All of this stands totally separate from whether you like the Vietnam War or don’t like it. This is not a word I toss around lightly, but it was inspiring to see him in the middle of this stupid damn war. Not to get too elaborate, but it approached the vicinity of the spiritual.… A few weeks later he was blown up by a mine.68
And in a letter left at the Vietnam Veterans Memorial in Washington, DC:
18 November 1989
Dear Sir,
For twenty two years I have carried your picture in my wallet. I was only eighteen years old that day we faced each other on that trail in Chu Lai, Vietnam. Why you did not take my life I’ll never know. You stared at me for so long with your AK-47 and yet you did not fire. Forgive me for taking your life, I was reacting just the way I was trained, to kill V.C. or gooks, hell you weren’t even considered human, just gook/target, one in the same.
Since that day in 1967 I have grown a great deal and have a great deal of respect for life and other peoples of the world.
So many times over the years I have stared at your picture and your daughter, I suspect. Each time my heart and guts would burn with the pain of guilt. I have two daughters myself now. One is twenty. The other is twenty two, and has blessed me with two granddaughters, ages one and four.
Today I visit the Vietnam Veterans Memorial in D.C. I have wanted to come here for several years now to say goodbye to many of my former comrades.
Somehow I hope and believe they will know I am here, I truly loved many of them as I’m sure you loved many of your former comrades.
As of today we are no longer enemies. I perceive you as a brave soldier defending his homeland. Above all else, I can respect that importance that that life held for you. I suppose that is why I am here today.
As I leave here today I leave your picture and this letter. It is time for me to continue the life process and release my pain and guilt. Forgive me Sir, I shall try to live my life to the fullest, an opportunity that you and many others were denied.
I’ll sign off now Sir, so until we chance to meet again in another time and place, rest in peace.
Respectfully,
101st Airborne Div. Richard A. Luttrell69
APPENDIX
FOR PITY’S SAKE
A Brief History of Battlefield Medicine
If you have two wounded soldiers, one with a gunshot wound of the lung, and the other with an arm or a leg blown off, you save the sonofabitch with the lung wound and let the goddamn sonofabitch with an amputated arm or leg go to hell. He is no goddam use to us anymore.
—A medic remembering advice given by General George S. Patton Jr.1
Were it not so tragic there would be something comical in the way man invents machines to kill and injure, then uses his ingenuity to provide methods of repairing damages caused by his own destructive genius.
—Mabel Boardman, Red Cross historian, 19152
IT IS A peculiar thing, this juggling between our relentlessly destructive inventiveness and our redemptive determination to fight against the dark side. Our technological and logistical genius, so brilliant at the harming, can also put back together what we have undone. We kill and we save, reveling in both.
In the ancient world any kind of serious wound would almost inevitably lead to the soldier’s death. There was no way to control this inexorable mortality. Little was known of the mechanisms and chemistry of the body—how the torn could be repaired, or the insidious workings of infection. Only the kindness of comrades, the limited effectiveness of herbal medicines, and above all, the fervent appeals to the gods, put up a fragile barrier between the doomed and the saved. Most were doomed.
This doleful state of affairs persisted pretty much until the Enlightenment of the eighteenth century began the process of putting less emphasis on appeals to the deities and more on scientific inquiry and medical organization. During the American War of Independence, for example, about a quarter of all patriot soldiers admitted to hospital died.3 In the Civil War it dropped to around 14 percent,4 but by the First World War the American soldier’s chances of surviving hospitalization for wounds had increased dramatically: Slightly over 6 percent were lost; in World War II, 4.5 percent; in Korea, 2.5 percent, and in Vietnam, 1.8 percent.5 What accounts for such a dramatic improvement? Several factors had to come together, each making a massive individual contribution but not a decisive one, until they acted in concert. They were the organization of medical services, the control of infection, blood transfusion, surgical procedures, and anesthetics.
Medical services, no matter how crude or sophisticated, have first to be delivered to the wounded soldier. For this to happen, there must be some kind of organization. Whether it is the provision of first responders working at the front line of combat, a system of more permanent hospitals with specialist medical staff, or simply the fundamental—and massively important—issue of transportation, there has to be the will and the wherewithal to create a medical organization.
In the ancient Greek world, care of the wounded was primarily the responsibility of comrades-in-arms, who in most instances were obligated by the tribal and familial bonds on which the army was built. Nothing much could be done other than the most basic remedial care of wounds: washing and binding, some anesthetizing with wine, and perhaps the use of natural soporifics and analgesics. The outcome was in the hands of the gods.
Imperial Rome brought its bureaucratic genius to the salvage work of the battlefield. Taxes were levied to finance the army. Permanent military medical personnel worked in the thick of combat. Specialist wound surgeons (medici vulnerarii) and a sophisticated system of hospitals (each military camp had its valetudenarium) tended to the wounded with a surprising awareness of the need for cleanliness to inhibit infection. Organizationally, the Roman soldier was afforded a level of care that would not be emulated until the nineteenth century.
A casualty of the dissolution of the Roman Empire’s brilliant bureaucracy was organized care for wounded and sick soldiers. (Pestilence was the greater killer for most of history. Not until the Franco-Prussian War of 1870–71 did battle deaths outnumber those dying from disease.) In the medieval West there was hardly any provision for the care of ordinary combat troops. Nobles were attended by their retinue, which might include a physician, but even so, their life expectancy from any kind of serious wound would have been on the short side. A historian of medieval epics has reconstructed the ministrations given to a badly wounded knight:
We see the wounded knight laid upon the ground, his wounds examined, washed and bandaged, often with a wimple from a woman’s forehead; the various practices of giving a stimulating wound-drink to relieve faintness, of pouring oil or wine into wounds, of stanching hemorrhage or relieving pain by sundry herbs, of wound-sucking to prevent internal hemorrhage; the mumbling of charms over wounds; the many balsams, salves and plasters used in wound-dressing; the feeling of the pulse in the cephalic, median and hepatic veins to ascertain the patient’s chances of recovery; the danger of suffocation or heat-stroke from the heavy visored helmet and coat of mail; the eventual transportation of the patient by hand, on shield or litters, on horseback or on litters attached to horses; the sumptuous chambers and couches reserved for the high-born, and the calling in of physicians, usually from the famous schools of Palermo or Montpellier in grave cases.6
For the ordinary soldier there is little evidence that the armies of the Middle Ages had any effective organization to deal with casualties.
It was not until the mid-eighteenth century that Western nations established institutionalized medical care for their armies or, indeed, for their civilian populations. The first permanent civilian hospital in America, for example, was established in Philadelphia in 1751 and the second in New York twenty years later. Military hospitals, including the fairly general provision of mobile field hospitals to accompany the army on campaign, did not guarantee effective treatment for a number of reasons: inadequate facilities, low-grade staff (in the British Army, for example, there was
no army medical school until 1858),7 lack of ambulances, and a general ignorance (by no means limited to military hospitals) of the principles of hygiene. Although two great military “hospitals” (Les Invalides in Paris, founded in 1676, and the Royal Hospital Chelsea, London, 1682) were established, they were not hospitals in the sense of treating the full range of combat wounded, but more like rest homes for a select number of wounded or aged ex-soldiers. The problem was the inadequacy and scarcity (often nonexistence) of hospitals proximate to the fighting.
All too often, those field hospitals that did follow the army on campaign were as much a threat to the soldier’s life as the enemy. The American doctor James Tilton, a pioneer of rational hospital design, viewed the field hospitals servicing the patriot army during the American War of Independence as lethal, where more men “were lost by death and otherwise wasted, at general hospitals, than by all other contingencies that have hitherto affected the army, not excepting the weapons of the enemy.”8 It is probably true that before the twentieth century, fragile medical facilities for soldiers on campaign were overwhelmed by any serious battle. A famous example, in relatively modern history, was the Crimean War (1854–56)—catastrophic even by the laissez-faire standards of the time. George Munro, an officer with the Ninety-Third Sutherland Highlanders, remembered:
We had a large number of regimental medical officers, but no regimental hospitals, and there were no field hospitals, with proper staff of attendants. We had no ambulance with trained bearers to remove the wounded from the battle-field, and no supplies of nourishment for sick or wounded.
On landing in the Crimea, the regimental hospital was represented by one bell tent, and the medical and surgical equipment by a pair of panniers containing a few medicines, a small supply of dressings, a tin or two of beef-tea, and a little brandy.…
The instruments were the private property of the surgeon, paid for out of his own pocket, as one of the conditions attached to promotion. The only means of carrying sick or wounded men consisted of hand-stretchers, entrusted to the [members of the regimental] band.9
At the beginning of the American Civil War, care for the wounded was entirely inadequate. At the outset the Union Medical Department consisted of a grand total of 98 officers. The early battles were a disaster on the medical front. At the first battle of Bull Run (Manassas, July 21, 1861) the Union wounded were abandoned, and just over a year later at second Bull Run, many of the wounded were left on the field for three days. The provision of field hospitals during the Peninsular campaign was lamentable. After the battle of Fair Oaks (Seven Pines, May 31, 1862) the Union field hospital had 5 surgeons and no nurses to treat 4,500 casualties.10 By the end of the war, however, the Union had the most sophisticated mobile military hospital and ambulance system in the world—and one that served pretty much as the organizational model for US battlefield medical care until the Vietnam War. This was due in large measure to the organizational genius of Dr. Jonathan Letterman, medical director of the Army of the Potomac, and William A. Hammond, who was appointed surgeon general in 1862. An illustration of the effectiveness of the Union medical system was that during Grant’s bloody campaign through Virginia in the later phase of the war, of the 52,156 gunshot casualties from March 1864 through April 1865, only 2,011 died from their wounds, a 3.2 percent mortality rate compared with the 10–25 percent rate for the period from July 1861 to March 1864.11
An organizational element of fundamental importance—transporting the wounded—was, until the late eighteenth century, either nonexistent or so cruelly jarring that it did more to kill men than save them. Improvements in either ambulance services that got the wounded soldier to a medical facility or, conversely, delivered medical services to the soldier in the field have been massively important in increasing casualty survival. All too often the wounded were simply left on the field, helped off by their comrades, or thrown into carts—or they crawled off as best they could.
Although the Austrians had some “flying ambulances” in the 1750s, it was not until the Napoleonic Wars that Napoleon’s surgeon general of the Imperial Guard, Dominique-Jean Larrey, emphasized the overwhelming importance of treating traumatically wounded men as soon after their wounding as possible, rather than waiting until the battle was over. The light field ambulances (ambulances volontes) he devised did two things: They not only got soldiers off the field and to a surgeon as quickly as possible, but they also delivered medical teams to men while the combat still raged—a model of battlefield medicine on which all modern practice is predicated. Nor did Larrey merely preach the doctrine of fast response. His own actions on the battlefield were inspirationally courageous. At Eylau (1807) he had become so involved in the combat zone that he had to be rescued by a cavalry detachment of the Imperial Guard, and at Waterloo he worked so close to the front line that Wellington recognized him and ordered his gunners to direct their fire elsewhere.12 In addition, Larrey refused to prioritize treatment on the basis of rank and social distinction, as had been the norm for centuries. The most grievously hurt were dealt with first, which has become the moral basis of triage in all modern military medicine.
Apart from the establishment of a system of divisional field hospitals, ambulance services gave the Union supremacy in battlefield medicine in the later half of the Civil War. In the beginning, though, it was dire. At the first and second battles of Bull Run (Manassas), civilian teamsters hired to drive wagons simply skedaddled (at first Bull Run not one Union casualty reached a hospital by ambulance). On the peninsula an army corps of thirty thousand had ambulance transportation for precisely one hundred men. At Shiloh (April 1862) and Perryville (October 1862) the ambulance service was shambolic. Letterman’s reforms of 1862 created a retrieval system that proved itself at Fredericksburg in 1862 and at Gettysburg in 1863, where there were one thousand ambulances and three thousand ambulance drivers and stretcher men.13
In the First World War the average time it took to get a wounded US soldier from first responder to definitive care was ten to eighteen hours. In World War II it dropped to six to twelve hours; in Korea, four to six hours; and in Vietnam, one to two hours (although it could be as short as forty minutes).14 As comforting as these ever speedier responses might seem (and in general they do reflect recovery systems of dramatically increasing effectiveness), it depended very much on where the wounded soldier was fighting. For example, within the tight perimeter of, say, Guadalcanal, a wounded US Marine could be extracted and delivered to a hospital ship in two hours. On the other hand, on Papua New Guinea the wounded had to be hand-carried down the Kokoda Trail for many hours, even days. In North Africa in 1942–43 “a wounded man could spend a day in a motor ambulance or a day and a night on a train reaching treatment.”15 Yet it was in those areas where evacuation was most difficult that air transportation of casualties was pioneered (the first helicopter evacuation, for example, was on April 23, 1944, in Burma).16 By the end of the war, 212,000 US wounded had been evacuated by air.17
BEFORE A CASUALTY can be mended by medical intervention, he must not be killed by medical intervention. It was not until the middle of the nineteenth century that such pioneers as Joseph Lister and William Detmold made the scientific link between uncleanliness, bacteria, and infection. Although there had been some understanding that uncleanliness and infection were linked (essentially that the wounded soldier should be treated in “clean” surroundings if possible), there were two problems. First, wartime circumstances often meant that soldiers were operated on under horrifically unhygienic conditions. Second, there was little understanding of how infection was transmitted. So doctors explored wounds with filthy hands and probes, swabbed wounds with sea sponges rinsed out in already contaminated water, irrigated wounds with unsterilized water, licked the silk sutures before threading them through unsterilized needles, wiped bloody instruments on dirty rags, and so on. General Carl Schurz described the scene after Gettysburg: “There stood the surgeons, their sleeves rolled up to the elbows, their bare arms as well as
their linen aprons smeared with blood, their knives not seldom held between their teeth, while they were helping a patient on or off the table, or had their hands otherwise occupied; around them pools of blood and amputated arms or legs in heaps, sometimes more than man-high. Antiseptic methods were still unknown at the time. As a wounded man was lifted on the table … the surgeon snatched his knife from between his teeth, … wiped it rapidly once or twice across his blood-stained apron, and the cutting began.”18
Gangrene, pyemia, tetanus, erysipelas, osteomyelitis, all blossomed. A Civil War surgeon describes losing a patient to pyemia after surgery:
Many a time have I had the following experience: A poor fellow whose leg or arm I had amputated a few days before would be getting on as well as we then expected—that is to say, he had pain, high fever, was thirsty and restless, but was gradually improving, for he had what we looked on as a favorable symptom—an abundant discharge of pus from his wound. Suddenly, overnight, I would find that his fever had become markedly greater; his tongue dry, his pain and restlessness increased; sleep had deserted his eyelids, his cheeks were flushed; and on removing the dressings I would find the secretions from the wound dried up, and what there were were watery, thin, and foul smelling, and what union of the flaps had taken place had melted away. Pyemia was the verdict, and death the usual result within a few days.19
Pyemia had a 98 percent mortality rate. In 1863 William Detmold made a connection between pyemia and puerperal fever—the great killer of women immediately following childbirth—and the connection was the doctor’s unclean hands and instruments. Like Lister he recommended thorough hygiene (Lister prescribed washing with carbolic acid), but “there is no evidence that Detmold’s precepts were followed.”20 Tetanus, with a death rate of 89 percent, thrived in the manure-rich battlefields of the Civil War and World War I. Stables were often the location of field hospitals in the Civil War and were nurturing environments for Clostridium tetani. Erysipelas, a streptococcal infection, was also introduced into wounds by dirty instruments, dressings, and hands. Infected soldiers had a 41 percent chance of dying.21
The Last Full Measure Page 39