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AIR SERVICE 
 MEDICAL MANUAL 
 
 WAR DEPARTMENT : : AIR SERVICE 
 
 DIVISION OF MILITARY AERONAUTICS 
 
 WASHINGTON, D. C. 
 
 WASHINGTON 
 
 GOVERNMENT PRINTING OFFICE 
 
 1918 
 
ly' 
 
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CONTENTS. 
 
 PART I. 
 
 Page. 
 
 Chapter I. — Aviation and its medical problems 7 
 
 II. — The selection of the flier 17 
 
 III.— The classification of the flier 23 
 
 IV. — The maintenance of the efficiency of the filer 29 
 
 (3) 
 
PREFACE. 
 
 In each of the countries at war there is a fully established Air 
 Medical Service. Early in the development of the Aviation Service 
 of our Allies, and even earlier in the German Air Service, it was 
 found essential to create a medical department as an integral part of 
 the Air Force. The French and the Italians for the past year have 
 had well-organized Air Medical Services, which include in their 
 personnel many of the foremost specialists of these respective coun- 
 tries. The British, whose Koyal Air Force exists as a separate arm 
 of the service, have a separate Air Medical Service with a Surgeon 
 General of Aeronautics. * In our own Service, this work has been 
 effectively handled by a division of the Surgeon General's Office, 
 assigned as a part of the Division of Military Aeronautics. 
 
 Aviation is new, and the Air Medical Service even newer; so that 
 for educational purposes the director of Military Aeronautics deemed 
 it advisable to issue this book. Its object is to set forth Aviation's 
 debt to Medicine and to make clear the part played by the Air 
 Medical Service in the " winning of the war in the air." 
 
 The book is presented in two parts. Part I is a shorter statement 
 of the essential facts which are of immediate general interest. Part 
 II goes into greater detail and is for the information of those who 
 belong to the Air Medical Service or of those who desire to make a 
 
 more thorough studv of this new work. 
 
 15) 
 
7a 
 
PART I. 
 
 CHAPTEK I. 
 AVIATION AND ITS MEDICAL PROBLEMS. 
 
 Wonderful has been the development of the airplane-mconceiv- 
 able has been the neglect of the MAN in the airplane. 
 
 Aviation began in the United States of America. The gemus ot 
 Lang y, Chanute, and the Wright brothers made it possible to ma n- 
 tain in^he air a machine heavier than air. Startmg as a scien fie 
 experiment, aviation has developed with such gigantic strides that 
 L- da"> the defense of our Nation, the Air Force has a place com- 
 parable in fighting importance with the land and ^^^ f^^^^, 
 ^ Ever since the time that man lived m a cave and was obliged to 
 chase his food or be chased by it, he has dreamed of flying He has 
 racked his brain and bruised his body in futile attempts to emulate 
 the bird. At various stages in his history we see him climbing to he 
 top of precipices, trees, bridges and houses, and from these heights 
 projecting himself into space, with nothing to break his fal except a 
 modified kite, parachute, or some similar contrivance, and landing 
 below with many regrets and broken bones. Gravitation was not to 
 be defied by such rudimentary methods. 
 
 Through all time man has been speeding up. The savage finding 
 himself upon a snow-capped height and desiring to go to the valley 
 below, was wont to set himself upon a piece of bark and slide down 
 to his destination; or, desiring to go down the valley, he stepped into 
 a hollow log and shot the rapids of some swiftly flowmg stream. 
 Desiring to cross the plain, he subjugated the horse and used him as 
 a more rapid means of transportation. Later on civilized man, 
 astride a pair of wheels, propelled himself along the highway by 
 means of a mechanical device. Then the steam engine was invented, 
 and with it the steamboat and locomotive, which enabled man to 
 travel with increased speed. The electric trolley car appeared soon 
 after the perfection of the electric motor. Eventually came the gas 
 en-ine, and with that the automobile, capable of even greater velocity. 
 It Is not surprising that in the United States, the least mature of the 
 progressive nations of the world, this speed mania broke all bounds 
 
8 
 
 AIR SERVICE MEDICAL MANUAL. 
 
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10 AIR SERVICE MEDICAL MANUAL. 
 
 and man flew off at a tangent into space. The Wright airplane had 
 set a new pace. 
 
 Each new mode of travel has evolved its own new and peculiar 
 human ills and medical problems. Reverting to the savage, we can 
 picture a new variety of accidents coincident with rudimentary 
 tobogganing. With water transportation came seasickness and 
 drowning, with the various methods of resuscitation. Railroading 
 developed a new category of ills, from caisson disease to " railroad 
 spine ; " railroad signaling emphasized the importance of normal 
 color perception. With the development of the electric railway 
 there opened up a new chapter of ills in the form of electric shocks 
 and burns. With the gas engine came Colle's fractures from crank- 
 ing and an increasing number of collision accidents with the ever- 
 increasing speed. Now with the airplane come the new problems of 
 air-sickness, oxygen-want, and the unprecedented demands on the 
 special senses, the nervous system, and the heart. 
 
 While American genius made possible the birth of the airplane, 
 its extraordinary development in such a short space of time is di- 
 rectly due to the drive of necessity arising from actual warfare in 
 Europe. Prof. Langley's theories of heavier-than-air machines were 
 correct ; the producers of airplanes have converted them into realities. 
 After the appearance of the Wright biplane, however, flying in this 
 country made little progress ; we Americans were slow to appreciate 
 the possibilities of this new invention. The Wright brothers took 
 their machine to Europe, where an immediate keen interest developed 
 in its sporting possibilities, which appealed particularly to the 
 French, Italians and English. The German, ever watchful of any- 
 thing calculated to enhance the value of his war equipment, immedi- 
 ately took notice and began airplane experiments. Thus the French, 
 Italian and English interest had its root in the appeal of the plane 
 to sporting instinct ; the German interest, on the other hand, sprang 
 from " Kultur," in recognition of its possibilities as an additional 
 weapon of war. The development of the airplane among the Allies 
 is a story of sportsmanship; among the Germans it is part of the 
 secret annals of war preparation. During the early stages of the war 
 air superiority lay with the Germans and was represented mainly 
 by their development of the Zeppelin. During this period the Ger- 
 mans placed their trust in the lighter-than-air type of machine; at 
 the same time they did not neglect the heavier-than-air type. It 
 was not until 1916 that, under the spur of war conditions, both bel- 
 ligerents came to a full realization of the immense possibilities of the 
 airplane as a factor in battle. It is, therefore, the other nations who 
 have developed the airplane, and we now look to these nations for 
 advice and instruction in aeronautics ; it is a case of the pioneer tak- 
 ing the position of a novice in his own field of endeavor. 
 
LANGLEY STEAM-DRIVEN AERODROME IN FLIGHT OVER POTOMAC RIVER NEAR QUANTICO, VA., 
 
 , „ MAY 6, 1896. 
 
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QUARTER-SIZE GASOLINE MODEL, LANGLEY AERODROME, IN ONE OF ITS FLIGHTS OF AUGUST 8, 1903, 
 
 ON THE POTOMAC RIVER. 
 
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CADET APPROACHING PLANE WITH INSTRUCTOR ON HIS FIRST TRIP. THE CADET 
 
 IS MERELY A PASSENGER. 
 
 A CADET AND HIS INSTRUCTOR. 
 
INSTRUCTOR IMPRESSING UPON THE CADET THE USE OF THE RUDDER. 
 
 CADET AND INSTRUCTOR IN THE MACHINE. 
 The instructor is assisting tlie cadet who is experiencing an air trip for tlic first time. 
 
 lOa-10 
 
CADET RECEIVING FINAL INSTRUCTIONS BEFORE GOING ON A FLIGHT ALONE. 
 This cadet has completed his preliminary course and is about to start on a solo flight. 
 
 lOa-11 
 
 STARTING OFF ON A FLIGHT. 
 
PILOT AND CADET SLOWLY AND CAREFULLY DESCENDING TO A LANDING PLACE. 
 
 lOa-12 
 
 CADET DESCENDING FOR HIS FIRST LANDING. 
 
CADET EXPERIENCES FIRST HALF HOUR IN AN AIRPLANE. 
 The instructor made a perfect landing without bumping, much to the satisfaction of the student. 
 
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r f r' r * I 
 
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 A CADET READY FOR HIS FIRST SOLO FLIGHT. 
 
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 A CADET AFTER HIS FIRST SOLO FLIGHT. 
 Having had his first ride he smiles all over upon landing. 
 
 \ 
 
AIR SERVICE MEDICAL MANUAL. 11 
 
 It is easy to see how the necessity for attention to the physical 
 efficiency of the pilot came to be overlooked ; the world over, everyone 
 has been so absorbed in the one effort — to increase the mechanical 
 efficiency of the airplane. Every thought has been directed toward 
 making each successive model safer and faster. 
 
 During this period, representing the first two and one-half years 
 of the war, the pilot was not selected because of any peculiar fitness 
 for flying; it was simply a question of whether he " had the nerve." 
 At one time circumstances made it necessary to place men in the 
 Aviation Service who were " all worn out by the more trying work " 
 of the Infantry or Field Artillery. The viewpoint was : " This man 
 is no longer fit for ground fighting; therefore he will do for the air 
 service." The result of this policy was that the average aviator had 
 a very short time of usefulness and there was, to this extent, some 
 truth in the persistent rumor that the " active life of the aviator at 
 the front was only a certain number of hours." There was enormous 
 avoidable wastage. Little by little the Aviation Services of our Allies 
 have come to realize that the advice of their medical officers was 
 sound; the mental and physical requirements for entering the Air 
 Service were raised, with an immediate saving of an unlimited 
 amount of money and personnel. This is the great lesson we have 
 learned from the bitter experience of our Allies. 
 
 The popular idea that a flier must be a " superman " is utterly 
 absurd. It would be much nearer the truth to say: "Anyone can 
 fly." Flying itself is now just as prosaic and commonplace as riding 
 in a motor car, and not more dangerous. To consider that the aviator 
 at the front is in greater danger than his brother in the trenches is 
 ridiculous ; actual statistics prove that it is far safer in the air. Fur- 
 ther than this, instead of living in the filth of the trenches, the fight- 
 ing pilot returns to a comfortable airdrome well behind the lines, 
 where he sleeps in comfort and one might even say in comparative 
 luxury. 
 
 Nevertheless, aviation is not merely spectacular; it does have its 
 unique problems and makes its unique demands upon those in 
 this service. Nature never intended that man should fly. From the 
 time that he leaves the ground until his return, he is living under 
 unnatural conditions. Although it should be emphasized again and 
 again that the flier at the front is safer than the infantryman in the 
 trenches this does not mean that we should belittle the conditions 
 which the aviator faces. He flies in an atmosphere lacking in that 
 oxygen which is the " breath of life " ; subjected to the shells of anti- 
 aircraft gims, or encountering enemy aircraft at any moment; with 
 his body at a dizzy height and hurtling through space at the rate 
 of 125 miles an hour— this represents the daily life of the fighting 
 
12 AIR SERVICE MEDICAL MANUAL. 
 
 pilot. The aviator himself is serenely unconscious of the effect of 
 these conditions upon his nervous system; he naturally regards it 
 as " all in a day's work." Yet in attaining altitudes and spending 
 much of his time in rarefied air, the flier is defying nature. 
 
 The conquest of the air represents man's maximum achievement. 
 There is no combination of wood and wire which is subjected to 
 such a variety and intensity of strain and stress as the airplane; 
 there is no living combination of muscle and nerve which, consciously 
 or unconsciously, may be subjected to such a variety and intensity of 
 strain and stress as the aviator. 
 
 To-day thousands of trained mechanics are working day and night 
 upon the engines of our airplanes ; thousands of expensively trained 
 riggers and sailmakers are tuning the wires and mending torn fabric ; 
 thousands of hangars are provided to house the planes when they 
 are not flying. A striking discrepancy is noted when we look about 
 to see what is being done to take care of that infinitely more delicate 
 organism — the man who flies the machine. 
 
 The pilot of the airplane is the heart and brain of the whole flying 
 apparatus. The engine may fail through lack of care, but the pilot 
 brings the machine safely back to the airdrome. A carelessly inspected 
 wire may snap in the air, but nothing serious results. When the 
 pilot breaks, even momentarily, nothing is left to direct the flight, 
 and the plane and engine, no matter how well they have been cared 
 for, crash and are lost. 
 
 The mechanic who looks after the troubles of the engine must be 
 an expert. Work like this is not for the mediocre. No less an expert 
 must be that man who supervises the condition of the pilot. Flying, 
 especially in the military service, coupled with the temperament 
 peculiar to the man choosing this kind of work, develops a most ex- 
 traordinary series of problems and complications. Many an aviator 
 in a short time becomes a subject over which a genius in medicine 
 might easily become discouraged. 
 
 The establishment by our forefathers of the West Point Military 
 Academy was a wise forethought. In this institution a curriculum of 
 four years' intensive study prepares our young men for the profession 
 of the soldier. In this war, however, an important and novel military 
 situation has arisen; even West Point does not offer a solution of 
 this problem. The Air Fighting Force is without military precedent 
 to furnish instruction in all its details. The problems of this war 
 on the ground, while new in many aspects, still could be met by the 
 skill of the engineer and the tactician with fundamentals furnished 
 by years of military experience and study. The problems of the pres- 
 ent war in the air lack the accumulated experience of previous wars 
 to indicate their solution; those difficulties, which early made it 
 apparent to our Allies that an air-fighting force has its own poten- 
 
AIR SEEVICE MEDICAL MANUAL. 13 
 
 tialities of disaster, presented the immediate problems of our Air 
 Service. 
 
 To the Air Medical Service the problems were presented of over- 
 coming all those conditions aifecting the physical fitness of the man 
 who, leaving his natural environment, the ground, straps wings to 
 his body and soars to heights into which even the eagle dare not go. 
 For work in this unnatural environment onlj^ the man who is in 
 every way physically fit should be selected. 
 
 When our Air Medical Service was established it was fortunate 
 to have at hand a series of reports of the Air Medical Services of our 
 Allies by medical officers who have attained distinction in the field 
 of scientific research. Birley, Dreyer, Haldane, Flack, Douglas, and 
 Priestly among the British ; Nepper, Josue, Lombaert, Guilbert, Gar- 
 saux among the French; Gradenigo and Herlitzka among the 
 Italians, had been studying for years the physical deterioriations 
 peculiar to flying which, even early in the war, so emphasized the 
 military importance of this particular problem of the Air Service. 
 
 The keynote of the American Air Medical Service is the handling 
 of the flier as an INDIVIDUAL. 
 
 During the early part of the war the German method of air fight- 
 ing was patterned after that of their infantry ; the pilot of the ma- 
 chine received his commands and carried them out regardless of 
 changing conditions. The observer in a two-seater machine gave 
 the pilot his orders, just as an infantry officer gave orders to his 
 subordinate. There were only a few picked flying officers, usually of 
 high social position, who were what might be called " sportsmen."' 
 The efficiency of the German Air Service was greatly increased in the 
 3^ear 1917 by their allowing a certain freedom of action to their pilots 
 in order to cope with the more speedy allied air-men who had proven 
 individually far superior in action, spirit and initiative. Infantry 
 and cavalry which strike in large numbers must be handled as a single 
 force ; they must have coordination and absolute oneness of action or 
 half their effectiveness is lost. The efficiency of such troops is meas- 
 ured by the successful handling of a large striking force as a single 
 unit. The aviator is the rank and file and commanding officer, all in 
 one. The outcome of a reconnaissance flight may determine the fate 
 of thousands on the ground; but it is the flier's individual decision, 
 initiative and action, that spell victory or defeat for him. 
 
 The Air Medical Service, devoted as it is entirely to the study of 
 the flier as an individual, naturally falls into three main lines of 
 activity — the Selection of the Flier, the Classification of the Flier, and 
 the Maintenance of the physical efficiency of the Flier. These three 
 branches of the Air Medical Service are presented in concise form in 
 Part I of this book. In Part II is given a fuller discussion of these 
 same subdivisions. 
 
14 AIB SERVICE MEDICAL MANUAL. 
 
 Underlying " Selection " is a full realization that it is possible for 
 a man to fly in spite of one or many handicaps; the object to be at- 
 tained, however — the defeat of the enemy — demands that only such 
 fliers be sent against him as are the very best air-fighting material — 
 not merely men who are able to fly. 
 
 " Classification " is the second step. The flying service is now 
 highly specialized. Men are called upon to perform widely diversi- 
 fied classes of work, such as pursuit, reconnaissance, photography, 
 bomb-dropping and night-flying. Not every aviator, regardless of 
 perfect training and physical fitness, is necessarily fitted for all 
 types of air activities. There is a marked difference in the individual 
 ability to withstand a diminished oxygen supply; this has made it 
 necessary to classify the fliers on an altitude basis. By means of 
 tests applied at the Medical Research Laboratory at Mineola, Long 
 Island, and at the branch laboratories in the various flying schools 
 throughout this country and overseas, fliers are being classified as 
 fitted for low, moderate, and high altitudes, night-flying, and other 
 special types of work. 
 
 The "Maintenance" of physical efficiency of the flghting force is 
 the supreme function of the Air Medical Service. There is a sharp 
 contrast between the work of selection and the work of maintenance. 
 In selection the sole object is that all questionable material be kept out 
 of the service. In maintenance the great object is that every aviator 
 be kept in r.he service. 
 
 When an airplane begins to show signs of trouble, it is taken off 
 the field and put in condition. This is the only way to keep a plane 
 in commission. When the flier shows the first signs of staleness, of nerv- 
 ous exhaustion, or of digestive disturbance he must be " overhauled " 
 by a medical expert. That distinctly American product — the Flight 
 Surgeon — bears the same relation to the flier that the mechanical ex- 
 pert bears to the airplane. 
 
 The airplane is in need of frequent overhauling ; the flier even more. 
 The secret of prolonged usefulness of any aviator is that he be kept 
 constantly fit. The Flight Surgeon, by both old and new diagnostic 
 methods, supplemented by his knowledge of the peculiarities of the 
 individual flier, is able to detect very early, the signs of deterioration. 
 The corrective measures to be applied will belong to one of three 
 classes. They are medical, physical, and what we may term nutri- 
 tional. The medical needs constitute especially the problem of the 
 Flight Surgeon. In order to supplement his work and take care of the 
 physical needs of the flier, there have been secured for the Aviation 
 Service the services of experienced college trainers. These men have 
 been given a course of instruction covering the special aspects of 
 physical training as it applies to the care of the flier, and have then — 
 as Physical Directors — ^been sent out to each flying field to assist the 
 
AIR SERVICE MEDICAL MANUAL. 15 
 
 Flight Surgeon. These Physical Directors fill a special need in the 
 work of " maintenance " in that they bring to this service the practical 
 experience already derived from the handling of athletes in colleges 
 or athletic clubs. 
 
 In order to handle most successfully the third class, namely, nutri- 
 tional problems, the services of the Nutrition Officer are required. 
 The Nutrition Officer must be a man well trained in the knowledge of 
 food values in relation to the body and he, under direction of the 
 Flight Surgeon, is charged with not only the problem of the proper 
 feeding of the normal flier, but especially of the flier suffering transi- 
 tory digestive disturbance — a type of defect that affects greatly the 
 efficiency of the flier when in the air. 
 
 The work of the Air Medical Service reached its culmination 
 with the placing of a Flight Surgeon in each flying school in the United 
 States where his work in the " care of the flier " has been but a prepa- 
 ration for the larger service to the aviator who is actually on the 
 fighting front overseas. It is only through the complete Flight 
 Surgeon Service, including those features supplied by the Physical 
 Director and the Nutrition Officer, that the flier may be maintained 
 at his full efficiency in active service. 
 
CHAPTEE II. 
 THE SELECTION OF THE FLIER. 
 
 When it was announced that a state of war existed between the 
 United States and Germany, it at once became apparent that a tre- 
 mendous number of aviators must be secured for the military service 
 within the shortest possible space of time. The medical problem 
 consisted of selecting thousands of physically acceptable men for avia- 
 tion and placing them in training for war service immediately. 
 
 It was found necessary to decide upon new methods of physical 
 examination and to adopt new standards of physical qualifications 
 for this branch of the .service. Before our entrance into the war con- 
 siderable thought had been given to the problem of what should 
 constitute the physical requirements for admission into the aviation 
 service, and medical officers had been in conference with other mem- 
 bers of the medical profession who were interested in this question. 
 Due consideration also had been given to the study of the require- 
 ments formulated by England, France, and Italy, and also Germany. 
 The examination according to amended blank 609, A. G. O., was put 
 into operation in May, 1917, and it is worthy of note that this same 
 series of tests remains unaltered, even to the minutest detail, up to the 
 present time. 
 
 The judgment applied to the original selection of those to consti- 
 tute the Air Fighting Force of the United States was not based upon 
 an attempt to decide whether or not the individual selected would be 
 able to fly. It was known that men had been able to fly in spit© of 
 one or more physical handicaps, such as having only one leg, having 
 one eye, having tuberculosis, or being cross-eyed, or having one col- 
 lapsed lung, or being well over 50 years of age. Instances were at 
 hand of those so handicapped who had been able to learn to fly and 
 to fly well. Ultimate economy as well as immediate efficiency indi- 
 cated unquestionably the wisdom of admitting to training only the 
 very best material. The enormous number of applicants at hand 
 made it possible to maintain the highest standards in selecting men 
 for this service. It had been demonstrated by the experience of our 
 Allies that careful selection would avoid the expense, in time and 
 money, of training large numbers of those who would not make good 
 in the service. Furthermore, our measuring stick was chosen in 
 anticipation of peak-load requirements. It was realized that each 
 man entering the flying service might be called upon to negotiate 
 89120—18 2 17 
 
18 
 
 AIR SERVICE MEDICAL MANUAL. 
 
 • m - »- =-:r^ =-~ 
 
 
 LOOPING. , . , ^ ,. 
 
 Success in looping impossible if the aviator has any "mental twists. 
 
AIR SERVICE MEDICAL MANUAL 
 
20 AIR SERVICE MEDICAL MANUAL. 
 
 critical emergencies in the air; that insufficient oxygenation coupled 
 with prolonged nervous tension under high altitude combat condi- 
 tions, actual injury, sudden changes in circumstances demanding in- 
 stant decision and action, would require of him the utmost mental 
 and physical capabilities. 
 
 It is only right that we should supply for our air fighters as good 
 if not better planes than those used by the enemy. In the same spirit, 
 it is our duty to bear in mind that when an American aviator meets 
 a German aviator the outcome of the encounter may easily depend 
 upon which of the two possesses the better vision and other special 
 senses, the better nervous system, and the better mental and physical 
 equipment in general. The flier starting for the enemy's lines car- 
 ries with him a certain potential disaster for the Hun. The one-eyed 
 man may succeed ; the possession of tvro eyes, however, would render 
 success more certain. The responsibility of the Air Medical Service 
 in the selection of the flier is that no aviator shall fail in his mission 
 against the Hun because of discoverable physical defect 
 
 In order to make the examination of standard character, it was 
 necessary to make the tests practicable of application in all parts of 
 the United States without at the same time in any way lowering the 
 requisite rigid standards or lessening the completeness of the exami- 
 nation. This could be attained only by (1) the standardization of 
 the tests and (2) the standardization of the examiners . • To accom- 
 plish this, a medical officer was sent to each of 35 cities throughout the 
 United States, with the result that in each one of these cities there 
 vx^as established a medical unit for the examination of applicants for 
 the Aviation Service. The requirements of the examination were 
 fully explained to each unit, so that not only the same equipment was 
 used, but also exactly the same technique. This made it impossible 
 for any applicant to say, " I wish I had been examined in a certain 
 city where the tests are easy, rather than in a certain other city where 
 the tests are exacting." Those specialists were selected who were 
 most expert in the practice of their chosen work; where a new type 
 of examination was essential, such as the turning-chair tests, those 
 otologists were selected who were familiar with these tests, and, in 
 addition, they were given intensive training by medical officers sent 
 for the purpose of establishing a uniform technique. Thus in a fe"v^' 
 months the examination was put on a uniform basis in all Physical 
 Examining Units. 
 
 In order to save time, alreadj^ existing institutions, such as large 
 hospitals or State universities, with their equipments, were utilized 
 as these examining centers. Volunteer staffs of civilian consultants 
 were locally organized and the work of the Physical Training Units 
 systematized to a point of highest efficiency, with the result that 
 
JUST MISSING A FLAGSTAFF. 
 
 Prompt action, intelligently executed, saved this flyer and his machine from a crash. Fighting in the air 
 
 makes continual demands on such ability. 
 
 MAKING A PERFECT LANDING. 
 This requires perfect stereoscopic vision. 
 
 20»-X 
 
FIGHTING IN THE AIR MAKES THE MOST SEVERE DEMANDS ON PILOTS. 
 Only the most fit are chosen for this work. 
 
 CADET AMONG THE CLOUDS. 
 
 A situation in which vision is of little use. The "motion-sensing" portion of the interval ear must 
 
 be normal, or the pilot can'not detect movement normally. 
 20a-2 
 
AIR SERVICE MEDICAL MANUAL. 21 
 
 within a few days after the arrival of the medical officer the units 
 were ready for work. By this method of decentralization the ex- 
 amination of thousands of applicants in a minimum time was made 
 possible. Once it was assured that those charged with the responsi- 
 bility of conducting the examination were fully equipped and capable 
 of making the tests, full authoritj' was vested in the medical officer in 
 charge. Thirty-two military units, later established in the divisional 
 camps of the United States, attended to the examinations of the en- 
 listed applicants for air training. By far the majority of applicants 
 were civilians, however, and the 35 original units in the cities, each 
 examining from 10 to 60 applicants a day, soon provided the thou- 
 sands of men required. 
 
 Attention should be drawn to the contribution to the Government 
 war work represented by the vast amount of professional service 
 rendered without pay by the civilian members of these units. These 
 civilian consultants included many of the foremost specialists of the 
 United States ; were the services rendered by them to be represented 
 in terms of Liberty bonds, the sum total would constitute a verj- 
 respectable loan without interest. It is worthy of special mention 
 that in addition to the routine examining work of the units, the 
 members performed many hundreds of surgical operations enabling 
 the applicants to qualify physically for this service, without cost 
 either to the applicant or to the Government. 
 
 A public meeting was held in each city under the auspices of the 
 medical profession of that city. The mere establisliment of the units 
 was by no means all that was accomplished by the work of the Medi- 
 cal Department. Throughout the United States there was no lack of 
 interest on the part of the young men of the country to enter the 
 flying service. There was, however, a striking need for authoritative 
 information regarding the Aviation Service and how to go about 
 getting into it. A by-product of the establishment of the units was 
 the stimulation in each city of large public interest in this branch of 
 the service. In one city after the meeting 95 men expressed their 
 desire to enter this service. 
 
 In the rush of events after our entrance into the war not only was 
 there a lack of information regarding Air Service, but there was a 
 considerable amount of misinformation, most probabh' attribut- 
 able to German propaganda. Throughout the country was spread 
 the information that the average life of an aviator was only a few 
 hours of actual service. Parents were given to believe that their 
 sons were being taken for an almost immediate and inevitable sacri- 
 fice. Furthermore, there was not a citv in the United States in which 
 it was not firmly believed by the public that the much-discussed 
 medical examination of an aviator was a form of refined torture. 
 One story was that of the "needle test." This mythical examination 
 
22 AIR SERVICE MEDICAL MANUAL. 
 
 was supposed to consist of placing a needle between the candidate's 
 forefinger and thumb, blindfolding him, then shooting off a pistol 
 behind his ear. The examiner would then note whether, due to his 
 supposed lack of nerve, the applicant had pushed the needle through 
 his finger. Another much-rumored test was described as follows: 
 When the applicant least expected it he would be hit over the head 
 with a mallet, and if he regained consciousness within 15 seconds he 
 was qualified as being of the stuff of which aviators are made. It 
 was the medical officer who could supply the needed information 
 and also demonstrate the utter nonsense of this prevailing misinfor- 
 mation. In this way parents were assured by the Surgeon General 
 that their sons were put through only an ordinary physical exami- 
 nation to insure their fitness for the service, and that for their own 
 protection they would not be accepted unless physically sound. The 
 mystery of the examination was removed by actual demonstration, 
 aided by moving pictures. 
 
 At these public meetings were gathered those of the medical pro- 
 fession and general public who were interested in aviation. The 
 interest aroused within the medical profession by the work of the 
 Physical Examining Units also resulted in bringing into the Air 
 Medical Service a large number of specialists whose training in the 
 examination of aviators fitted them later for a larger sphere of use- 
 fulness in the care of the flier. 
 
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 23a-4 
 
CHAPTER III. 
 CLASSIFICATION. 
 
 The flier, who through good training has become perfect in his 
 technique and who through proper care is physically fit, is not neces- 
 sarily fitted for all types of air activities. When the present war 
 first began, there were but few airplanes and what airplanes existed 
 were used for all kinds of work. If an airplane and a man could 
 stay in the air, they were used for any service which an emergency 
 might call for. On one day the pilot might be asked to go across 
 the lines on a reconnaissance mission and with the same machine, 
 which was very limited in climbing ability and speed, he would be 
 called upon the following day to go into the air to fight. 
 
 With the coming of improved designs and the more skillful manag- 
 ing of airplanes by fliers, different types of machines have become 
 classified into special groups for special work. The flying service is 
 now highly specialized. Men are called upon to perform widely 
 diversified classes of work, such as pursuit or scout work, recon- 
 naissance, photography, day or night bombing, artillery observation, 
 ynd for each of these special missions the pilot is provided with a cer- 
 tain type of plane adapted to the work in hand. 
 
 Both the enemy and ourselves divide the machines used for service 
 into two distinct classes; we have both the fighting machines which 
 are a fast, quick-climbing type, easily and quickly maneuvered, and 
 heavier machines which are slower in action and capable of carrying 
 almost any weight. 
 
 It is easy to see that a fast-climbing machine is bound to carry 
 the pilot to greater heights than the slow, weight-carrying machines. 
 Whereas in 1915, flying rarely exceeded 8,000 or 10,000 feet, through 
 improved designs scouts of to-day climb to altitudes even as high as 
 25,000 feet, and this height is attained in a very short space of time. 
 The nature of the work of a scout, which is simply hunting out the 
 enemy and attacking him, also necessitates descents from high alti- 
 tudes at tremendous speed. 
 
 Night bombing has been carried out at altitudes as low as 300 
 feet. Day bombing, in order not to reveal the objective of the flight 
 and to guard against concentrated anti-aircraft fire, may call for 
 flights at very high altitudes. The possible necessity of attaining 
 
 23 
 
24 AIB SERVICE MEDICAL MANUAL. 
 
 sucli altitudes presents a nice problem when we consider the weight 
 of bombs which must be carried, together with the protective equip- 
 ment with which the plane must be loaded. Reconnaissance ma- 
 chines rarely get to high altitudes owing to the necessity for more or 
 less close observation of the ground, and machines doing this work 
 must accomplish very low flying even in the face of highl}^ concen- 
 trated anti-aircraft fire and enemy activity in order to fulfill their 
 mission. Machines cooperating with the artillery which have to 
 make range corrections for batteries do not often work above 6,000 
 or 8,000 feet. From this we can see that the machines doing the types 
 of work just mentioned, except day bombing, fly very much lower 
 than the pursuit or scout planes. With their capacity for carrying 
 a larger amount of fuel, they can remain in the air for very long 
 periods. When a long trip is to be made, such as a bombing raid far 
 into the enemy country, at least four or five hours must elapse and 
 the pilot is apt to be fatigued to the limit of his endurance. Espe- 
 cially is this the case in cold weather and under the long strain of 
 an extended flight encountering anti-aircraft fire and enemy planes. 
 
 Pilots of scout machines, on the contrary, owing to the speed and 
 climbing abilitj^ possessed by planes built for this type of work, never 
 stay in the air much over two and one-half or three hours on account 
 of being unable to load up their machines with more than a moderate 
 weight of fuel. But they have to go to tremendous heights, they have 
 to change those heights very quickly and very often, and they are 
 subject to quick changes of temperature as well as sudden variations 
 in oxygen content of the air. 
 
 In view of these facts the Air Medical Service realized the im- 
 portance from a purely military standpoint of careful classification 
 of fliers. The work of the Medical Research Laboratory has demon- 
 strated that of each 100 carefully selected fliers only 61 are physically 
 and mentally capable of attaining an altitude of over 20,000 feet 
 with safety; 25 out of each 100 are physically and mentally unsafe 
 at altitudes above 15,000 feet; and 14 out of each 100 are physically 
 and mentally unsafe at altitudes above 8,000 feet. Or that 61 of 
 the 100 are fit for any type of air work; that 25 may do bombing; 
 that 14 should be limited to reconnaissance or night bombing. Such 
 classification of pilots for specific duties constitutes a new factor of 
 conservation and safety to our forces. 
 
 The feature of knowing the limitations of a valuable man spell 
 increased efficiency. 
 
 Just as the pilot is provided with a certain type of plane adapted 
 to the work in hand, so the plane must be provided with a pilot 
 adapted to the work in hand. 
 
 It is true that in the absence of a pilot physically and mentally 
 adapted for high-altitude work it is possible to use one who is 
 
AIR SERVICE MEDICAL MANUAL. 25 
 
 adapted only for low-altitude work by equipping him with an 
 apparatus to supply oxygen according to his needs. Supplying 
 oxygen to fliers has been a subject of much experiment and study 
 during the past two years both by the enemy and by the allies. 
 The British have used an oxygen apparatus of satisfactory type for 
 two years — the Dreyer Apparatus. This type of apparatus is being 
 produced in the United States in increasingly large numbers, and at 
 the same time modifications and improvements are being constantly 
 made. In the very nature of things, however, it is impossible to count 
 upon adequate and ready-to-serve oxygen supply for each aviator in 
 each machine which emergency may send into high altitude. Until 
 the final absolute perfection of oxygen apparatus for the flier and the 
 equipping of each high-altitude plane has been accomplished, cogni- 
 zance must be taken of altitude rating of the flier in " selecting the 
 man for the job." 
 
 Physiologic studies on men undertaking to live at high altitude, 
 such as Pike's Peak, have proven that a very complex series of 
 changes occur before their bodies become able to live normally 
 with less oxygen. This is acclimatization, and this occurs m the 
 man living on Pike's Peak, but not in the aviator who alternates 
 constantly between high and low altitudes. 
 
 The flier must undergo abrupt changes in atmospheric pressure 
 and oxygen supply. Atmospheric pressure plays a very unimpor- 
 tant role ; the whole problem resolves itself into a deprivation of the 
 normal oxygen supply. The fact that there is " oxygen -want " at 
 high altitudes suggested that any piece of apparatus that would 
 permit the breathing of a reduced amount of oxygen could be used 
 to test the ability of men to withstand high altitudes. The Flack 
 bag was the prototype of the rebreathing apparatus which has been 
 developed in the Medical Research Laboratory and perfected for such 
 tests. By means of this apparatus the aviator rebreathes air con- 
 fined in a tank, from which he gradually consumes the oxygen. As 
 the percentage of oxygen decreases the aviator, in effect, is slowly 
 ascending to higher altitudes. In the course of 25 to 30 minutes he 
 lowers the oxygen content of the air in this tank to 8 or 7 per cent, 
 which is equivalent to attaining altitudes of 25,000 to 28,000 feet. 
 
 Another method of attaining the same result is by means of the 
 diluting apparatus, which supplies directly to a mask over the face 
 whatever proportions are desired for a mixture of air and nitrogen. 
 All of these tests have been standardized and confirmed by the low- 
 pressure tank, in which the air is rarefied to correspond to any given 
 
 altitude. 
 
 By a comparison of the percentage of oxygen to which the aviator 
 succumbs when on the low-oxygen tests it is possible to determine 
 precisely the altitude at which the aviator would fail were he in the 
 
26 AIR SERVICE MEDICAL MANUAL. 
 
 air. This determination is made on the gi"ound, without danger 
 either to the aviator or to his machine, and has been taken as the 
 basis for the classification of aviators now in use by the Medical 
 Eesearch Laboratories. 
 
 It may be noted that these tests of the ability of an aviator to 
 withstand oxygen reduction could not be made safely in the air, as 
 the effects of oxygen-want are insidious and often the aviator suc- 
 cumbs very suddenly and completely when his limit is reached. 
 
 The effect of low oxygen upon the mental processes of the aviator 
 varies greatly in the individual. The aviator usually becomes men- 
 tally inefficient at an altitude at which there is as yet no serious fail- 
 ure of his vital bodily functions. If he were sent to an altitude 
 which his heart could safely stand, his efficiency would nevertheless 
 suffer because his brain is not acting properly. By simple tests of 
 mental alertness during rebreathing it is easy to determine that one 
 flier becomes mentally inefficient at 15,000 feet, in sharp contrast to 
 another aviator who has his full mental powers up to and beyond an 
 altitude of 25,000 feet. 
 
 Low ox3^gen has a marked effect upon vision. Oxygen-want ex- 
 aggerates to a marked degree any existing defect of the eyes. In 
 many young healthy men the rebreathing tests made manifest eye 
 defects which may have eluded detection by the most expert exami- 
 nation. Crash reports have demonstrated that a large proportion 
 is due to such eye defects. Again, in night flying it is most impor- 
 tant that the flier shall be able "to see well in the dark." Many 
 aviators are able to fly well without any difficulty in the daytime, but 
 not at night. Laboratory tests determine definitely which individ- 
 uals possess the ability to see well at night. 
 
 " Stunting " is essentially an internal-ear problem. During and 
 after rapid turnings the flier's brain is receiving impulses from his 
 semicircular canals. Nothing can control or alter the sending or 
 receiving of these impulses. These imj^ulses produce sensations of 
 motion. Fliers vary greatly in their ability to interpret correctly 
 the significance of these impulses. Experience alone enables the 
 aviator to familiarize himself with the meaning of these impulses; 
 those who develop the greatest ability in this respect naturally fall 
 into the scout-pursuit class. Those who, in spite of training, are still 
 disturbed or bewildered by stunting should be reserved exclusively 
 for straight flying, such as bombing and photography. Again, the 
 peculiar demands of night flying, reducing, as it does, at times to 
 the vanishing point, information coming from the eyes, require a 
 type of flier who possesses the keenest ear sense for the detection of 
 movement. 
 
 The rebreathing test is also very valuable in determining staleness 
 in aviators. As staleness is caused by frequent exposure to high 
 
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 DREYER DILUTING APPARATUS. 
 
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 26a-4 
 
 VERTICAL BANK. SIDE SLIPPING— 2,000 FEET IN THE AIR. 
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AIR SERVICE MEDICAL MANUAL. 
 
 27 
 
 I 
 
 THE CHASE. 
 
 ™1 ^.,1-1 li. 
 
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 28 AIE SERVICE MEDICAL MANUAL. 
 
 altitudes, evidence of this is easily obtained by means of the rebreath- 
 ing machine. Where originally a flier was able to tolerate an alti- 
 tude of 20,000 feet or more before showing certain symptoms of stale- 
 ness, after flying for 100 hours or more, it is frequently found in re- 
 examination by means of the rebreather that he is stale and is unable 
 to tolerate the oxygen reduction equivalent to 10,000 feet. Incipient 
 cases of staleness are thus easily detected. The detection of the early 
 cases of staleness is of greatest importance in that it makes it possible 
 to ground a man for a certain period and thus enable him to recover 
 entirely, whereas if this condition is not diagnosed early it will pro- 
 gress until a point is reached where it is impossible for the aviator 
 to " come back " and his services as a flier are thus lost to the country. 
 ^Vhen the staleness becomes marked the aviator is very liable to faint 
 in the air, thus losing his life and wrecking his machine. By periodi- 
 cally examining aviators the first signs of staleness will be detected 
 early and measures can be taken to conserve the efficiency of those 
 who would otherwise be inevitably lost to the service. 
 

 
 
 
 
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 28a-4 
 
CHAPTER IV. 
 THE FLIGHT SURGEON. 
 
 The Flight Surgeon constitutes the ultimate "answer " to the main- 
 tenance problem of the Air Medical Service. 
 
 In the foregoing chapters has been presented the work of the selec- 
 tion of the aviator and of the classification of the aviator. The Air 
 Medical Service, however, does not end here. It is all very well to 
 have chosen with great care those hand-picked men who constitutt 
 our Air Force and, thanks to the enormous number of applicants, to 
 have adhered to the highest standards in their selection. It is all 
 very well to have medical specialists classifying fliers and deter- 
 mining their peculiar fitness for special branches of aerial activity. 
 This, however, by no means marks the limit of usefulness of the 
 Air Medical Service. The one immediate need of the military avi- 
 ator in all the services of the world is an organization for his up- 
 keep and care in actual service. After two and one-half years ol 
 bitter experience it was gradually borne in upon the allies that at 
 the end of a certain amount of continuous service the flier begins to 
 show unmistakable signs of deterioration, and the economical thing 
 to do is to relieve him temporarily from active flying. This was a 
 new thought in aviation. Up to that time it had been the practice 
 to keep the flier at it until he broke. His breaking was signalized 
 sometimes by simple failure to return from behind the enemy lines; 
 sometimes by becoming mentally and nervously so exhausted as to 
 be of absolutely no use ; at other times becoming so physically worn 
 out that even the casual observer would recognize his unfitness for 
 service. 
 
 The old method was to get as much out of a flier as possible, then 
 discard him as useless for further air service. The alumni of this 
 old school, although not all present, because of the graduation of 
 so many behind the enemy lines, are now represented by the hun- 
 dreds of " washed out " fliers from the Italian, French, and British 
 services that one meets in various ground activities in the flying 
 schools of America and Europe. 
 
 Many of these are unnecessarily wasted. Their loss to active serv- 
 ice could have been materially reduced by means of competent medi- 
 cal officers who, recognizing the early beginnings of deterioration, 
 
 29 
 
30 AIE SERVICE MEDICAL MANUAL. 
 
 could have taken them off in time to permit full recuperation and 
 restoration to active flying. 
 
 It is easy to sum up the various means by which a flier's usefulness 
 may be terminated. They are exactly three : 
 
 (1) The Hun. 
 
 (2) Failure of the engine or plane. 
 
 (3) Failure of the flier himself. 
 
 While it is not possible to arrive at exact percentages, estimates 
 based upon information from every source in Italy, France, and 
 Great Britain, interviews with commanding officers and medical ex- 
 perts in all the flying centers and at the various fronts, indicate that 
 not 2 per cent of the fliers lost to active service are put out by the 
 Hun. Failures of the airship are, at the present time, responsible for 
 very limited losses to the service, thanks to the inspections to which 
 they are constantly subjected. Two years ago this statement would 
 not have been true; the mechanical genius of the world has been 
 applied to make the airplane safer and with such effect that it hap- 
 pens onl^' rarely that the flier becomes useless through the fault of 
 the ship. Statements from all sources agree that of the total number 
 of fliers permanently out of flying service, not over 8 per cent have 
 been rendered unserviceable because of mechanical shortcomings of 
 plane or engine. When it has been stated that 2 per cent of the total 
 number of fliers incapacitated for further air service are put out by 
 the Hun, and 8 per cent because of mechanical shortcomings of the 
 airplane, the remaining 90 per cent looms large, when it is realized 
 that this proportion represents troubles in the flier himself. 
 
 After assembling all possible information, subjecting it to careful 
 study by competent experts and reaching definite conclusions, the 
 material so obtained has been put into shape for further training of 
 a corps of medical officers who have had opportunity to become 
 familiar with the Air Medical Service by actual experience in the 
 examination of applicants, the post-surgeon work in flying fields, 
 and the reexamination of fliers. This is the epitome of the develop- 
 ment of the flight surgeon idea. Through such a corps of officers, 
 established in the various flying fields, practical application can be 
 made of means and methods devised for the better maintenance of 
 the physical efficiency of the flier. Just as the Medical Department 
 of the Army has been able to wipe out typhoid fever, and made it 
 possible to construct the Panama Canal by the elimination of yellow 
 fever, so the Air Medical Service is destined to serve by prevention 
 of the crash rather than by " picking up the pieces " afterwards. 
 
 Medical officers of the various air services had observed that more 
 than half of the injuries sustained in crashes were caused by the 
 aviator striking his head against the cowl. It was suggested that 
 the cowl be cut out so as to give 8 inches more room in front. A 
 
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 30a-2 
 
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 30a-7 
 
 EXAMINATION OF FLIER. 
 

 MAJ. HITCHCOCK l.N I'lLUTS SKAT. 
 
 30a-9 
 
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 I 
 
AIR SEEVICE MEDICAL MANUAL. 
 
 31 
 
 DECOYED. 
 
32 AIE SERVICE MEDICAL MANUAL. 
 
 report just received from the Royal Air Force, Canada, states that 
 since this change in the cowl has been made these head injuries have 
 been practically eliminated. Another suggestion was to lash the 
 safety belt to the machine by a simple rubber shock absorber; the 
 same report states that since this has been done, the number and 
 extent of injuries to the upper abdomen and ribs have been de- 
 cidedly reduced. The problem, of protecting the flier against the 
 extreme cold of high altitudes in winter was solved by designing 
 electrically warmed clothing, thereby enabling him to continue his 
 flying under conditions, which, up to that time, had rendered it 
 impossible. The problem of enabling a flier to withstand the glare 
 of reflected sunlight above cloud banks and to enable him to pierce 
 camouflage was solved by furnishing him with the " Noviol " type 
 of goggles. During the first two and one-half years of the war no 
 attempt was made to compensate the flier for his lack of sufficient 
 oxygen in high-altitude work. There is one British squadron which 
 has used the Dreyer oxygen apparatus since January, 1917 ; a recent 
 report from the British front states that this squadron has been 
 performing six times the amount of work of any other similar 
 squadron which is not supplied with oxygen. 
 
 The above are examples of what has already been accomplished 
 towards reducing this " 90 per cent;" many other methods are now 
 being developed. Within the past few months has been perfected 
 an apparatus whereby cadets may acquire flying experience and 
 training without leaving the ground.* This machine is a modifica- 
 tion of the old-fashioned universal joint, composed of three con- 
 centric rings so pivoted together as to permit the fuselage, which is 
 pivoted within the innermost ring, to be put through every possible 
 evolution to be experienced in actual flying. This apparatus is 
 practically an airplane in every respect. The cadet sits in the fuse- 
 lage and by means of the joystick and rudder puts himself through 
 practically all the evolutions which he is later to experience in the 
 air. An analysis of the " crash reports " has shown that a remarkably 
 large number are solely due to a failure to come out of the spinning 
 nose dive or tight spiral. The only reason that the cadet has failed to 
 come out of these maneuvers is that he had not yet become accus- 
 tomed to these unusual movements. These evolutions stimulate the 
 internal ears which send nerve-impulses to the brain. The individual 
 has no control over these impulses; the only thing he can do is to 
 learn the significance of these impulses by experience. The problem 
 is extremely simple. All that is needed is that every cadet shall 
 " fly " the apparatus day after day until he is entirely familiar with 
 these new sensations. Any mistake that he makes causes him no 
 harm, because he never leaves the ground. He is then prepared to 
 
 ♦The Ruggles Orientator. 
 

 kl<;(;li:s uuientatok." 
 (Supplied througli tbe courtesy of the Naval Consulting Board.) 
 

 " RUGGLES ORIENTATOR." 
 
 (Supplied through the courtesy of the Naval Consulting Board.) 
 
 132-2 
 
■ KUGGLES OIUENTATOIt." 
 (Supplied throuffh the courtesy of tlif Naval Consulting Board.) 
 
< t c r ' 
 
 " RUGGLES ORIENTATOR." 
 (Supplied through the courtfsy of the Naval Consulting Board.) 
 
 132-4 
 
"RUGGLES ORIENTATOR." 
 (Supplied through the courtesy of the Naval Consu ting Board.) 
 
THE SIXTH SENSE. 
 
 (Diagrammatic.) 
 
 THE THREE SEMICIRCULAR TUBES CONSTITUTE THE 
 '•MOTION-SENSING" ORGAN. 
 
 The internal ear or labyrinth consists of a bony and a membraneous part, the latter contained in the 
 former. The bony labyrinth is composed ofthe vestibule, the semicircular canals, and the cochlea. 
 These three canals constitute what is known as the static labyrinth. The bony canals contain the mem- 
 branous canil, an 1 the membranous canil, in turn, contains the endolymph, which is a fluid that 
 fills the membraneous canal. This posterior part of the internal ear is constructed .solely for the detec- 
 tion of movement, anl constitutes the special sense organ of "motion-sensing". Man is acquainted 
 ■with movement through this organ by the flowing of the endolymph within the canals. 
 
 HUMAN TEMPORAL BONE, NATURAL SIZE, INTERNAL OR BRAIN SURFACE; SHOW- 
 ING INTERNAL EAR CONSISTING OF COCHLEA (a), THE SUPERIOR AND POSTERIOR 
 SEMICIRCULAR CANALS (b and e) MHICH HAVE BEEN EXPOSED BY REMOVING 
 PORTION OF THE BONE. 
 
 (Actual photograph.) 
 32a-6 
 
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 32a- 
 
83 
 
 AIK SERVICE MEDICAL MANUAL. 
 
 .■ " in the air Flying training by this " ground 
 ..ndertake " stunting n the ai^ y »^ ^^^^ ^^^^^^.^^^ supervision 
 
 training flying apparatus ■^'^""'"J j^ g; j.^ surgeon. 
 
 of the ollicer in charge of flying and the mg ^ _^^^^^^ ^^ g^^^g 
 
 Anotlier method of educating the «.det ^ J ^^^ ^^^^,^ 
 
 calisthenics. By daily '— ^ »i~on becomes accustomed 
 
 -"" "\""' .:,rtr:t :^t w, -111 h; had previously been un- 
 to positions ana n.o\uiit-"" 
 
 accustomed. . overseas means an expendi- 
 
 men we '-^f"^^^!*^* -as represented by his training m the 
 ture of upwards f . ^^O'""^" ..^". 'J,„o, by the employment of air- 
 ground school and ni the fl>;"8 *;°'' J ^eir upkeep, as well as 
 planes and the necessary n^"^';^; ^^ ,„d transportation- 
 his personal expense t^ the ^''^""^^^t^rian standpoint, there is a 
 „e realize that, apart f™" ^-^j^fj^p,, care of this tremendous 
 purely military aspect wh^h ^^^^'^„m, buman material 
 financial investment. This sa^ mg ,oviding a specially 
 
 and money can be »<:™'"l'l^^^>'^'^,.™f,Ss„r to the Commanding 
 ii-ained medical "f -^ ^'^^ ^.^ of " — ing the mental and 
 
 '^ '^: m^^if^bif ;SL, the general ^« .nth^^ed th^s^n^^ .ade 
 in the tables of organization, the W ^ur ^^^ ^^.^.^^^ 
 
 nr;S ro^S t^ ^StlL nmted state, and the 
 others for overseas service »« M«lcd. ^ ^^^ ^^ ^^^■^^. 
 
 Specifically, "the duty of *«/ ^f ^Is and squadron groups, 
 to the Commanding Oftcer of ^^'"8 f™" f^,,^ao.n of independent 
 Although under the Post S-f--,^- j^f a ators or cadets. Sub- 
 initiative in all questions of Aj^^S 6 ^^^ ,., ^ expected to m- 
 ject to the approval of the <;'7'"f " '"'"^^ation, and temporary ex- 
 stitute snch measures as P»™''^^f ^^^''^s*!^- «» takes sick call 
 cuse from duty, as may seem to ^im a^.isao ^^ ^^^^ 
 
 for aviators and -'j^ts aiul .-coX« *^^^^ 
 
 excused from duty. He w HI MSit snc ^^ physician 
 
 at the post and consult with ^^\^l^''^^^^^,,^,„„rmev<.^xo.min^- 
 vegarding them. From time '« '""\^ ,7 J^Xrexaminations as he 
 tions of aviators and cadets; ako « h spec ^^^^.^^^^ ^^ ^^^ 
 
 , may deem advisable, being ^f'^^fj^^'^^ ^^^ ,i^, ;„ as close touch 
 
 ^ Branch Medical Eesearch I^*°™"'3'-.„„\7is consistent with the 
 with the fliers and cadets at his station as 
 
 conditions." 
 
 89120—18 3 
 
34 AIR SERVICE MEDICAL MANUAL. 
 
 " Each Flight Surgeon will have as an assistant a Physical Director, 
 whose duty is to supervise such recreation and physical trainiug of 
 aviators and cadets as is considered necessary. He will live and mess 
 with the cadets, keep as closely in touch with them as possible, stud}' 
 their habits, temperaments, and physical fitness, and advise the 
 Flight Surgeon in all matters regarding these points." 
 
 So much for the official routine ; it needs but a glance at the many 
 activities suggested to realize that back of this order was a great 
 need — the daily care and watchfulness over the aviator. 
 
 The medical study of aviation is so new that unless a medical 
 officer has been specially trained for the aviation service he can have 
 no idea whatever of the methods of making diagnosis of the ills 
 peculiar to flying. For this highly specialized phase of medical 
 work the Flight Surgeon must have certain special qualifications. 
 For this reason the greatest care has been exercised in the selection of 
 each Flight Surgeon, as it was recognized that the entire success of the 
 work depended upon the personality, experience, and diagnostic skill 
 of the medical officers selected for this special duty. 
 
 Ideal material for Flight Surgeons became available when a large 
 number of Plwsical Examining Units completed their work. Those 
 medical officers were chosen who had had large experience in examin- 
 ing hundreds or thousands of applicants for the service. From this 
 group were selected those whose personality was such that they could 
 not only command the respect but the confidence of the individual 
 aviator. This is essential. The efficient Flight Surgeon is one whose 
 personality is such that the cadet, flying officer, or aviator at the 
 front, feels that he has, in his Flight Surgeon, one to whom he can go 
 Avithout restriction — in the same spirit with which, in civilia)i life, 
 he was accustomed to consult his family physician. When a prospec- 
 tive Flight Surgeon had been selected for his exceptional ability and 
 knowledge of the special diagnostic tests, and for his personality, he 
 was then sent to the Medical Research Laboratory at Mineola, Long- 
 Island, where he received intensive training in those special tests with 
 which he had not yet become familiar in his original examining 
 work. 
 
 The Flight Surgeon was also given adequate opportunity to acquire 
 actual flying experience both at Mineola and at the flying fields. 
 This enabled him to supplement his other special preparations for 
 his own peculiar work with the much needed first-hand " knowledge 
 of the air." Permission has been granted by the Director of Military 
 Aeronautics for these officers, among others, to take regular ground 
 and air courses of instruction in flying, and many of the Flight Sur- 
 geons have already (pialified for R. M. A. Actual flying is of great 
 value as an additional aid in rendering the Flight Surgeon better able 
 
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 MAJ. WM. R. REAM, THE FIRST FLIGHT SURGEON 
 TO BE PUT ON FLYING STATUS. 
 
 MAJ. REAM IN HIS PLANE. 
 
 34a-S 
 
AIR SERVICE MEDICAL MANUAL. 
 
 35 
 
 to realize and cope with the peculiar conditions and ills incidental 
 <"'^> aviation. 
 
 .t the Medical Research Laboratory he was enabled to secure all 
 tile up-to-the-minute information regarding the e3'e, ear, nose and 
 throat, cardio-vascular, physiologic, psychiatric, and psychologic 
 work. Of the new problems taken up at the Medical Research Lab- 
 oratory, studies in psychiatry were of peculiar importance. No Flight 
 Surgeon can adequately diagnose an aviator's condition Avho has not 
 the ability to determine the mental condition of the individual. If 
 ftn aviator is having sleepless nights, worr3dng over financial problems, 
 anxieties regarding the wife at home who is about to become a mother, 
 or other anxieties of everyday occurrence in human life, it is not sur- 
 prising if we find that he is not in fit condition to fly. It has been 
 repeatedly proven that if the aviator who has Ijeen flying badly under 
 such a mental handicap, tells his troubles to an intelligent and sympa- 
 thetic listener, he is almost invariably able to '' get hold of himself,'" 
 after which he goes out again and flies well. The Medical Research 
 Laboratory provides instruction in all these essential branches: after 
 a course of four or five weeks of such intensive instructions the Flight 
 Surgeon is then sent to work among the aviators, under actual service 
 conditions. 
 
 It has become evident during the past nine months through activi- 
 ties of nutritional survey parties of the Food Division, Surgeon Gen- 
 eral's Office, that there is great need in each aviation camp for a 
 Nutrition Officer. Stated in the briefest terms the needs for his serv- 
 ices are these : 
 
 The strain on the flier — especially the mental strain — is great. 
 He is very susceptible while on flying duly to influences that would 
 ordinarily not aft'ect him at all. To reach and maintain his maximum 
 efficiency requires his being in the best ph3'sical and mental condition. 
 In peace times, under conditions where neither life and death nor 
 great ideals are at stake, a "training table" is maintained for club 
 or college athletes. This is done because it is recognized that im- 
 proper feeding may reduce a man's efficiency, or even put him " out of 
 the running " in a contest in which his best is required to win. In 
 the case of the flier w-e are concerned, when he goes up, not only with 
 questions of life and death and ideals, but with the fact that he, more 
 than the average athlete, depends for success upon clearness of mind, 
 quickness of thought, keenness of judgment. All these are mental 
 faculties, not muscular. The nervous system is more highly differ- 
 entiated than the muscular system, and by reason of that fact more 
 easily upset by improper food. 
 
 For the highest efficiency of the flier there is required some form 
 of training table. At times when he is slightly unfit, with headache, 
 constipation, etc., this is doubly needed. A Nutrition Officer with 
 
36 AIE SERVICE MEDICAL MANUAL. 
 
 special training in knowledge of food values should supervise the 
 messes of all students and officer fliers in order to keep up the effi- 
 ciency of the fliers and prevent as far as possible the development 
 of digestive ailments of even minor character. But in addition to 
 this, everj' flier who develops a digestive disorder should constitute 
 a special problem for the Nutrition Officer so that he may become 
 " fit " again at the earliest possible, moment. With such food super- 
 vision the general efficiency of the fliers can be raised definitely, the 
 number of hours per month that these men are fit for flying duty 
 increased, and finally the danger to both life and equipment of the 
 flier greatly reduced. 
 
 With expert supervision of the flier's nutrition and exercise, sup- 
 plementing his own professional knowledge concerning flying and 
 the aviator, the Flight Surgeon neglects nothing of a practical value 
 which can be used in maintaining in the highest degree the physical 
 efficiency of the Air Fighting Force. 
 
 Without exception the Commanding Officers of the aviation fields 
 have welcomed the advent of the Flight Surgeon. They realize the 
 tremendous responsibility of sending a man into the air who may, 
 at the time, be mentally or physically unfit for flying. No Command- 
 ing Officer has, for the sake of a large record, ever shown a tendency 
 to force his men into the air. From a military standpoint they re- 
 alize that an attempt to escape duty on the part of an aviator is an 
 altogether different matter from such an attempt of men enlisted in 
 other branches of the service. The Commanding Officer, or officers 
 in charge of flying, who are constantly observing their men in flight, 
 sense certain transitory changes in a man's condition which impair 
 his air efficiency. They are often called upon to ground such a man 
 or relieve him from duty. It is not to be wondered at, therefore, 
 that they welcome the support of the Flight Surgeon who adds a 
 medical knowledge to their own, which after all is based upon ex- 
 perience alone. The Flight Surgeon, in addition to maintaining at 
 the highest point the physical efficiency of the flying force of 'a 
 command, is prepared at any time to furnish to the Conmianding Offi- 
 cer a reliable expert opinion as to each individual's mental and physi- 
 cal fitness for flying duty. 
 
I 
 
•...• • 
 
 •.* . • . • • •• • • !,• *, • • 
 
 INDEX. 
 
 Page. 
 
 Air service, policy of placing worn-out men in 11, 29 
 
 Air superiority held by Germans during early stages of the war 10 
 
 Airplanes: 
 
 Altitudes attained by 23 
 
 Development of, among the allies, a story of sportsmanship 10 
 
 Extraordinaiy development due to necessity arising from actual warfare. . 10 
 
 Failures of, responsible for limited losses 30 
 
 Interest in, by European nations, when first invented 10 
 
 Losses of, responsibilities for 30 
 
 Progress in development of 7, 10 
 
 Realization of the possibilities of the airplane as a factor in battle 10 
 
 Altitudes, liigh: 
 
 Proportion of fliers capable of attaining 24 
 
 Rebreathing apparatus for attaining 25 
 
 Apparatus for acquiring experience and training without leaving the ground ... 32 
 Aviators: 
 
 Altitudes capable of attainment, by 24 
 
 Carelessness in selection of, in early stages of war 11 
 
 Classification of, as to fitness for different types of air activities 14, 23 
 
 Flier at the front safer than infantryman in trench 11 
 
 Low oxygen, effect of, upon mental processes 26 
 
 Low oxygen, effect of, upon vision 26 
 
 Ninety per cent of losses due to physical defects 30 
 
 Oxygen, apparatus for supplying 25 
 
 Physical fitness of 13 
 
 Proportion of fliers capable of attaining high altitudes 24 
 
 Selection of, method of 17 
 
 Study of, as an individual 13 
 
 Though physically fit, not necessarily fitted for all types of air acti\'ities. . 23 
 
 Charts 8, 9, 18, 19, 27, 31 
 
 Classification as to fitness of fliers for different types of air acti\dties 14, 23 
 
 Cowl, change in, to avoid injuries in crashes 32 
 
 Dreyer oxygen apparatus 32 
 
 Electrically warmed clothing 32 
 
 Examination, physical, of applicants, form used 17 
 
 Flight Surgeon, duty of 14, 29, 33 
 
 Goggles, " No\-iol " type of, furnished 32 
 
 Medical units, establishment of, for examination of applicants 20 
 
 Mental processes, effect of low oxj^gen upon 26 
 
 Nutrition officer, duties of 15, 35 
 
 Oxygen: 
 
 Apparatus for supplying 25 
 
 Low, effect of, upon mental processes 26 
 
 Low, effect of, upon ATsion 26 
 
 Physical director, duty of 14, 34 
 
 37 
 
38 INDEX. 
 
 Physical examinations: Page. 
 
 Medical units for examination of applicants established in 35 cities 20 
 
 Methods of, in selection of fliers 17 
 
 Form used in 17 
 
 Uniform tests throughout all examining units 20 
 
 Shock absorber for use in lashing safety belt to machine 32 
 
 Staleness in aviators, rebreathing test in determining 26 
 
 Stunt flying 26 
 
 Uniform tests throughout all physical examining units 20 
 
 Vision, effect of low oxygen upon 26 
 
 Wright biplane, interest in, by European nations when first invented 10 
 
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