, re-examined the problem in low-pressure chambers reproducing conditions predicted for combat. The two related factors to be determined were the limit of tolerance for rate of pressure change and for extent of pressure change. Keeping the extent, or
the differential, constant at 1.8 times, Col. Harry G. Armstrong found that 16,000 feet per second could be tolerated safely. At a rate of 20,000 feet per second, other investigators went from 10,000 to 40,000 feet with only minimal symptoms due to expansion of gas in the bowel. It was now apparent that the most critical factor was the size of the hole in the cabin to be expected from enemy action, since this would control the rate of change of pressure. The engineers provided pressurized planes for the flight surgeons, and battle damage was studied through use of actual weapons. The biggest holes resulted from disintegration of the plastic scanning blisters (observation posts), some of which were 30 inches in diameter. The flight surgeons then went back to their low-pressure chambers to reproduce combat situations, using themselves as subjects. They found that they could tolerate 87 psi per second with few or no symptoms. This condition resulted when a hole 66 inches in diameter was produced in a bomber cabin whose volume was 1,000 cubic feet, pressurized to an altitude of 10,200 feet, and "flying" at an altitude of 35,000 feet. This research program was an integral part of the development of the Superfort, the B-29, and similar studies established safe limits for fighter planes. The way was now clear for production of military aircraft which could be operated safely at the altitudes to which their engines could drive them.
These two accounts of research have been given in some detail in non-technical terms to permit the general reader to appreciate the vital importance of human engineering and of the role that was played by flight surgeons. Dozens of other examples could be offered, for aviation medicine and human engineering were new additions to the biological sciences. There were no authorities to be consulted, no books to go by; these men were writing the books as they went about their duties.
In addition to the research conducted by the Aero Medical Laboratory, SAM, the Flying Safety Branch, and dozens of university medical laboratories under Office of Scientific Research and Development (OSRD) contracts, very significant investigations were made in the field. In England at the 1st Central Medical Establishment, the problems that developed in the ETO, and to some extent those of the MTO also, were studied at firsthand, usually with the active participation of the flight surgeons concerned. It was hoped that the other central medical establishments, particularly the 2 d on Guadalcanal,
would work the same way. For a variety of reasons neither the zd nor the 3d ever got an experimental program going, although their staffs collected and analyzed important "care of the flyer'' data for studies which formed the basis for research programs in the United States. Research and statistical analysis were key factors in the success of the AAF. From the commanding general down, their significance was appreciated, and there was never any question about funds or priorities for projects which might facilitate any aspect of the war effort.
Post Mortem
The medical service of the AAF played a crucial role in the achievement of victory in the air. It operated the selection-classification program that provided over 600,000 aircrewmen, 194,000 of whom were pilots. In spite of using the latest diagnostic methods, psychological testing, and psychiatric evaluation, this group of successful flyers represented only 61 per cent of the cadets accepted for flying training. In World War I the primitive techniques of the fathers of aviation medicine selected about 20,000 pilot candidates, 55 per cent of whom earned their wings.
The "care of the flyer'' program paid handsome dividends. In spite of battle attrition so severe that 77 per cent of the men who flew against the Nazis were casualties, and in spite of disease conditions so bad that malaria rates on Guadalcanal exceeded 1,000 attacks per 1,000 men per year, the doctors kept the aircrews flying. Permanent removals from flying status never exceeded 2 or 3 percent in any air force for the whole period of the war.
Unauthorized hospitalization in the field, which had to be improvised with equipment begged and borrowed because of the stubborn resistance of the War Department to change, was so successful that all the old arguments collapsed. And when the USAF was established in 1947, the Air Surgeon had a free hand to develop a complete medical service responsive to the needs of the Air Force.
It almost seems that the wartime medical service thrived on controversy, there was so much of it: between the Air Surgeon and the Surgeon General; between flight surgeons and line officers; between flight surgeons and the Air Surgeon; and between the psychiatrists and everyone else. Much of the controversy reflected no credit on
the medical profession, but at least the issues were discussed openly, and everyone knew what the doctors thought, even if they disagreed.
The really important principles for which the air medical service fought seem to be correct, and, to the extent that medical support contributed to victory, the Air Surgeon's stand is vindicated. These principles were: ( 1 ) in an air weapons system, the human factor is equal in importance to the plane; ( 2 ) the chief medical officer of the system must be directly responsible to the chief executive, and this relationship should extend to every echelon of command; and ( 3 ) a major combat force must control its own medical service.
Contents * Previous Chapter (12) * Next Chapter (14)
1 M. M. Link and H. S. Coleman, Medical Support of the Army Air Forces in World War II (Washington, 1954) (hereinafter cited as Medical Support). Much of the material in this chapter was excerpted from this official medical history.
2 Ibid., pp. 2, 192 ff.
3 The selection and training of flight surgeons also changed progressively during the early years of the war (see, for details, ibid., pp. 159–96).
4 Duties and responsibilities of flight surgeons are described authoritatively in Harry G. Armstrong, Principles and Practice of Aviation Medicine (1st ed.; Baltimore, 1939; zd ed.; Baltimore, 1952), pp. 2–24. (This classic work is hereinafter cited as Armstrong, Aviation Medicine.)
5 "By 1926, in spite of all the work that had been done by aeronautical engineers, the problem [i.e., blind flying] seemed no nearer solution than it had been in the beginning, and finally, the aid of medical science was solicited. In that year Maj. David A. Myers, MC, a flight surgeon … began a study of the physiologic factors involved in instrument flying and shortly thereafter demonstrated the fundamental principles which have made possible blind flying as we know it today" (ibid. [1st ed.]), p. 220).
6 For further discussion of this, see Douglas D. Bond, The Love and Fear of Flying (New York, 1952). The quotation of André Malraux is from Man's Hope.
7 Medical Support, chap. iv.
8 The designation of the human factor as the "weakest link" was Armstrong's estimate of the situation prior to the development of the wartime research program (cf. Armstrong, Aviation Medicine [2d ed.], p. 47.
9 The historical background of this objective is fascinating. In a letter, dated I October 1917, to Commanding General, Air Division, Signal Corps, Lt. Col. Theodore C. Lyster, MC, Chief Surgeon, Air Division, wrote substantially as follows: Good administration requires that all medical matters affecting any unit of the Aviation Section (it became the Air Division about this time) be the province of the chief surgeon, and that the medical service, in the name of the commanding general, be permitted to handle all administrative matters without additional orders from the Medical Department of the Army: in other words, an organic medical service. The first indorsement to this letter, recommending approval, was signed by Col. Henry H. Arnold! (Medical Support pp. 14–15).
10 The wanderings of the medical service in the organizational chart of the air
arm deserve attention. The chronology and nomenclature were as follows:
- 1917—Medical Department, Air Division, Signal Corps
- 1918—-Air Service Division, OSG
- 1919—Medical Division, Administrative Group, Air Service
- 1921—Medical Section, Office of Chief of the Air Service
- 1921–29—"various places in organization chart of air service and air corps"
- 1929—Medical Division, Office of the Chief of the Air Corps
- 1936—Medical Section, Personnel Division OCAC
- 1939—Medical Division, Training Group, OCAC (April)
- 1939—Medical Division, OCAC (September)
- 1941—Office of the Air Surgeon, Hq, AAF (October)
11 The efforts of the flight surgeons to retain direct access to command is justified by what happened to the Office of the Surgeon General in the course of reorganization of the War Department, 1942. Prior to 1940, the SG was the chief medical officer of the Army reporting directly to the General Staff. Formal actions of the Medical Department channeled through The Adjutant General and were thus the concern of AC/S, G-I; other medical affairs involved AC/S, G-3; and hospitalization was the responsibility of AC/S, G-4. Although direct communication was authorized between the SG and the divisions of the General Staff, the impact of the medical adviser was not great and the multiple channels led to a cumbersome organization. When mobilization began, the training organization, GHQ, also had medical problems, so there was another subdividing of the SGs authority. The WD reorganization of 1942 established the Services of Supply, to which the Medical Department was assigned. The SG now became a member of the special staff of CG, SOS, and medical matters of concern to the WD General Staff passed through him. This separation of the SG from the General Staff became even greater when an Operations Division was established in H , SOS, and was assigned the responsibility for the Hospitalization and Evacuation Branch. The Ofice of the Surgeon General (OSG) operated on the same echelon as operations, but the functions were separate. Finally, in the latter part of the war, the situation was somewhat improved by abolishing the branch, whose functions were transferred to OSG, and by authorizing direct communication between the SG and the General Staff and the Secretary of War.
12 For a fuller discussion, see Medical Support, chaps. i and ii.
13 Ibid., pp. 51-66.
14 Ibid., pp. 539-40.
15 Ibid., pp. 71-74.
16 Ibid., p. 94.
17 Bond, Love and Fear of Flying, p. 125.
18 From instructions concerning physical examination of candidates for aviation duty, published by WD, 2 Feb. 1912, quoted in Armstrong, Aviation Medicine (1st ed.), p. 8.
19 Medical Support, pp. 180–81
20 Ibid., p. 8.
21 Ibid., p. I I.
22 WD SGO, Air Service Division Memo No. 79, 3 June 1918
23 Medical Support, pp. 547–48.
24 Supplement, Journal of Medical Education, Dec. 1956.
25 AAF Regulation No. 55-7, 30 May 1942.
26 Ltr., Hq., AAF, to All High Altitude Indoctrination and Classification Units, sub.: "High Altitude Indoctrination and Classification Program, 19 Mar. 1942."
27 Medical Support, p. 212; see also ibid, pp. 210–17.
28 Ibid, pp. 189–91.
29 Morale is discussed exhaustively below, chap. 14. Careful reading of this chapter discloses no evidence that deficiencies in the medical service contributed to low morale. Virtually every other aspect of military life is the object of criticism.
30 Medical Support, pp. 647–55.
31 Ibid., pp. 635–47; see also ibid., p. 679.
32 Ibid., pp. 655–60.
33 The relationship between plane losses and grounding for neuropsychiatric (or emotional) reason was studied extensively by Bond and is discussed in Love and Fear of Flying, pp. 177-90. Data collected by Bond in England were interpreted to demonstrate a significant correlation (r = +0.7) between emotional casualties and aircraft losses. For a one-year period (May 1943–May 1944), the ratio of emotional casualties to losses was said to be 1: 2. Likewise, when the loss rate of planes (per month) exceeded 8 percent, Bond reported a "sharp increase" of emotional casualties. It is to be noted that many of the "casualties" were returned to flying status after rest leave, appropriate treatment, etc.
34 Medical Support, Table 83, p. 703, and Table 85, p. 706; see also ibid., pp. 704–8.
35 Ibid., pp. 617–35.
36 Ibid., pp. 679–80.
37 Quoted from General James H. Doolittle's Introduction in Bond, Love and Fear
of Flying.
38 Medical Support, passim.
39 Ibid., p. 80.
40 Ibid., p. 104; see also ibid., pp. 103–7.
41 Ibid., p. 571.
42 The estimate of "a few per cent" is obtained as follows : During the three-year period (July 1942 through June 1945) 421,162 individuals from the air forces in Western Europe were hospitalized, losing a total of 3,469,015 mandays from duty. This works out to about 100,000 mandays per month. In a sample month (February 1944) 1,370.2 L (the decimals are meaningless) mandays "would have been saved if AAF hospitalization was available." In another sample month, the saving would have been 848.94 mandays. Taking 1,000 mandays as a fair average, and doubling it for aircrewman, gives the "few per cent" estimated. Had data been available from other theaters, it seems probable they would have been similar. This agrees substantially with other figures given in Medical Support, p. 708.
43 Ibid., p. 565. This is an astounding statement and demonstrates clearly the wide area of disagreement between the respective medical services. Apparently, General Hawley realized that it was beyond the SG's power to provide the medical supplies that the ground forces required for a modern medical service.
44 Ibid., p. 671.
45 Chap. 9
46 AAF Regulation No. 35-16, to Oct. 1944; and AAF confidential letter 35-18, 7 Dec. 1944.
47 Medical Support, p. 498.
48 Ibid., p. 663.
49 Ibid., p. 857.
50 Ibid., p. 856.
51 Ibid., p. 234, Fig. 8.