HOMEPAGE AND INTRODUCTION

CURRICULUM VITAE

WARFARE

LETTERS AFTER LOOK

MY PATIENTS

LETTERS FROM PATIENTS

NARRATIVE IN PROGRESS

243 MEN OF HARVARD

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.

Looking back decades later the figures of troops in country and numbers killed illustrated our presence through the  years during our nation's involvement: 

SOURCE: Dept of Defense Manpower Data Center
https://www.americanwarlibrary.com/vietnam/vwatl.htm

   End of Year                        U.S. Troops in South Vietnam            Total Killed to Date

1959                                                760                                                            -
1960                                                900                                                           8
1961                                             3,205                                                         24
1962                                           11,300                                                         77
1963                                           16,300                                                       195
1964                                           23,300                                                       401
1965                                         184,300                                                    2,265
1966                                         385,300                                                    8,409                                
1967                                         485,600                                                  19,562
1968                                         536,100                                                  36,151
1969                                        475,200                                                   47,765
1970                                        334,600                                                   53,849
1971                                        156,800                                                   56,205
1972                                          24,200                                                   56,845
1973                                                50                                                    57,011 

           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

An expandable shelter in place

A utility module




The interior of an expandable unit

Central Material Supply with autoclave

X-ray room

Laboratory

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 sentence 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 Handbook, 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.

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

Nurses and student nurses - 2

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

Grounds of the Cong Hoa army hospital in Saigon

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. 

A few pictures from Kontum in the Central Highlands:

An army helicopter about to transfer patients from Kontum to the next echelon of care

Performing a lumbar puncture while Montagnard tribesmen observe