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CURRICULUM VITAE

WARFARE

LETTERS AFTER LOOK

MY PATIENTS

LETTERS FROM PATIENTS

NARRATIVE IN PROGRESS







 

WARFARE



"There is always inequity in life.
Some men are killed in a war and some men are wounded, and some men never leave the country...
Life is unfair."
John F. Kennedy in a press conference on March 21, 1962



What follows is now history. At that time, long ago and far away, it was very much the present, and for many it can never be history, for they can neither forget it nor confine it to their past. Pictures that speak for themselves can perhaps provide the most honest and straightforward view of what war can be. The text below is excerpted and paraphrased from a letter to President Nixon sent during the summer of 1970 and published in LOOK Magazine on July 28, 1970.



"They have been in a war for years and years and they are quite debilitated and decimated, and I don't think they are capable with any kind of resistance of continuing this fight."
Spiro T. Agnew, Vice-President of the United States
Face the Nation (CBS-TV)
May 3, 1970


I had been practicing neurosurgery before my commissioning, and naturally enough assumed I'd soon be in Vietnam. The army does move in strange ways at times, and I found myself outside Tokyo for somewhat less than two years. C-141 transport planes would pick up our patients at various staging facilities in South Vietnam, wherever large enough airfields were secure, and would fly them to the next hospital in the evacuation chain. This meant the Philippines, Japan, occasionally Okinawa or the United States. We were privileged at the 249th General Hospital in Japan to see the majority of seriously injured patients with wounds of the central nervous system, and thus had a fair overview of how things were in military neurosurgery during this time.

I'm certain that many of our patients would not have survived long after initial wounding in previous wars. It was not unusual for us to receive gravely brain-injured men who had had their initial brain surgery within one to two hours of wounding. Needless to say, because of the tactical situation, it was sometimes impossible for a helicopter to reach a man for twenty-four hours or more, but these isolated delays were more the exception than the rule.

The 249th General Hospital, where I worked, was located in Asaka, just northwest of Tokyo. It was a one-thousand-bed general hospital. We received about one thousand wounded each month and either evacuated or returned to duty slightly less than that number. The hospital gates were manned by local Japanese security guards, and the hospital complex was protected by a high wire fence.




"I would never send troops there."
Dwight D. Eisenhower
General, United States Army
New York City
June 8, 1952

Each ward in the hospital had its own medical flavor, and one could tell at a glance which subspecialty was represented. We had a full service hospital of course and did just about anything you could think of, except for organ transplants.

The two neurosurgical wards had between sixty and eighty beds. and the evacuation system kept our census fairly high. We had two fully trained neurosurgeons, myself and a surgeon from southwest of Worcester, Mass. All our patients had something wrong with one part or another of their nervous system--usually something was missing after injury. Although we usually kept patients between five days and several weeks, the turnover could be quite brisk. During times of stress--for instance, during Tet when the enemy was acquiring its psychological victory--we continued our patients' evacuations to the United States as briskly as possible. I would usually write out the patient's discharge and transfer summary at the same time that I did his admission history and physical.

May I suggest that if another 'Tet-like' period occurs in this non-war, it would save a lot of time and effort if patients were sent directly back to the United States from Southeast Asia rather than to Japan. Undeniably, Japan is a wonderful land, and its culture is fascinating, but so few of our patients really enjoyed the time they spent there. Mostly, they wanted to know why they had come to Japan, and what were they doing in that part of the world. I never really did find the answer to that question in my one year, eleven months and twenty-eight days of active duty, and must further confess that I never heard a very reasonable explanation of what any American was doing over there.

 



"Vietnam has been good for the Marines, and the Marines have been good for Vietnam."
Herman Nickerson, Jr.
Lieutenant General, U.S. Marine Corps
Danang, South Vietnam
March 9, 1970



I wonder if you ever got that report from the costs analyst who visited with us in Japan. He came from the Department of Defense. I tabulated a list of patients on our ward about that time, and tried to determine from a medical point of view what percentage actually benefited in their treatment by coming to Japan instead of taking an extra five or six hours to go directly home. We had somewhat more than sixty patients on the two wards then, and I could honestly say that two or perhaps three of them might have benefited by not taking the more direct route. I'm not quite certain of the final figure the Pentagon was given, but I was told that the costs analyst received from our medical command in Japan the statement that fifty to fifty-five percent of our men benefited from their time with us. It is interesting to see how the assessment of the situation varies depending on what level in the chain of command you are watching from.

Many of our patients with severe degrees of brain injury showed very little resentment against the circumstances that found them in Vietnam . In one sense, the more severely brain-injured were fortunate in that they were less aware of their deficits and certainly experienced less anguish. I doubt the same would hold true of their families.

I was never entirely satisfied with treating one particularly severe type of problem. Briefly, the difficulty arises because such a large amount of nose, middle face, and base of skull are destroyed, along with brain substance. Infection and continued leaking of spinal fluid were most difficult to manage. I do not think we have found an ideal way yet of treating this type of injury.

The loss of tissue in land-mine injuries is rather common. Such wounds are extensively debrided in Vietnam, and after five to seven days of care, they are either further debrided of dead and necrotic tissue or sutured. Many of our men had multiple-fragment wounds from rockets, land mines, booby traps or mortars. When the brain or spinal cord was also damaged, they'd be assigned to our neurosurgical service and we'd have an opportunity to extend and broaden our general surgical experience with caring for their associated injuries.

 



"So I really personally believe the introduction of U.S. ground troops in South Vietnam today would hinder rather than help the campaign against the insurgency."
Robert S. McNamara,
Secretary of Defense
Washington, D.C.
February 17, 1964



Injuries such as the ones I photographed in my operating room are really what prompted me to write you the letter. The burden of what's on my mind these days is really about patients such as these. I admit I'm not terribly interested in dominoes, or in Laos, or in who's threatening whom in Cambodia or Thailand. My background is not in power politics or in Southeast Asian culture; it's in caring for patients and in trying to make sick people well. I must admit I've had a terribly difficult time trying to understand why these young kids were being mashed in Vietnam when I thought they should be back home growing a little, or with their wives and children, or with parents and friends.

Many of our patients' wounds covered a fairly wide spectrum. Some men died in hospitals in Vietnam, some died in the Philippines or in Japan, and some died back in the States. Some survived to reach veterans' hospitals, and some returned to civilian life. There are some brain-injured men who will one day resume the support of their families and eventually return to ways of living pretty much the same as before they went off to non-war. These are the luckier ones who'll bear only a few scars. Their less lucky comrades will have a paralyzed limb, or two or three or four. Some will be quite bright and alert again, but some will not be able to speak, reason, protest or assent. It's for these, a sort of silent majority, that I'm writing you.

If you had visited our ward, you might have seen young soldiers on their sides and facing down so that they will not aspirate or breathe into their lungs any excess secretions or vomit that would make their situation more precarious. Tubes carry moist air through small holes in their windpipes, and this makes it easier for the staff to aspirate secretions and prevent pneumonia. With a large number of unconscious patients, these measures greatly reduced the incidence of pulmonary complications. As you can appreciate, these patients are unable to cough if they are deeply comatose, and they're not aware of the need to empty their bladders or evacuate their bowels.

The Vice President's recent remarks that if we had shown a little more backbone in the Republic of Vietnam we would have won the war sooner reminded me of one young man I had treated. He had a complete loss of spinal cord substance in his midback with resultant inability to feel or move his legs. A small amount of bone protruded through his surgical incision and this was obviously infected, as was the surrounding tissue. We discovered that the whole vertebral body, a fairly vital part of this boy's backbone, was infected. When I grasped the bone itself and pulled gently, the entire segment released from its surroundings. This is a fairly common maneuver in the autopsy room on a cadaver, but I had never done this or heard of its being done to a living person.

The Red Cross and other woman workers were awfully helpful to our troops as they returned from the combat zones. They would write home and let the Stateside family know how the young soldier, soon to be veteran, was getting along. Their aid was invaluable with the sightless, paralyzed, amputated, and mentally subdued, of course. In our ward, these women often helped with patients confined to CircOlectric beds. These beds were so useful that I often thought the Veterans Administration should see to it that each quadriplegic patient who reached home received one along with his discharge papers. These powered beds were most useful at our hospital in Japan, as the staff could adjust a patient's position not only for comfort but also for nursing wounds other than crippling spinal injuries. As you may realize, one of the biggest problems in these cases is that not only do the patients have no movement of their limbs, but they also have no sensation of their paralyzed parts, and these areas may break down, become necrotic and thus rather difficult to manage.

The wounds could be quite devastating to the brain. I was impressed by the amount of brain one could lose and still live, in a way. As I'm sure you know, in most people, the brain is a fairly important organ, and when mortar fragments, or dirt, or splinters of bone scatter through the head, it's pretty hard not to cause some fairly extensive injury. One boy with a very damaged head was so ill when he reached Japan that it was apparent he was not going to survive to make the trip home. His parents came over to spend his last days with him. I might just mention the local problem with the wound. You see, he had lost a great deal of skull and brain covering along with his scalp, and the wound and underlying brain were infected and under very increased tension.

Well, in any event, Christmas Eve arrived, and the children from one of the local schools were serenading the wards of the hospital while this boy's parents maintained their vigil. As the youngsters came onto the ward, you could have hoped for a little bit of a miracle, but instead, the patient passed on at that moment. We all celebrated Christmas in different ways that year.



"I have never been more encouraged in my four years in Vietnam."
General William C. Westmoreland
Commander, United States Forces in South Vietnam
Washington D.C.
November 15, 1967

I must sadly confess that from my vantage point, we weren't winning very much. Clearly, it was a long time ago that we were told we'd soon be done with it. We were assured and reasssured that victory was almost in sight. Now, I wouldn't presume to contradict men who were my military superiors, and I wouldn't for a moment question the statements of either the elected representatives of the South Vietnamese people, or of our own field commanders and generals in the Republic of Vietnam, but I would in all humility submit that these boys and men who came under my care were not cheered by the thought that we were winning. These boys felt that they had lost; and, of course, in a simplistic sense, I guess that they had lost -- an arm, a few legs, some brain, a little bone, a kidney, a lung or spleen, perhaps some liver. I must sadly observe that despite our cheery casualty statistics that we've killed fifteen times as many North Vietnamese and Vietcong as they've killed of us, the fact remains that many of my patients felt that they had lost.

I guess it's difficult to avoid giving you the impression that I'm sort of an anti-war kind of person. I admit that I didn't feel too strongly one way or the other before putting on my uniform. It really took very little time to realize that there were better ways of dying for one's country than the ways we devised for our younger brothers and neighbors. Not all my patients were draftees or short-termers who were anxious to serve their hitch and get out; we often had patients on the ward who were career soldiers, and at times we even had some officers.




"He was a farm boy who had worked in the fields, and his family just didn't believe sunstroke killed him.
"I checked into it, and the Pentagon reported his face and body were reddened by the sun while he waited three hours to be evacuated by helicopter from combat.
"Finally they acknowledged he was waiting to be evacuated because he had three bullet holes in him. And they call that an incidental death; Well, they changed it.
"The number of combat killed and wounded have become so great ... they are trying to hide it...a clumsy effort to deceive the public about casualties in this most unpopular and undeclared war."
Stephen M. Young
Senator from Ohio
Washington. D.C.
April 29, 1969



My own ward was fairly characteristic. Comatose patients certainly can be seen wherever much neurosurgery is being done, but we had a rather large volume of them. The Army cared for its paraplegic and quadriplegic patients with Stryker frames and CircOlectric beds that provided movements and changes of position the men could not provide themselves. In our ward, we had quite a bit of difficulty trying to decide who should continue evacuation back to the States and who should return to combat. I'm glad to hear that the burden of making this decision has been eased, and that all patients who reach Japan are now able to continue home. I must confess this seems quite reasonable; the other way seemed somewhat cruel -- almost like sending men back to combat because they hadn't been hurt badly enough the first time.

I'd like just once more to reemphasize that I do not intend this letter as criticism or expression of disapproval. Why, you weren't even my Commander-In-Chief during most of this time, and the President who preceded you was being reasured that the end was just around the corner, that the enemy was on his last legs, that we had just to buckle down a little longer and the coonskin would be on our wall, etc.

I was happy to read not long ago that the Army Chief of Staff has stated that the Vietnam War has technologically been a great success. I assumed he must have had in mind such developments as a MUST unit. This is a Medical Unit Self-contained Transportable and will certainly be useful in situations where a small hospital must be rapidly set up near a large disaster area. If I understand the concept correctly, the idea is to send the hospital to any area where large numbers of casualties are being generated. I must apologize at this point for a temporary diversion.

I had never before thought of sick or wounded people as being generated. It's a concept I learned during my indoctrination period at Fort Sam Houston in Texas. You will agree, surely, that it is a modern way of thinking about these problems. It's clearly much nicer to sit in a conference and hear about five hundred or five thousand casualties being generated in a given situation. It's a much nicer way to think of large groups of people in this manner, somewhat like electricity being generated at some power plant or other. Well, in any event, I just never could get it into my own head, or discipline myself to think of my patients in this fashion -- being generated here, stored there, transported, re-stored, etc. This probably accounts for my hesitancy in being more outspoken with that costs analyst from the Pentagon. I just couldn't convince him that we were dealing with patients, not packages.

I must confess that despite the nice commendation the country has given me, and despite your enthusiastic support during this conflict, I didn't ever come to feel that being part of the Army team was really my cup of tea. I just never managed to get into the spirit of it.

This letter has far exceeded my original intention of just jotting down a quick note; but if it's provided you with any information or a viewpoint somewhat different from what has reached you through more standard and orthodox channels, then it has certainly been worth my time. I do hope I have not bored you, either, with my thoughts or these photographs.

When I left active duty and was being discharged through Oakland, I was gratified to see a welcoming sign in the corridor. I regretted only that my own patients who had been evacuated through medical channels were unable to see this concrete expression of their nation's gratitude.


"It simply does not matter very much for the United States, in cold, unadorned strategic terms, who rules the states of Indochina. Nor does it matter all that terribly much to the inhabitants. At the risk of being accused of every sin from racism to communism, I stress the irrelevance of ideology to poor and backward populations."
J. William Fulbright
Chairman of the Senate Foreign Relations Committee
Washington. D.C.



I appreciated the opportunity of visiting Japan and of broadening my medical experience during that time. I regret that we lost so many men, not only in Vietnam, but also in our overseas hospitals. Some of the casualties were more difficult to retrieve or repair than others. Caring for the wounded is indeed a privilege; but I was never able to convince myself that they had been wounded for any good end. They were, after wounding, and I'm certain before wounding also, the finest men I've seen. But I cannot help but point out my feeling that this war was unworthy of them. They gave too much in that far-off place -- and we should not have sent them there.

I know that you deplore this conflict as much as I, perhaps for different reasons. I did hope that sharing these few pictures and thoughts with you would in some way explain why I felt compelled to submit my resignation as I did, rather than to extend my time in the Army. There are, happily enough, younger men now available to carry on the neurosurgical tradition in and after combat. I do hope that they are made of stronger stuff inside than I, and that their tours of duty will not remain in their minds quite so indelibly as has mine.

Knowing how the military operates, I'm certain that neither you nor your predecessors have had the opportunity to see these scenes. We who were fortunate enough to be brought into active service as two-year doctors have, of course. When we reported for duty, the threats that our orders would be changed for Vietnam if we didn't extend for a third year seemed somewhat hollow. None of our group being indoctrinated at San Antonio was cowed. Things evidently later changed, for we had several men appear in Japan this past year after having extended their tours of duty for that very reason. I must admit that I was never terribly impressed by the personnel procedures or procurement policies of the Army. But if the courts allow this practice to continue, then I suspect the military may have found a way to get one-and-one-half times as much wear out of this former group of two-year doctors. I congratulate your planners.

I really had hoped to send you this note while I was still on active duty, but we were somewhat busy most of the time, and my colleagues and superiors cautioned me that it might be more appropriate to allow a seemly interval to pass before trying to record my recollections for you. I'm afraid I'm leaving out a great deal that seemed important to me at the time, but I'm nevertheless able to recall a few glimpses of what was occurring. I had been told that if I waited long enough, perhaps the war would go away. I did wait, but it didn't seem to go away at all...

It's hard to believe in war if you take the preceding or following seriously.

Here are six Pictures without Words that appeared in the LOOK article:


 

 

 

 

 

 

I know the aphorism that "a picture is worth a thousand words," but I've never felt that any picture or series of pictures could equal the power of Dalton Trumbo's novel: Johnny Got His Gun.