He stated that the flight surgeons had maintained a sympathetic but firm view on the subject. They believed that they could carry a normal combat crew through a tour of combat duty and return them to the United States through "honorable channels rather than devious back door means." The only thing needed was a policy as to what constituted a normal tour of operational duty. It was believed that if a tour of duty could be announced it would be possible to increase the operational efficiency of the organization, but to that time Headquarters, Army Air Forces, had refused to approve a fixed, announced policy as to what constituted a normal tour of duty.

Health and Fighting Effectiveness: China, Burma and India

Very limited data pertaining to the health of the XX Bomber Command are available. Table 94 shows a comparison of the XX Bomber Command, as a whole (as well as separately for its forward and rear areas), with the total theater for the period June-December 1944.

During the reported period, the XX Bomber Command accounted for 10.7 percent of the strength in the theater, of which 13.6 percent of this strength was in a forward area.

Data pertaining to the incidence of all conditions are not known; however, the relative frequencies of malaria, gastro-intestinal diseases and venereal diseases indicate these diseases to have been of major importance in the theater. Incidence of all three conditions was lower for the entire period for the XX Bomber Command than for the theater as a whole.

The incidence rate of malaria in the entire XX Bomber Command did not exceed that for the theater as a whole in any month. However, the "Forward Area" portion of the XX Bomber Command did report higher malaria incidence rates in July, August, and September than for the theater as a whole, with the peak rate (809.66) in August being more than 21⁄2 times the rate for the theater as a whole.

The occurrence of simple diarrhea in epidemic proportions in the rear area of the XX Bomber Command accounted for the reported higher incidence rates for the XX Bomber Command in June and July than those reported for the entire theater.

Venereal disease incidence rates were consistently lower in the XX Bomber Command than in the theater as a whole. However, higher venereal disease incidence rates were reported for the forward area section of the XX Bomber Command in November and December than for the theater as a whole during these months.

The noneffective ratio here represents the proportion of troops remaining in the theater who were not available for duty because of medical reasons, and does not account for patients generated within the theater and evacuated to other areas for treatment. It appears that the noneffective ratio of 13.81 per thousand in June 1944 could have been due to more patients having been transferred out of the theater, and that the establishment of more adequate facilities within the theater accounted for some portion of the reportedly higher noneffective ratios in subsequent months. In any event, noneffective ratios shown separately for the "Rear Area" and the "Forward Area" and for the XX Bomber Command as a whole have the same limitations as for the theater as a whole, i. e., the noneffective ratios are more likely indices of the availability of medical facilities than indices of the health of troops."

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In the spring of 1945 the XX Bomber Command completed the first systematic study of a series of 48 casualties sustaining injuries all of which were directly attributable to enemy weapons. In this series it was determined that approximately 50 percent of all injuries received by combat crew members were caused by 22 mm. shells. A total of 70 percent of all wounds were caused by either 20 mm. shells or anti-aircraft. Machine gun bullets accounted for less than 8 percent of the wounds. Only one wound could be attributed to aerial phosphorous bombs. Table €95 shows a compilation of all wounds as to cause.

TABLE 95.-Direct Cause of Wounds in Forty-eight Wound Cases

Wounds received by combat crew members were almost evenly distributed over the body, although approximately 70 percent involved wounds of the extremities, head, face and neck. No statistics were available to determine the number of wounds prevented by the use of flak suits and helmets, but the small number of wounds involving the trunk and abdomen would indicate that adequate protection was furnished by the flak suit. Of the 30 percent of the wounds received on the trunk and abdomen, approximately 80 percent of these were received on either the right or left side of the body, areas not protected by the

flak suit. There was approximately an equal distribution of the wounds between the right and left sides of the body.

Approximately 55 percent of all wounds received involved gunners, with about 42 percent of all wounds received involving either the Right, Left or Senior Gunner, all of which were located in the Central Fire Control section of the aircraft. The injuries were approximately equally distributed among all three gunners' positions. It was not determined why those persons riding in this section of the ship should be more susceptible to injuries than those in other sections of the ship. Moreover, this distribution of injuries to these crew members was difficult to explain in view of the fact that the majority of enemy attacks had been high frontal, at either 1100 or 1300 o'clock. Table 96 tabulates by position the wounds received by crew members.

The majority of the severe wounds were caused by either 20 mm. shells or anti-aircraft and flak. Machine gun bullets caused wounds of a more severe nature in a higher proportion of cases than other types of missiles. Table 97 indicates the severity of wounds in a series of 43 cases. Those wounds on this chart that are classified as "Unknown" in all likelihood were of a superficial or minor nature.

It was determined that flak suits were not worn in 12 cases where wounds were received, and in 19 cases involving head wounds the flak helmet was not worn. Nine of the 19 cases could have been prevented or alleviated by the proper wearing of the flak helmet.

From the findings of this first systematic report in the XX Bomber Command it was concluded that the majority of wounds incurred by combat crew

TABLE 97.-Severity of Wounds Tabulated as to Cause

members were directly attributable either to 20 mm. cannon shells or to flak. The majority of wounds were received by either the Senior Gunner, Left Gunner, Right Gunner, or Tail Gunner, with the wounds approximately equally distributed among these four crew positions. It was believed that approximately 25 percent of wounds received could have been prevented had the flak suit and helmet been worn properly.

Withdrawal to the Pacific

During the summer and fall of 1944 the XX Bomber Command had to depend more and more upon Air Transport resources to carry supplies across the Hump and it became increasingly clear that China-based missions were logistically unsound. Moreover, the problems associated with construction and maintenance of airstrips and other facilities, together with the oncoming winter season, aggravated the situation in the Chengtu area. As a result, missions were based during the late winter season in India and the China bases abandoned.

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Meanwhile, at the Joint Chiefs of Staff level, plans were taking shape for the ultimate withdrawal of XX Bomber Command personnel to the Pacific. The Command historian notes that this "didn't catch the men of the XX Bomber Command with their plans down"; " nor did it catch the Command Surgeon unaware. In a letter to the Air Surgeon in late December 1944, he

I am convinced that we should handle our own hospitalization (Station Hospitals). I am also well aware of the politics involved and the attitude of the Surgeon General on matters