Aeromedical Challenges in Mounting an Attack from Great Britain

The medical lessons of the North African and Italian campaigns proved especially valuable after D–Day, June 6, 1944. The northern theater, however, already had a unique set of aeromedical challenges arising from the AAF buildup in Great Britain that started early in the summer of 1942 and the ensuing high-altitude Combined Bomber Offensive against Germany. Bombing Germany was eventually the greatest challenge, but merely getting established in Great Britain in 1942 and 1943 required extraordinary efforts, because many AAF units were out of reach of Army hospitals. The small AAF units needed at least two doctors, a dentist, and about fifteen enlisted medics. Because not enough Army medics were available at first to organize effective medical support for U.S. troops, the theater surgeon had to send about 30 percent of Army and AAF patients to British hospitals. The problem abated but was not solved in 1943 when more medics arrived in theater.

Construction of U.S. Army hospitals was generally slow, and British hospitals were understaffed and too distant from AAF bases. There were 5,600 AAF troops living near Burtonwood, England, but the nearest American hospital was seventy-five miles away. Although the AAF population at Burtonwood grew to 20,000, only one American dispensary became available for its medical service. London also had no American hospital, even though the city housed a large contingent of Eighth Air Force troops. The theater-stationing plan seemed to ignore medical considerations. Until early 1944, most AAF units were in northeast England, but the Army theater SOS installations were in the south. Almost half of Eighth Air Force troops in 1942 and 1943 were isolated from all medical facilities.

Eighth Air Force surgeon Colonel Grow had two ideas to reduce the damage caused by a shortage of AAF doctors. First, he suggested creating a “casual” pool of medical officers from which to assign personnel to isolated air groups. Although this idea was rejected, he was allowed to create small Medical Dispensary Detachments, Aviation, one for every 5,000 troops. The dispensaries were only partially motorized, but they were easily air transportable.

Although first-echelon support for the AAF was at last available, its value was limited. The European theater surgeon, Col. (later Maj. Gen.) Paul Hawley of the U.S. Army, prohibited the AAF from operating a medical facility intended to hold a patient more than four days. More advanced treatment would require evacuation to an Army facility. The AAF resisted this policy, in keeping with Air Surgeon Grant’s views. General Grant wrote that medical care of AAF personnel “does not end with the squadron Flight Surgeon, but that to assure the maintenance of the striking force of the air command, medical service must include hospital, sanitary, and daily hygiene inspection facilities.” In August 1942, Colonel Grow got permission to operate AAF rest homes for patients with flying fatigue. When the air surgeon later tried to convert them into de facto AAF hospitals, the Army’s theater command denied the request.

Facilities were not the only problem. Medical supplies and equipment were also scarce in 1942 and 1943, and inexperienced personnel often handled them improperly. Until early 1944, the theater surgeon seldom filled Eighth Air Force medical supply requisitions. As a result, the Eighth Air Force set up its own Air Service Command, allowing medical and other supplies to flow to Great Britain through a depot at Newark, New Jersey, without passing through SOS channels. The AAF in Great Britain soon had its own medical supply distribution points at a few advanced depots.

Concern for his aircrews was Grow’s chief motivation. He created a “Care of the Flyer” section on his staff and established a facility in Great Britain for AAF medical research, development, and training. In August 1942, when the air war over Germany began, the Provisional Medical Field Service School officially opened at High Wycombe, England, a small town northwest of London. The school’s first task was to expand AAF understanding of the medical and psychiatric problems of combat aviators, and give aviation medical training to new arrivals in Europe. In 1942, about two-thirds of the Eighth Air Force medical staff had no aeromedical training, and only 10 percent of medics in tactical units had any training. Several bombers and their crews already had been lost because of the lack of trained medical officers.

To make sure the training at High Wycombe was suitable, Colonel Grow added a medical board, altitude training unit, psychiatric unit, and research and development unit. He appointed as its first director Col. Harry G. Armstrong, Medical Corps (MC), a prewar pioneer in aviation medicine, who renamed the whole facility the First Central Medical Establishment. A second such facility was created in the Pacific, and a third was created in March 1944 for the Ninth Air Force, which moved from North Africa to Great Britain in October 1943 to support the ground forces invading France.

The medical research program at High Wycombe concentrated on high altitude bombing and airplane ditching. Flying a series of bomb runs on Germany was one of the most dangerous and physically demanding tasks of the entire air war. Sortie rates were high because of AAF pressure to win an early aerial victory, and fighter escorts were not made available for the early missions. About one-fourth of the returning bombers had sustained some form of battle damage. The normal maximum tour of twenty-five (later thirty-five) missions in a heavy bomber (the most dangerous) left a crew member with less than a 50 percent chance of escaping death or physical harm. Only one-fourth of the crew members could expect to complete all twenty-five missions.

Starting in 1942, preventing and reducing these casualties became the focus of medical research at High Wycombe. Some form of personal armor soon looked promising against the German flak and 20-mm cannon shells that began to ravage high-altitude bomber crews in 1943. A British firm, the Wilkinson Sword Company, produced a light armored suit of thin manganese plates to protect the chest and pelvic area. An improved helmet was soon added, and by January 1944 enough suits were available to equip every crewman in heavy-bomber groups. The program worked. Armored crewmen had 75 percent fewer injuries and death from flak and cannon fire. There were many reports of the body armor’s effectiveness, including the following:

A 20-mm cannon shell exploded in the radio compartment of a B–17. A fragment of casing approximately 2 cm by 1 cm by 4 mm in thickness, struck the radio gunner in the left side of the abdomen. It spun him around but, being deflected by the armor, caused no wounds. The armor plate was bent but not penetrated. The gunner, slightly stunned by the impact, continued firing his machine gun throughout the action.

Medics at High Wycombe also helped prevent anoxia deaths at high altitudes. These deaths were caused both by inadequate training with oxygen equipment and by the faulty design of the first AAF oxygen masks, which often froze up at high altitudes (above 25,000 feet) and shut down the oxygen flow. Most anoxia deaths occurred among recently arrived crew members, whose lack of experience at high altitudes sometimes caused their oxygen masks to disconnect from the hoses. Training in the proper use of oxygen equipment began in March 1943 at the school unit at High Wycombe. High-altitude flights in training chambers were made available to almost everyone in the Eighth Air Force, including the medical staff, and training exposure to the first stages of hypoxia (shortage of oxygen) was especially valuable because it emphasized this silent danger that could kill quickly and unexpectedly. By September 1944, oxygen training was completely adequate. Meanwhile, designers improved the standard AAF oxygen mask by substituting a demand flow for a continuous flow system. And new pressurized oxygen systems succeeded in sustaining operations above 43,000 feet. From November 1943 to November 1944, oxygen programs reduced the anoxia accident rate by 80 percent and the anoxia fatality rate by 68 percent.

Cold injury was another worry. Frostbite casualties were caused by the extreme cold and wind blast in AAF bombers flying at high altitudes. Unheated sections of bombers were sometimes –60°F, and the open waist gunner windows were especially dangerous. Yet less than one-fourth of the aircrews arriving in Great Britain knew how to prevent frostbite at high altitudes. Extreme cold often hampered first aid efforts. A ball-turret gunner described one such instance:

At 26,000 feet the tail gunner had both cheeks of his buttocks torn by a 20- mm shell. We had him lie face down and put a dressing on as well as possible. Bleeding continued so we put a 140-pound ammunition box directly over the wound. The pressure seemed to stop the bleeding. He rested comfortably but was almost frozen because his heated suit was torn and we had no blankets available.

In March 1943, in response to these problems with oxygen and cold temperatures, the Eighth Air Force designated one member of each unit the 22 “personal equipment officer.” His principal duties were to maintain coldweather clothing, protective gear, and oxygen equipment in perfect condition, and to train crews in their proper use. Personal equipment officers were ground officers because pilots, navigators, and bombardiers were usually too busy with their standard duties to perform equipment work properly. New personal equipment officers were trained at High Wycombe. Laboratories in the United States helped the technicians in Great Britain devise better electrical heating for flying suits, gloves, boots, and casualty bags. Engineers reduced wind blast by structurally altering the aircraft. By March 1944, for example, they closed the waist windows. Most of the training problems were solved by June 1944, and equipment improvements reduced the rate of cold injury during late 1944 and 1945.

Another problem in 1942 and early 1943 was the lack of an effective AAF air–sea rescue program for crews who ditched in the North Sea or the English Channel. There was an urgent need for smarter ditching procedures and faster rescue responses to support an expanded AAF role in the war. Fortunately, the RAF’s Air–Sea Rescue Service was already able to save about one-third of the British crews who landed in the water. The British, therefore, helped the U.S. personnel at High Wycombe work out better ditching procedures and demonstrate them to Eighth Air Force crews and air–sea rescue units. New ditching and rescue procedures were established by Lt. Col. (Dr.) James J. Smith of the First Central Medical Establishment. In 1943 alone, these improvements saved the lives of about 650 Eighth Air Force men, about 43 percent of those who ditched.

Eighth Air Force medical researchers also had to tackle a special aviator’s disease known as aerotitis media, an inflammation of the middle ear caused by the ear’s inability to adjust between its internal pressure and that of the surrounding atmosphere. Aerotitis media was prevalent in all theaters because the cabins of most AAF planes had no pressure systems. It was especially troublesome among heavy-bomber crews in Europe, and there was no agreement in the first two years of the war on how to treat the problem.

A research program on aerotitis media was started in May 1944, concentrating on heavy-bombardment crews in the Eighth Air Force. It soon became clear that the principal cause was multiple descents after long flights at high altitudes. Respiratory disease could also contribute to the ear inflammation. Some improvement was available through radium treatment of the lymphoid tissue around the eustachian tube opening, but no single prevention or cure was discovered. The noneffective rate resulting from aerotitis media fell during the war, partly because of a fall in the rate of respiratory disease. There were no meaningful changes in protective equipment, preventive measures, or indoctrination to cope with the problem.

In January 1944, preparations for the invasion of Normandy affected medical assignments and organizations. The Eighth and Ninth Air Forces in Great Britain combined to form the United States Strategic Air Forces in Europe (USSTAF), with Gen. Carl A. Spaatz as commanding general and Brigadier General Grow as USSTAF surgeon. Colonel Armstrong became the new Eighth Air Force surgeon and continued to work with the incumbent Ninth Air Force surgeon, Col. Edward J. Kendricks, MC.

The U.S. air forces in northern Europe, unlike those in the Mediterranean, never acquired long-term control over fixed Army medical facilities. The medical service of the Ninth Air Force was limited to the flight line and dispensary level, except for some clearing stations in the aeromedical evacuation chain. Grant was not happy with this situation, but could do nothing about it; Grow and Kendricks thought it best not to press the issue, although they agreed that AAF control of fixed facilities would probably simplify the aeromedical evacuation of patients to AAF installations in the United States.

By 1944, AAF patients were receiving adequate care in Great Britain. The Army had set up several fixed hospitals, and AAF flight surgeons attached to them were effective in handling the disposition of AAF patients referred to Army facilities. Both the Eighth and Ninth Air Forces had adequate numbers of flight surgeons and other medics. The challenge was to preserve this medical care in future operations. In March 1944, forty aviation medical dispensaries were activated to support the Normandy invasion. Because of their limited resources, these dispensaries could hold patients no longer than seven days. In AAF clearing stations that were formed from the 39th and 40th U.S. Army field hospitals and assigned to the Ninth Air Force, patients could remain no longer than fifteen days. The clearing stations, however, could function independently, unlike the aviation medical dispensaries. Some of the forty such dispensaries assigned to the Ninth Air Force joined the first waves of troops landing in Normandy; others stayed in England to care for returning AAF patients.

The range as well as depth of activity grew for AAF medics after D–Day. As the ground troops advanced toward Germany, most AAF medical units became more independent from their British medical counterparts and gave less support to British troops because USSTAF’s goal in Operation Overlord was to preserve the autonomy of its combat and support forces—a goal that had not been possible in North Africa.

AAF medical units also began to evacuate Army and AAF patients to England. Responsibility for air evacuation belonged to commanders of the U.S. First Army, the theater SOS, and the Ninth Air Force. Invasion plans directed the Ninth Air Force to equip all transport aircraft with suitable litter racks, give medical care and treatment to all casualties in flight, give emergency medical care at airdromes, deliver casualties to airfields in Great Britain convenient to fixed hospitals, and try to use all aircraft returning from forward areas for patient evacuation. Air evacuation, however, would only supplement evacuation by road, rail, and sea, and would depend on the degree of air superiority, the tactical situation, and the weather. De- 25 tailed plans and operations for air evacuation were the responsibility of the commanding general of the Ninth Air Force troop carrier command and his air evacuation officer.

Successful aeromedical evacuation operations began informally and ahead of schedule after D–Day. By July 23, AAF medics helped fly to Great Britain 18,415, or 33 percent, of the total 55,674 American casualties. (The others went by sea.) The medical units of the Ninth Air Force offered first-echelon patient care in the aeromedical evacuation chain. Although air evacuation in July and August was unreliable, it proved valuable nonetheless. C–47 crews often found themselves assigned to ad hoc medical evacuation missions. One crew member recalled these flights:

Often, after unloading supplies in some part of France or Belgium, we would be ordered to a different airfield on the Continent, where we might find a nurse, medical crew, and a group of wounded (either walking or litter cases) waiting for us to take them to a hospital base in Britain.

One pilot flew a lot of missions supplying Gen. George Patton’s tanks with fuel. According to the pilot’s estimate,

Maybe 50 percent of these flights finished by evacuating wounded men back to England. After off-loading the diesel there was always a scramble to install the litters and get the plane ready to receive the wounded soldiers.

On August 30, General Hawley, the chief surgeon in Europe, won approval for an expansion of air evacuation operations. He made air evacuation a separate mission not entirely dependent on cargo flights to the front, ordered airfields in France to function as patient destinations when weather did not allow landing in England, and established a formal method to inform the AAF commander about air evacuation needs. Hawley could not get approval, however, to dispatch empty cargo aircraft to the Continent simply to pick up patients. Grow’s September 2 proposal to set aside fifty C–47s as dedicated air evacuation planes, under medical control, also met with disapproval.

The limited air evacuation expansion was inadequate to meet all medical needs. By late September, a backlog of almost 7,000 patients on the Continent prompted the theater surgeon to resubmit the proposals for a dedicated air evacuation force. But the chief of staff in Europe, Lt. Gen. Walter B. Smith, again rejected the idea and directed the surgeons to consider air evacuation “a bonus to be available from time to time as conditions permit.” When Lt. Gen. Omar N. Bradley, the commander of the Twelfth Army Group, asked for dedicated air evacuation, Smith again rejected the idea and wrote that “any evacuation system based on air transport will break down.”

There was no question that transport and ground crews with little or no medical training sometimes had emotional problems in handling severely wounded patients. One mechanic wrote:

Whenever they brought in the wounded, some of us would go up on the flight line and help unload those fellows. A few of us, I remember, couldn’t handle that; they couldn’t stand being near wounded people. Some of these had arms gone, legs gone, the sides of their faces shot away, holes in their bellies and more of that sort of thing. But somehow I was able to cope with this; I helped unload many of those poor fellows into ambulances.

Lower-level commanders, however, found ways to make the necessary cargo aircraft available. Some medical supplies were stored at airfields for opportune shipment forward, coinciding with requests for emergency air evacuation. Newly arrived C–47s from the United States were dedicated to air evacuation before they were reported to theater headquarters. Grow also got a squadron of twenty small UC–64 bush planes and dedicated them to medical missions. Based at Le Bourget Airdrome in France, they resupplied forward areas with blood and critical medical items. Equipped with three litters each, they evacuated 1,168 patients between September 23 and December 29, 1944.

Although Europe used air evacuation more than other theaters, especially from forward areas, many patients still traveled by ship—especially for evacuations from Europe to the United States; only 15 percent of such patients traveled by air. There were not enough transport planes or suitable patients to justify a more significant use of aeromedical evacuation to the United States.