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LETTERS AFTER LOOK

MY PATIENTS

LETTERS FROM PATIENTS

NARRATIVE
IN PROGRESS

Practicing neurosurgery in a community west of Boston came after studying and
training in four cities. The geographic cycle had come full circle,
Born and raised in and outside of Boston, undergraduate studies in
Cambridge, medical school in St. Louis, general surgical training in
Baltimore and  neurosurgical residency in Boston, work in
Stockholm both as a medical student and as a physician.

The two most intense years in my career came during service in the United States
Army in Asia during The International Armed Conflict in South Vietnam.

The following is very much a work in progress as I reflect on my life and
the times during which I practiced neurosurgery both as a civilian and
as an officer in the United States Armed Forces. This text is a rough
draft that will be often revised until I am satisfied that the finished
narrative is the best I can produce.

Many of the graphics are heart-wrenching and horrible to behold, but they are pictures
of some of the best young men of that generation.

The draft notice arrived in May of 1967, shortly before my thirty-fourth birthday.
I reported to an army facility in South Boston for a physical examination and
was pronounced fit for service. I was ordered to report to Fort Sam Houston
in San Antonio, Texas in August.

The International Armed Conflict in Vietnam was continuing with no clear end in sight. 
Doctors were needed and the draft provided them. The previous year 3,692 were commissioned.
The numbers would gradually decrease as our nation disengaged from the conflict,
2,229 in 1967, 1,126 in 1968, 246 in 1969. The draft ended in 1973.

The total number of U.S. military members killed in The International Armed Conflict in Vietnam
from 1959 through 1975 was 58,169.

At the time of the dedication of The Vietnam Veterans Memorial Wall in 1982 only 57,939 names appeared.

The time span for inclusion on The Wall then extended from November 1, 1955 to May 15, 1975.

As of May, 2018 there were 58,320 names on The Wall.       

In April, 1966 Secretary of Defense Robert McNamara had proposed

constructing a "fortified barrier" south of the Demilitarized Zone

(DMZ), the line of demarcation between North and South Vietnam, to

interrupt supplies of men and material from North Vietnam. It seemed

like a good idea. During the summer of 1966 forty-nine prominent

academics, including some of our nation's best scientists, had gathered

at Dana Hall, a private girls school in Wellesley, Massachusetts and

produced the Jason study. The study concluded that our current reliance

on air power and the bombing of North Vietnamese and Viet Cong sites

were having limited effect on the enemy's infiltration. They finally

endorsed McNamara's proposal for a one hundred mile electronic fence

that would impede enemy advances from the north.

On September 7, 1967 at a press conference in Washington, DC, Secretary

McNamara announced plans for building that electronic barrier. It would

extend from the South China Sea to the Laotian border with roads and

trails monitored by high-tech electronic equipment. Khe Sanh would be

the linchpin of this barrier defense. The Secretary of Defense's

announcement came when I was back in Boston after completing my

training at "Fort Sam" and before deploying to the 249th General

Hospital outside Tokyo, Japan.

The project began despite opposition from General Westmoreland and other

army officers. The principal purpose of this "McNamara Line" was to

sound the alarm when the enemy crossed the barrier. Allied firepower in

the form of air and artillery strikes would rain down upon the People's

Army of Vietnam (the North Vietnamese Army) in order to curb

penetration from the north. This McNamara Line was an attempt to merge

modern technology with one of the oldest defensive techniques in

warfare. The United States would unfortunately learn that more than

sophisticated technology was necessary to make an effective barrier.

The project was begun, but it turned out to be impractical and was

eventually discontinued.

On September 3, 1967, four days before Secretary McNamara's Washington

press conference, Nguyen Van Thieu was elected President of South

Vietnam and Nguyen Cao Ky Vice-President. During these events in the

summer and fall of 1967 I was making the transition from civilian to

military life. Also in September General Westmoreland began to fortify

Khe Sanh

Caring for patients and raising a family had consumed most of my time, energy

and attention since entering medicine. I had been practicing

neurosurgery and worked primarily as an attending surgeon at the

Framingham Union Hospital and as a clinical associate at the

Massachusetts General Hospital where I had trained. I knew only vaguely

about the conflict in Southeast Asia. I had paid little attention to

the news from those distant lands. I began a course of self-instruction

to understand what I would soon be experiencing. Current events were to

become quite important in my life. During the two years that the

selective service system required physician-draftees to serve I would

become more knowledgeable about both the political and the military

challenges facing the nation.

I had been happily surprised when orders came through assigning me to

Japan after the month of training in Texas. I knew that the evacuation

of gravely wounded soldiers from Vietnam was a multi-tiered process and

Japan was in that stream of traffic. I also knew that there were ten

military neurosurgeons in South Vietnam and that yearly tours of duty

meant that twenty replacements would be needed before my own two year

deployment was completed.

The conflict was escalating, and with the increase in hostilities there was

an increase in casualties. In 1965 there was only one army hospital in

Japan and that facility at Camp Zama had 100 available beds. By 1966

there were four hospitals, including the 7th Field Hospital (400 beds),

the 249th General Hospital (1,000 beds), and the 106th General Hospital

(1,000 beds). The U.S. Army Hospital at Camp Zama had increased the

number of its beds from the original 100 to 700. It was in the summer

of 1967 that I drove to San Antonio, Texas for an introduction to the

military and basic training at the Medical Field Service School and

Brooke Army Medical Center before assuming responsibilities for the

neurosurgical care of soldiers wounded in what was called the

International Armed Conflict in Vietnam.

The view of Fort Sam Houston as we approached in a helicopter while

transporting a severely wounded soldier from the 249th General Hospital

later in my tour of duty.

Fort Sam Houston provided a four-week overview of the military and the

practice of army medicine. It was a very relaxed and low-key

experience. Certain aspects of the training seemed quite unnecessary

but the weeks of instruction necessarily had to follow a one-size fits

all program. Among our group were all the medical specialties:

internists, dermatologists, general surgeons, psychiatrists,

ophthalmologists, obstetricians, pediatricians, and on and on. Our

assignments after Fort Sam would be worldwide, from stateside to

Europe, the Far East, South East Asia, wherever our nation had army

installations.

It was at Fort Sam that I acquired some historical background of the

facility that had been established in 1876. More recently, in May of

1962, one of the first military units sent to Vietnam from San Antonio

was the 178th Signal Company. Twelve medical units shortly followed. In

1967 medical training reached its peak with the graduation of 

29,000 from the Medical Training Center.

The common experience shared by my classmates was that we were all

qualified to practice medicine. Most were younger than I. Most had

experienced long work hours and the responsibilities of caring for ill

patients. But the transition from civilian to military practice was

going to be a jolt, especially for those who would be practicing in the

combat zone.

Because of the large number of our entering group there was insufficient

housing on base. We were billeted in local motels, posh compared to the

quarters located on base. Outside my room was a swimming pool and the

weather during the length of my stay in Texas was ideal for unwinding

and relaxing before turning in for the night. Another unanticipated

benefit was the equestrian stable with horses available for

recreational riding in the afternoons after classes and training were

completed. I took advantage of as many free late afternoon hours that I

could to enjoy riding the extensive grounds of the installation. The

Artillery Post Stables had been moved from West Point in 1955 and were

included in the United States Modern Pentathlon Training Center.

We received a clothing allowance that covered the basics and early on we

purchased the required uniforms. A number of approved civilian

tailoring companies had contracts with the army and they were on the

base to outfit us with the necessities. We were fitted for the Class A

and Class B uniforms, green coat and trousers, long-sleeved tan shirts

and trousers, four-in-hand black neckties, dress blue uniform, head

gear, black shoes, boots, insignias.

The dress blue uniform seemed quite inappropriate. When were we going to

wear it? In my case it turned out to be only once during the next two

years. That one time was for an early morning inspection when the

entire class stood in formation for inspection. After my tour of duty I

gave this uniform to a recently drafted plastic surgeon with whom I had

worked during my years of residency on the neurosurgical service at The

Massachusetts General Hospital. With the hostilities gradually

subsiding I hoped that John would have more use for the dress blues

than I had. At the PX I purchased a copy of The Officer’s Manual of

1967-1968 in which I read the regulation that introduced me to one of

the many things I came to know as “the army way.”

“The Army Blue uniform is the prescribed uniform for officers and warrant

officers for social functions after retreat. Its wearing may be

prescribed by local commanders for specific occasions. On other

appropriate occasions it may be worn as desired by the individual. All

officers and warrant officers are required to own the Army Blue uniform

for wear on appropriate occasions, except Reserve Component officers in

a Reserve status or on active duty for training for periods of 6 months

or less. They may purchase the Army Blue uniform on an optional basis.”

Although my orders were to report for duty in Japan I assumed that I might be

diverted or later transferred to Southeast Asia because that was where

the need for qualified neurosurgeons would be the greatest and I would

not be needing this dress blue uniform overseas.

Contemplating the immediate future before leaving for basic training I had read as

much as I could about what to expect during the next two years, the

duration of my military obligation. In civilian training and practice I

had cared for many patients who had suffered injuries to the nervous

system and I knew that I soon would be seeing many more. The four-week

basic training course was rudimentary. There was no need to transform

health professionals into fighting men and women.

There was a fair amount of classroom instruction and studying printed handouts on army rules and regulations.

We marched in formation, carried out physical training drills, ran through

woods at night with compass and map, crawled under barbed wire while

blank tracer bullets were fired overhead. We had a gas mask drill. On

the shooting range we qualified with M-14 rifles. We received

immunizations against smallpox, typhoid, tetanus, typhus, cholera,

yellow fever, influenza, polio, and plague. We went through field

training and exercises at Camp Bullis, the army's 27,000 acre facility.

There was one session spent debriding gunshot wounds on anesthetized goats.

The exercises on these goats reminded me of the fundamental operative

techniques I had taught third year medical students when I was the

Harvey Cushing Fellow in the Hunterian Laboratory at The Johns Hopkins

Hospital.

We learned that the conflict in Vietnam had brought about significant

changes in military medicine since our nation's most recent extended

fighting in Korea. Two major improvements were in aero medical

evacuation and in the mobility of well-staffed and well-equipped

hospital facilities. Combat medical support had to be modified in this

region where the battlefront was ill defined and the guerilla tactics

of the Viet Cong gave the enemy the opportunity to strike deep within

areas once thought to be well under our control.

The UH-l (Huey) helicopter could transport as many as six to nine patients

at one time. Most patients could be evacuated within 30 to 35 minutes

of wounding and the skill and competency of the medics both on the

ground and in flight resulted in salvaging the lives of many soldiers

who would not have survived in earlier conflicts. Before our

involvement in Vietnam came to an end 7,013 Hueys had been deployed in

country. 3,305 were destroyed, 1,074 pilots were killed along with

1,103 other crew members.

A second major change was to be in the deployment of the MUST (Mobile

Unit Self-Contained Transportable) structures that had been developed

to replace the MASH (Mobile Army Surgical Hospital) units of the Korean

conflict.

A prototype of this unit was set up on the base. In the field we were

told that such a hospital could be set up within 25 minutes. With

varied configurations these structures could have a capacity of 200 to

400 beds.

The MUST comprised three basic elements in their own shipping containers

that could be transported by cargo plane, helicopter or ground
transport.

1) The utility element had a multifuel gas turbine engine that supplied

electric power for air-conditioning, refrigeration, heating and

circulation, water heating and pumping, air pressure for the inflatable

elements, and compressed air or suction.

2) A rigid-panel surgical element was expandable with accordion sides.

3) An air-inflatable element with a doubled-walled fabric shelter could

contain wards for patients and other expandables could contain central

supply, laboratory, X-ray, pharmacy and kitchen facilities.

The following are pictures of various MUST components:

Individual containers before assembly

The interior of an expandable unit

Central Material Supply with autoclave

X-ray room

The first MUST hospital to arrive in Vietnam had been the 45th Surgical Hospital that was set up in Tay Ninh in October, 1966.
Its commander, Major Gary Wratton, MC, was killed in a mortar attack before the unit began functioning in early November.
In time a total of six MUST hospitals was established in Vietnam.

I had brought along my copy of the NATO Handbook “Emergency War Surgery” that I planned to study before turning in each night.

At Fort Sam the most potentially useful booklet the army gave us was a ninety-four-page publication entitled
“Military Surgical Practices in the United States Army in Vietnam.”
The introduction’s first sentence I recognized as a quotation from the NATO handbook:

“Military surgery is a development within the art and science of surgery which is designed to carry out a specialized, essential
and highly significant mission under the adverse conditions of war.”
Not included in the
booklet was the second se entence from the NATO Handbook:

“It is distinctive in that, contrary to the usual medical practice, the
care of the individual must necessarily become secondary to the
military effort whenever a given tactical situation so demands.”

[Emergency War Surgery, NATO Haandbook, US Government Printing Office, Washington, D.C., 1958, p. 1.]

The initial sentence I remembered from the text that I had first studied as a Halsted intern at The Johns Hopkins Hospital.
The second sentence, omitted in the booklet that we received, troubled me when I first read it and would continue to trouble me over the next two years.

I was not alone in my feelings about this subordination of the individual soldier-patient to the military effort
I had earlier read a study of

several thousand army physicians many of whom who had similar

misgivings.

This study of 3,000 army physicians conducted over an eight year period and published early in 1967 included in its summary:

“The

most difficult concept for the group to accept was in the area of the

philosophy of military patient care. It appeared to be based upon an

assumed conflict involving principles of medical practice. Most

physicians found it difficult, if not impossible, to accept that their

responsibility might be to an organization rather than the individual

patient. To many of the entering physicians, one of the cardinal

principles of military medicine, namely, ‘The greatest good for the

greatest number,’ was unacceptable.”

[Archives of Environmental Health, Volume 14, February, 1967]

My

only extended personal interaction with a single individual during the

month-long introduction to the army was an interview regarding my

future in the military. The interviewing officer explained the

advantages of extending my term of service from two to three years. He

assured me that this would make my posting to Vietnam much less likely.

I could have an assignment at one of the major army hospitals outside

the theater of operations in Southeast Asia. I didn’t bite. I had no

doubt that the needs of the service would determine where I might be

stationed during the three years. My interviewer couldn’t convince me

that the three years in a non-hostile setting could be guaranteed. I

opted to let the army send me where it wished, but I wanted my two-year

obligation to be the total of my service time. I had read enough about

the current conflict to know that the sooner I returned to civilian

life the happier I’d be.

There

was a two-week interval after Fort Sam Houston before my flight from

the West Coast to my assignment in Japan. I returned to Massachusetts

to make arrangements for the army to ship family items overseas and to

rent our house to a colleague who was emigrating from the United

Kingdom to practice medicine in Boston. I had left the family station

wagon in San Antonio and it would be sent overseas in time to arrive in

Japan about the same time as I. Two of my four children were in

elementary school and I explained to them the advantages of living

overseas for two years, and the great opportunities that we would have

contrasted with two years in our Boston suburb. In any event it was

certainly preferable for all of us to be together rather than separated

for these years. Transportation for my wife and four children was

arranged. They would join me in Japan after I had arranged for housing

and schooling for the two older children. In late August I flew to the

west coast and stayed with a fellow medical draftee and his family in

San Francisco before boarding a chartered flight at Travis Air Force

Base midway between San Francisco and Sacramento. We flew to Tokyo with

a refueling stop at Elmendorf Air Base in Alaska. I arrived in Japan in

mid-September and my family joined me in mid-October.

These are a few photos taken on the hospital grounds soon after my reporting for duty:

The

249th General Hospital was located northwest of Tokyo in Asaka

prefecture. This unit was among the nearest complete hospital centers

for army casualties in South Vietnam. We were 2700 miles from military

action. The order of evacuation of the sick and wounded followed an

established protocol. Five echelons of care determined the disposition

of the individual soldier. The exigencies of combat in Vietnam dictated

this evacuation process. Military medical facilities varied in distance

from the combat zone. The nearest U.S. logistical support base was in

Okinawa, ca. 1,800 miles from Saigon. I would serve a short TDY

(temporary tour of duty) stint in Okinawa during my tour of duty. The

nearest complete hospital centers from Saigon were in Japan, 2,700

miles distant. Travis Air Force Base in California was 7,800 miles away

and Andrews Air Force Base outside of Washington D.C. was ca. 9,000

miles away. We would be caring for young soldiers.

"The

average age of the American soldier in Vietnam was nineteen, seven

years younger than his father had been in WW II." (Stanley Karnow,

Vietnam: A History, page 26)

One

major difference between practicing neurosurgery in the army and in

civilian life was that the continuing care I could provide patients in

the latter was no longer practicable. Severely wounded soldiers would

pass through the five levels of care. I would be working at the fourth

level where patients could be treated for as long as sixty days if they

could to return to active duty in Vietnam. The men who required longer

hospitalizations would be evacuated to hospitals in the United States -

the fifth level of care. This five-tier system determined where

patients were hospitalized.

The

first echelon: In the combat zone the Medic would render emergency care

and begin evacuation to the forward aid station where a medical officer

would continue care and resuscitation if needful while preparing the

patient for further evacuation to the second echelon (the division

clearing station) or to the third echelon (a definitive treatment

center).

The

second echelon: This is the division clearing station where relatively

minor injuries were treated. More complicated injuries received

continued resuscitation and initial surgery before continued evacuation

to the third echelon, a mobile surgical or evacuation hospital.

The

third echelon: More definitive surgery was available here along with

full resuscitation. This third echelon Surgical Hospital would often

receive the seriously wounded directly from the first echelon, the

combat zone itself or the forward aid station. These seriously wounded

would go directly from the forward aid station to the surgical hospital

as rapidly as practicable. The Evacuation Hospital would receive not

only the soldiers from the aid station but also those needing specialty

surgery from the second echelon division clearing station and patients

already operated on at the Surgical Hospital. Medical and psychiatric

patients also came to the Evacuation Hospital.

The

fourth echelon: These hospitals were based in Japan and Okinawa and

were much like the stateside ones with general surgical and surgical

specialties along with medical and psychiatric facilities. This was the

level at which I would work. These facilities provided care for three

types of patients:

1) Those who might return to duty within sixty days.

2) Those who were so severely wounded that after ongoing care they would be transferred back to the continental United States.

3) Those who were unlikely to survive because of the extent of their wounds and would likely die before reaching home..

The

fifth echelon: These hospitals were located in the Continental United

States and received the men and women who were unlikely to return to

continued service in Vietnam.

In

the combat zone small arms automatic weapons accounted for about

one-third of the injuries and fragmentation missiles, most often from

booby traps, comprised the majority of the others.  Most of the

men who reached us at the 249th hospital had been thus injured. 

The

pattern of evacuating the wounded by ground that had served in so many

previous conflicts was not practicable in Vietnam.  Distances and

hostile terrain necessitated aeromedical support on a scale not before

realized.

Prompt

evacuation of the wounded from the battlefield saved many lives that

would otherwise be lost. The use of the helicopters that had provided

rapid air evacuation on a large scale in the Korean Conflict in the

early 1950's was essential in Nam. It was now possible for a casualty

in Viet Nam to have extensive life-saving surgery within an hour of

being wounded in the field. An advantage of air transport was that it

was often possible for a wounded soldier to be flown directly to the

unit best equipped to care for him, whether that was in the first,

second or third echelon.

During

my tour of duty the number of army hospitals in Vietnam increased to

twenty-three with five thousand, two hundred and eighty-three

beds.  In Cam Ranh Bay the 6th Convalescent Center provided care

for men who would be sufficiently fit to return to active duty within

thirty days.

Our

patients reached us from South Vietnam in stages and by progressively

smaller transports. The longest leg of the trip was in C-141 planes

especially outfitted to accommodate not only the most seriously injured

but also those who might be able to return to Vietnam within sixty

days. The C-141s landed at Yakota Air Base and then helicopters would

transfer the most severely injured soldiers while buses and ambulances

would transport the less critically wounded to the general hospitals.

When

I arrived in Japan there were some hectic days of settling in, meeting

the hospital commander and getting acquainted with the hospital

facilities and staff, especially those medics, nurses and doctors with

whom I'd be working on the two neurosurgical wards. Before assuming my

responsibilities on the neurosurgical unit I retrieved and registered

my station wagon that had reached the depot in Yokohama and then

arranged with a local broker to rent a house that I felt could

accommodate my young family for our anticipated stay of two years. The

house was some distance from the hospital - a commute of one and one

-half hours on the congested Tokyo roads but only a few blocks from the

bus stop where a commuter bus from the American School in Japan would

pick up and deliver our two school age children.

It

would be one month before my family's arrival in Japan. By then I was

settled into the hospital routine and was immersed in the challenges of

caring for the quantity and variety of injured soldiers who had reached

the fourth echelon of care at our hospital.

Our two wards could accommodate eighty soldiers. For any overflow we could find beds on other wards.

My

reading in anticipation of military service had raised some strong

feelings about our role in the conflict in Southeast Asia and it did

not take long for me to feel that we were sacrificing brave young men

in an ill-advised adventure far from our own shores. As I made rounds

on our wards, treated the continuing stream of casualties that passed

through our operating rooms and pronounced dead so many soldiers who

had been grievously wounded in combat I resolved to do what I could do

to end the carnage. I was enough of a realist to know that while I was

on active duty there was nothing I could do but strive to do the very

best that training and experience had taught me. I would treat, comfort

and whenever possible restore to some semblance of well-being those who

came under my care. However, I knew my own tour of duty in the army

would last for only the mandatory two years, and if the war had not

ended when I was discharged then I would do what I could to help end

it. How I would do that I did not know, but I did know that it must end.

[From Washington Post - 04/30/2017:

The

year 1967 saw the deaths of 11,400 Americans, and 1968 claimed 16,900,

the worst yearly toll of the war, according to the National Archives.

These

two years account for almost half the 58,307 names on the Vietnam

Veterans Memorial in Washington, which honors those killed in the war.]

Early

on I purchased at the Tachikawa Airbase PX a 35 millimeter Nikon FTN

camera that I kept close at hand and recorded much of what I

experienced both on and off base. Towards the end of my tour I gave a

slide presentation of my impressions and thoughts to my colleagues at a

Grand Rounds session. Choosing which slides to show from the hundreds

that I had by then accumulated was difficult. There were no objections

to the efforts of myself and those who wanted to see an end to our

involvement in Nam but the highest ranking attendee, a career colonel,

adamantly refused to join the post-presentation discussion of what he

considered to be a political issue.

A partial view of our ward with trapeze and safety rails on almost all beds.

Nurse

and physician caring for a paraplegic patient on a Stryker frame,

enabling the patient to be rotated 180 degrees frequently in order to

prevent skin breakdown and the formation of bed sores.

View of patients in beds with safety rails and CircOlectric beds in background.

A nurse caring for a paraplegic patient on a CircOlectric bed.

Two nurses with recovering patient.

Two general surgeons consulting on one of our patients.

In the neurosurgical operating room.

The

249th General Hospital was not so very different from the major

hospitals where I had received my general and neurosurgical training in

the States. Both health professional draftees and career army officers

represented the various specialties. The medical staff consisted of

captains, majors and colonels with the rank determined by degree of

training and experience. The nurses who were the closest to the

continuing oversight and care of the patients were drawn from both

military and civilian lives. Assignments of the doctors on the

neurosurgical wards overlapped so that there was sufficient time for

the outgoing surgeons to orient the newcomers to the individual

patients and their clinical situations. Our two wards at the 249th had

two fully trained neurosurgeons and two medical officers attending the

patients throughout my tour. The chief of service was a major who would

be promoted to lieutenant colonel during the tour, and I began with the

rank of captain to be promoted to major. Two captains completed the

physicians' staffing on our unit. The military nursing staff on our

wards contained lieutenants and captains. There were also a number of

civilian nurses, spouses of active duty military personnel who were

stationed in Japan.  The medics varied in rank. The census on our

wards during most of my tour varied between sixty and eighty patients.

The

soldiers on our neurosurgical wards often had injuries that extended

beyond the nervous system. Many of these patients had sustained

multiple fragment wounds from high-velocity missiles, land mines, booby

traps, and mortars. They had received excellent initial and ongoing

care in Vietnam before evacuation to Japan. By the spring of 1967, when

I received my draft notice, there were ten neurosurgeons operating at

the five army hospitals in the combat zone. In addition all the medical

and surgical specialties were available for acute care in country. The

quality of care available to the wounded soldier was superior to that

in any previous conflict in large measure due to the talents of the

skilled medical/surgical staff and the supporting team members and

facilities.

The

majority of our patients would not be returning to active duty in the

combat zone within the allotted sixty days and therefore much of our

work was devoted to repairing and stabilizing wounds and preparing

patients for evacuation and the return home to the fifth echelon of

care. For most of these returning men the war was over. The long-term

effects of the conflict and their residual deficits would not be over.

The

pace and stress accompanying our workload varied with the progress of

hostilities in Vietnam as most of our days and nights were centered on

the tasks at hand. We concentrated on admitting and evaluating patients

as they arrived at the hospital from the C-141 transport planes that

had evacuated them from Nam. Our assignment was to provide continued

surgical treatment in our operating rooms, and then prepare them for

further evacuation back to the States or, in fewer cases, back to

active duty in Southeast Asia. It was years later when I could

correlate the conditions that obtained in the combat zones with what we

were witnessing in our hospital. It was not until 1972, three years

after my tour of duty, that I went to work in Vietnam and saw first

hand some of the results of our intervention..

The

soldiers who reached our hospital presented many of the same challenges

that I had encountered and treated in civilian life but the extent,

variety and devastation of injuries far exceeded what I had encountered

in my previous years of residency and practice.

We

were not the first neurosurgeons to care for our patients. The majority

of soldiers whom we treated after evacuation from Southeast Asia had

injuries that required additional cranial or spinal surgery before

continued transport to the continental United States. Rarely would

these men be returning to active duty in Nam. Now and then we could

chuckle at our circumstances and those of our patients. One such event

was the evacuation from South Vietnam of a soldier who had no injury

but had gone through induction, training and deployment to Vietnam

despite lacking a significant portion of his skull. One quarter of the

bony protection of his skull had been removed following an adolescent

injury and this had never been replaced. The scalp was well healed and

he was in fine physical shape, but the skull defect and the underlying

pulsating brain were prominent. The private enjoyed a few weeks of

unanticipated rest and relaxation after the replacement of the defect

with a methylmethacrylate plate insertion. Then he was back to fight

another day.

During

my tour of duty military actions in Nam and events at home occurred

that were to influence the course of the hostilities and eventually the

departure of our own troops from South Vietnam. At the end of 1967

American troops in country numbered 485,600. Total deaths of U.S.

troops in the "Vietnam War" had reached 19,562. General Westmoreland

had started to fortify Khe Sanh, the linchpin of the contemplated

electronic barrier monitoring infiltration from the north. Anti-war

protests were escalating at home. Our workload at the hospital followed

a routine - regular arrivals from the airbases, helicopter or ambulance

transfer to our wards, triage, evaluation, observation, pre-operative

treatment, surgery as needed, post-operative care and preparation for

continued evacuation to the continental United States or occasionally

back to the combat zone.

The

years of 1967 and 1968 were pivotal as events unfolded both at home and

in Vietnam. Although what was happening on the "home front" had little

impact on our daily activities the battles in Nam did. On October 21,

1967 there was a march on the Pentagon that brought out 100,000 antiwar

protesters. In November there were heavy casualties in fighting around

Dak To in the Central Highlands. That same month the Secretary of

Defense, Robert McNamara, who was having misgivings about our

involvement, resigned. A day later Senator Eugene McCarthy, who had

long opposed the war, began a challenge to President Johnson for the

presidential nomination in 1968. Anti-war protests increased.

The Tet Offensive began on January 31, 1968.

Our

workload had been steady and heavy up to Tet when it increased with the

escalation of hostilities. Each year from 1965 had brought greater

numbers of army patients evacuated from Vietnam.

1965 - 10,164

1966 - 12,606

1967 - 22,702

1968

- 35,391 (with the greatest number yet recorded in a single month -

3,576 in the month of February during the Tet Offensive)

1969 - 35,916

[Medical

Support of the U.S. Army in Vietnam, 1965-1970 by Major General

Spurgeon Neel, Department of the Army, Washington, D.C. 1973, page

77 

Source:

Army Medical Service Activities Report, MACV, 1965; Army Medical

Service Activities Reports, 44th Medical Brigade, 1966, 1967, 968,

1969.]

Belatedly, but happily, after 1969 a gradual de-escalation of our nation's combat role in Vietnam began.

Before

then General Westmoreland had requested 206,000 more troops. Clark

Clifford, who had succeeded the unhappy Robert McNamara as Secretary of

Defense advised against this buildup and President Johnson concurred.

1968 was an election year and antiwar protests were increasing. On

March 12 in New Hampshire's Democratic primary Eugene McCarthy received

42% of the vote. On March 16 Robert Kennedy announced his candidacy for

president. Creighton Abrams replaced Westmoreland in Vietnam and the

latter was appointed Army Chief of Staff.

We

knew about the unrest at home. In early November, 1968 I accompanied a

critically ill soldier from the 249th to Walter Reed Hospital. Passing

through the streets of Washington I saw the lingering results of the

rioting and destruction that had followed Martin Luther King's

assassination in April. One thousand, one hundred, ninety-nine

buildings had been badly damaged or destroyed. Many remained abandoned

and boarded up. Over one thousand citizens had been injured. Twelve had

been killed. To combat the unrest and looting the White House had

dispatched some 13,600 federal troops. That occupation of Washington

was the largest of any American city since the Civil War. How ironic

that our marines had deployed machine guns on the steps of the capitol

while their comrades in arms were fighting for their lives halfway

across the world!

In

Japan the census in the medical and surgical services remained high.

The flow of head, spine and peripheral nerve injuries continued. Many

of the spinal injuries we encountered brought new experiences. I had

previously operated up and down the spine in what were textbook

situations: disc disease, fractures of the vertebral column, tumors,

neonatal deformities, vascular anomalies, degenerative disease, but our

patients returning from combat presented new and unique challenges.

Closed

wounds of the spine were less frequent than open ones. The former

usually resulted from helicopter crashes or explosions below vehicles.

The latter, caused by penetrating missiles, were more common and more

complicated because of associated injuries to other parts of the body.

In

the combat zone life-threatening wounds frequently mandated the

treatment of associated chest or abdominal trauma that took precedence

over surgical intervention at the spinal column. When many such

patients reached us the medical and surgical hurdles were unique.

Some

patients who had lost movement and sensation in their lower bodies

arrived with extensive breakdown of their skin and muscle below the

site of injury. These pressure or decubitus ulcers were often infected

and required removal of gangrenous tissue, frequent cleansing, Betadine

(povidone-iodine) applications and dressing changes. Skin grafts or

flaps were necessary in many of the more extensive wounds and further

surgical procedures would often be deferred until evacuation back to

the States.

Necrotic decubitus ulcer

Deep wound of low back

Removing infected vertebral body from soldier's back

Necrotic vertebral body now freed from back and surrounding infected site

Exposed spinal nerves and nerve roots of the cauda equina (Latin for "horse's tail") in an open low back wound

As

previously noted The Vietnam Veterans Memorial Wall in 2018 listed

58,320 names. The names of the 3 million Vietnamese who perished in the

conflict have no such wall, but as Philip Jones Griffiths, the renowned

photographer of the conflict, observed,

"Everyone

should know one simple statistic: the Washington, D.C. memorial to the

American war dead is 150 yards long; if a similar monument were built

with the same density of names of the Vietnamese who died in it, [it]

would be nine miles long."

(Messer,

William, "Presence of Mind: The Photographs of Philip Jones Griffiths,"

Aperture No. 190 (2008), http://www.aperture.org/jonesgriffiths/)

Some

of our patients were doomed to die before further transport could be

attempted. However, a greater number were ultimately sufficiently

stabilized to allow transfer to stateside hospitals where the prognoses

for meaningful recovery for a large number were unhappily exceedingly

bleak. We did not lose many patients whose wounds were below the head.

Even those men with extensive associated injuries involving the chest,

abdomen and limbs in addition to the spine could often be treated and

stabilized before further evacuation.

The

causes of wounds in Vietnam reflected the increased use of small arms

and automatic weapons contrasted with the earlier experiences of World

War II and the Korean Conflict. In these earlier engagements about 75

per cent of all wounds were attributed to missile fragment wounds from

artillery, mortar and aerial bombs. In Vietnam such missile wounds made

up 49.6 per cent of injuries while gunshot wounds made up 42.7 per cent

(Military Surgical Practices of the United States Army in Viet Nam,

Medical Field Service School, Brooke Army Medical Center, Fort Sam

Houston, Texas, 1966 by Yearbook Medical Publishers, Inc.).

Soldier with multiple fragment wounds of back and buttock

Bilateral lower limb injuries necessitating further revision of amputation stumps

Leg amputation

Multiple fragment wounds with loss of right lower leg

Gunshot wound to head with breakdown of scalp closure

Scalp breakdown following debridement of infected entry sites over

the skull of a soldier who had sustained multiple fragment wounds

Death after uncontrollable generalized infection of brain

Disruption of base of skull after devastating facial and sinus missile injury

On

January 30, 1968 the Viet Cong and North Vietnamese began the Tet

Offensive and the next few weeks were the busiest of my tour of duty.

During the second week in February the 543 Americans killed in action

marked the highest weekly total of the war. The soldiers had the

support of 116 air ambulance detachments.  Five to seven Huey

helicopters were assigned to each detachment and they could carry six

to nine casualties on one flight.  On

average

the wounded often reached a surgical unit within thirty-five

minutes.  That the men who survived to reach a hospital survived

in over ninety-seven percent of cases was a testament to the medevac

crews' skill, heroism and devotion.

Thirty-nine

crew members were killed and two hundred-ten were wounded in a two-year

period as they flew rescue missions [Neel, page 73].  The number

of flights increased in proportion to our escalating involvement. 

1965 - 13,004, 1966 - 76,910, 1967 - 85,804, and in 1969 - 206,229

[Neel - page 75].   In 1969 hoist retrievals of casualties by

dust-off helicopters rescued 2,516 patients [Neel - page

75].   

As

the numbers of wounded reaching our hospital escalated my determination

to do whatever I could to protest the enormity of the conflict became

an obsession. I had to wait until September, 1969.

In

contrast to the hospital environment and ongoing care of casualties

life away from the base provided a welcome respite. Our home for the

overseas years was a classic Japanese house, a wooden structure of two

stories and much like what I had come to expect from my preparatory

reading in anticipation of the move. With the help of colleagues at the

hospital I had found live-in help, a young woman who had a fair command

of English and whom I hoped would make the transition for my family as

easy as possible.

My

wife, four children and one beagle arrived in mid-October and I

introduced them to what would be somewhat less than two years in this

country. I would likely be at home even less than when I had been in

private practice. In Framingham I lived within fifteen minutes of my

office and hospital. The longer commute and the responsibilities of

treating wartime casualties would likely result in my having not much

time at home. I was thinking that the relatively comfortable and

somewhat exotic living arrangements, the presence of live-in help and

the opportunity for the older children to attend school with a group of

international students would help in this transition. There would

certainly be new experiences. Living in a home with movable Shoji

screens for walls, tatami mats for flooring, sleeping on futons that

would be folded for storage each morning. The wooden components of the

house were Japanese cypress. The fenced-in garden allowed a safe place

for the children to play and our beagle Tammy to run. Our full-sized

Ford station wagon could fit in a detached garage that was constructed

of sturdy plastic walls and a corrugated roof. One of the many

novelties was the deep cedar tub that afforded us the unique Japanese

bathing ritual. Food stalls and shops were less than one hundred yards

down the street as was the local railroad station with direct service

to downtown Tokyo. 218 Karasuyama, Setagaya-ku was to be our home for

most of the next two years.

Directly

across the street from our home was a Shinto shrine.  During

comparatively "quiet" periods at the hospital we were able to visit

sundry Shinto shrines and Buddhist temples while exploring further

afield.

The

majority of my days was spent at the hospital but there were also

opportunities to take advantage of free hours and vacation days to

explore some of the attractions of not only Tokyo but also of other

parts of the country. It was a long two years and much of my work was

necessarily heart-wrenching. The respite from the hospital activities

was welcome and there was much to see and value about this country that

I would never had had the opportunity to appreciate were it not for the

ongoing hostilities in Nam.  Needless to say, I would have gladly

forgone the adventures of traveling in this land had there been no

conflict responsible for bringing us here.

Temples in Kyoto:

The Temple of the Golden Pavilion (Kinkakuji) in northern Kyoto:

The Great Buddha of Kamakura, over 37 feet high, cast in 1252:

Cherry blossoms in Ueno Park:

A chance to picnic:

Kite flying:

TV before bedtime:

Bath time in a ryokan, a traditional Japanese inn

Hear no evil, speak no evil, see no evil

During

the same period that we were working in Japan the conflict and military

activities in Nam itself occupied most of the news. Much of what was

happening during that time I learned only after retiring from active

duty. Journal articles and books appeared with increasing frequency as

we slowly reduced our commitment to the South Vietnamese government.

General Westmoreland assigned Major General Spurgeon Neel the task of

preparing a monograph of the army's medical activities in Vietnam for

the years 1965-1970. It was from this monograph, Medical Support of the

U.S. Army in Vietnam, 1965-1970, that I came to more clearly understand

the challenges that faced our troops and the physicians tasked with

their care in the combat zone during those years.

After

leaving active duty in 1969 I returned to the practice of civilian

neurosurgery in Massachusetts, but I continued to closely follow the

news from SouthEast Asia and became increasingly active in opposing our

continued military activities in Vietnam. I presented my impressions

and slide presentations on TV stations in Boston, New York and

Baltimore and college campuses both locally and as distant as Kansas

City, Missouri. On December 7, 1970, thirty-nine years after "a date

which will live in infamy" the University Program Council Lecture

Committee at The University of Missouri-Kansas City sponsored my slide

presentation. The campus magazine quoted one of the more telling points

of this talk, the fact that had continued to disturb me as the

hostilities continued:

"81

per cent of the Vietnam War's wounded survive. Although this is an

improvement over previous wars, there will be three times as many men

who are totally disabled as there were in World War II."

I

shared a platform with Ramsey Clark in Chicago at a meeting of Business

Executives Move for Vietnam Peace. I presented facts and figures to

colleagues at meetings of The Massachusetts Medical Society and the New

England Neurosurgical Society.

By

the end of 1971 56,205 U.S. troops had been killed in the Vietnam War.

In our country opposition to the war continued. On March 23rd of 1972

the United States suspended the Peace Talks in Paris, and a week later

the North Vietnamese began a new offensive, the heaviest since 1968.

The next month saw the initiation of Operation Linebacker, expanding

air strikes against the North Vietnamese fighters in South Vietnam.

During these same months, sponsored by the Agency for International

Development of the Department of State, I was in Vietnam.

I

had traveled to South Vietnam to see for myself not only the results of

our ongoing intervention in country but also the conditions under which

medical teams tried to deliver care to the large numbers of sick and

wounded. I worked primarily in Saigon as a Visiting Neurosurgeon at the

Cho Ray Hospital and Lecturer in Neurosurgery at the medical school,

but was also able to travel further afield to military and civilian

medical facilities in Pleiku, Kontum and Nha Trang.

Scenes from The Cho Ray Hospital in Saigon - the unit in which I spent the most of my time.

Patients lining the corridors waiting to be seen

Three infants - one crib

A representative ward

Two nursing instructors

Nurses and student nurses - 1

Child with scalp wound

Child recovering from head wound

Wound care

Despite

the wartime conditions education of young doctors and ancillary health

professionals continued at the medical school and hospital with

conferences, bedside rounds, x-ray review sessions and anatomical

studies, including "brain cutting" as in training programs throughout

the world. Operating rooms functioned with state of the art equipment,

facilitated by contributions from around the world.

Conference and review of skull x-rays

"Brain cutting" demonstration

 Operating room

Operating room during cranial surgery; overhead lights provided by

The Republic of South Korea

Contrasting technologies - from a state of the art operating room to

an abrasive wheel for re-sharpening metal intravenous needles.

Entrance to military hospital

Audience of army doctors as we discuss neurosurgical challenges in wartime

Entrance to children's hospital

Outside the hospital I spent as much time as I could exploring Saigon, visiting

the orphanages and schools, photographing street scenes and contrasting

how removed from life in the hospitals and rehabilitation units were

the everyday activities in the capital city. Striking were the smiles

and cheerfulness of the children, especially the younger ones.

Saigon Orphanage

A few pictures from Kontum in the Central Highlands:

Performing a lumbar puncture while Montagnard tribesmen observe