Contemporary Aspects

Abstract

Between December 1965 and December 1971 the Unit-

ed States maintained armed forces in Vietnam never less

than 180000 men and women in support of the war At

one time this commitment exceeded half a million sol-

diers sailors and airmen from both the United States and

its allies Such forces required an extensive medical pres-

ence including 19 neurologists All but two of the neu-

rologists had been drafted for a 2-year tour of duty after

deferment for residency training They were assigned to

Vietnam for one of those 2 years in two Army Medical

Units and one Air Force facility providing neurological

care for American and allied forces as well as many civil-

ians Their practice included exposure to unfamiliar dis-

orders including cerebral malaria Japanese B enceph-

alitis sleep deprivation seizures and toxic encephalitis

caused by injection or inhalation of C-4 explosive They

and neurologists at facilities in the United States pub-

lished studies on all of these entities both during and af-

ter the war These publications spawned the Defense and

Veterans Head Injury Study which was conceived during

the Korean War and continues today as the Defense and

Tatu L Bogousslavsky J (eds) War NeurologyFront Neurol Neurosci Basel Karger 2016 vol 38 pp 201ndash213 (DOI 101159000442657)

Neurology in the Vietnam War

Carl H Gunderson a Robert B Daroff b

a F Edward Heacutebert School of Medicine Uniformed Services University of the Health Sciences Bethesda Md and b Department of Neurology Case Western Reserve University School of Medicine Cleveland Ohio USA

Veterans Head Injury Center It initially focused on post-

traumatic epilepsy and later on all effects of brain injury

The Agent Orange controversy arose after the war during

the war it was not perceived as a threat by medical per-

sonnel Although soldiers in previous wars had devel-

oped serious psychological impairments post-traumatic

stress disorder was formally recognized in the service-

men returning from Vietnam copy 2016 S Karger AG Basel

The Practice of Military Neurology during the

Vietnam War

Background Although the legendary history of the Southeast Asian Peninsula and Vietnam (spelled lsquoViet Namrsquo by its citizens) extends back 5 millennia its writ-

The views expressed here are those of the presentersauthors and do not reflect the official policy of the Uniformed Services University the Department of Defense or the US Government

Dow

nloa

ded

by

Ver

lag

S K

AR

GE

R A

G B

AS

EL

172

166

107

- 5

42

016

848

58

AM

202 Gunderson Daroff

ten history began in the year 111 AD with a Chi-nese invasion The subsequent history of the area is turbulent including the French invasion in the mid-19th century The French consolidated con-trol of the peninsula (except Thailand) and intro-duced the term lsquoIndochinarsquo The French occupa-tion continued until midway through World War II when the Japanese took over After that war the French were allowed to return but the Viet-namese particularly in the north waged a war of insurrection against the renewed French occupa-tion This was temporarily resolved by the Gene-va Convention of 1958 which recognized a North Vietnam state above the 17th parallel and a South Vietnam state below The Vietnam War began in 1959 when Communist-dominated North Viet-nam changed their approach to South Vietnam from lsquopolitical strugglersquo to lsquoarmed strugglersquo This was during the lsquoCold Warrsquo between the Soviet communist countries and the Western democrat-ic countries led by the USA At the time the pre-vailing belief by the US Government was the lsquoDomino Theoryrsquo which contended that if a country fell into Communism it would spread into neighboring countries like a row of falling dominoes The entirety of Southeast Asia was considered to be at risk if South Vietnam entered the Communist bloc In January 1963 the South Vietnam Army suffered its 1st major defeat Dur-ing the next 2 years the decision was gradually made to take the war into American hands [1]

The Vietnam War proved to be a totally differ-ent conflict from the war in Korea also fought to stop the military spread of Communism The Ko-rean War began on the 25th of June 1950 less than 5 years after the end of World War II In many ways it was a traditional war of position similar to World War II In Vietnam the Ameri-can forces now had to fight a war of insurrection not unlike the British struggles during the Amer-ican Revolution

In Korea the medical emphasis was on mobil-ity Medical facilities followed the movement of the fighting front whether in attack or retreat Ini-

tial evacuation was usually by ambulance through layers of increasingly technically sophisticated medical care The more seriously injured would be flown by helicopter to a Mobile Army Surgical Hospital By contrast in the Vietnam War hospi-tals and other support facilities were located and fixed in relatively secure areas As in Korea the more gravely ill and wounded were sent to Ameri-can facilities in Japan or the Philippines

Summersrsquo [1] Vietnam War Almanac provides a rich source of information on the timing of events during the Vietnam War By the end of 1964 there were 23300 American military per-sonnel in Vietnam This small contingent did not require a substantial medical presence on the ground Most of what was needed could be pro-vided by the medical facilities of the Air Forceand Navy in Japan and the Philippines All this changed when the first American combat troops arrived in Vietnam on 29 March 1965 By De-cember there were 184300 American military personnel in the country and by December 1968 this number had swelled to 536100 not including the 65000 troops from allied countries Extensive medical support was needed to attend to routine health needs treat casualties and deal with the medical challenges of operating in a tropical cli-mate these services could no longer be supported from a distance A large number of medical per-sonnel were needed to provide both primary and specialty care within Vietnam Not only was this demand met but also many physicians including neurologists took advantage of the opportunity to extend medical knowledge in a number of ar-eas including the long-term effects of penetrating brain injuries the management of cerebral ma-laria and viral encephalitis the toxic effects of cooking food with pilfered explosives and the ill effects of sleep deprivation on soldiers

American Military Neurology during the Vietnam War Period Neurology was involved quite early in the war [2] In late December 1965 the USNS General LeRoy

Tatu L Bogousslavsky J (eds) War NeurologyFront Neurol Neurosci Basel Karger 2016 vol 38 pp 201ndash213 (DOI 101159000442657) D

ownl

oade

d by

V

erla

g S

KA

RG

ER

AG

BA

SE

L

17

216

61

07 -

54

201

6 8

485

8 A

M

Neurology in the Vietnam War 203

Eltinge arrived in Saigon ( fig 1 ) after 23 daysat sea carrying the US Armyrsquos 935th MedicalDetachment (Neuropsychiatry [KO] team) The 935th KO team was one of many such specialty units or K Teams (eg Orthopedics KB Thorac-ic Surgery KF and Neurosurgery KE) used to augment the general surgeons and medical offi-cers assigned directly to either combat units or various numbered hospitals designated as Field Evacuation or Surgical Hospitals A KO team in-cluded three psychiatrists one neurologist one clinical psychologist one psychiatric nurse two social workers 11 enlisted personnel and a Jeep Captain Robert B Daroff [3] was the first neu-

rologist to serve in a war zone since 1945 He was followed by 14 US Army and 3 US Air Force neu-rologists who served in Vietnam until June 1971 ( table 1 ) By then as the war effort was rapidly ratcheting down troop strength had been re-duced to 156800 with an additional 53900 free world troops [1] All except one of the neurolo-gists were reserve officers (drafted or volunteered as opposed to the career or lsquoregularrsquo officers) and nearly all were draftees Nearly half of the neu-rologists were assigned to the 935th KO team lo-cated at Long Binh ( fig 1 ) and attached to the 93rd Evacuation Hospital ( fig 2 3 ) Most of the others served with the 98th KO team originally

Table 1 Neurologists who served in Vietnam

Neurologists in the 935th KO Team at the 93rd Evacuation Hospital in Long BinhRobert B Daroff MD (December 1965 ndash November 1966)Stanley Ginsburg MD (December 1966 ndash December 1967)Edward D Amorosi MD (September 1967 ndash May 1968)Arthur K Parpart MD (February 1968 ndash January 1969)W Bruce Ketel MD (December 1968 ndash December 1969)Eduardo Bonilla MD (October 1969 ndash October 1970)Leon Menzer MD (September 1970 ndash September 1971)

Neurologists in the 98th KO Team in Nha TrangAndrew C Carr MD (July 1966 ndash July 1967)Roger Q Cracco MD (July 1967 ndash May 1968)Eduard D Amorosi MD (May 1968 ndash September 1968)Peter B Dunne MD (July 1968 ndash July 1969)

Neurologists at the 95th Evacuation Hospital in Da NangCharles W Hall MD (August 1968 ndash August 1969)

Neurologists in the 98th KO Team in Da NangJohn D Hastings MD (August 1969 ndash August 1970)Marvin P Rozear MD (August 1970 ndash August 1971)

Neurologists at the Cam Rahn Bay Air Force HospitalCharles B Perkins MD (November 1967 ndash November 1968 [dates unconfirmed])Hershel Goren MD (November 1968 ndash November 1969)Robert AT Scott MD (November 1969 ndash November 1970 [dates unconfirmed])

Other neurologists in VietnamAlbert E Breland Jr MD (August 1968 ndash September 1969)Nick Keller MD (July 1970 ndash June 1971 [dates unconfirmed])

Modified from Gunderson and Daroff [2]

Tatu L Bogousslavsky J (eds) War NeurologyFront Neurol Neurosci Basel Karger 2016 vol 38 pp 201ndash213 (DOI 101159000442657) D

ownl

oade

d by

V

erla

g S

KA

RG

ER

AG

BA

SE

L

17

216

61

07 -

54

201

6 8

485

8 A

M

204 Gunderson Daroff

Fig 1 Map showing the locations of US Army hospitals in South Vietnam Internal Medicine in Vietnam Vol 2 General Medicine and Infectious Disease US Government Printing Office Wash-ington DC p 51

Tatu L Bogousslavsky J (eds) War NeurologyFront Neurol Neurosci Basel Karger 2016 vol 38 pp 201ndash213 (DOI 101159000442657) D

ownl

oade

d by

V

erla

g S

KA

RG

ER

AG

BA

SE

L

17

216

61

07 -

54

201

6 8

485

8 A

M

Neurology in the Vietnam War 205

located at Nha Trang and later transferred to Da Nang ( table 1 )

Most Army and Air Force neurologists were 2-year draftees At the time young men were ei-ther subject to the draft after graduation from high school or received a deferment in order to complete college and possibly graduate school depending on military needs Students entering medical school were deferred for the 4 years of medical school and 1 year of internship Students could volunteer for the lsquoBerry Planrsquo which per-

mitted further deferment for training in selected specialties followed by an obligated 2-year lsquotourrsquo of active duty Eight young physicians were de-ferred for neurology training in 1959 to be avail-able for service in the Army Medical Corps by the summer of 1962 including the first author (CHG) [4] Six were similarly selected in 1960 for service beginning in 1963 including the sec-ond author (RBD) [3] As an additional re-source the Army maintained residency programs at Walter Reed Army Medical Center in Wash-

Fig 2 The 93rd Evacuation Hospi-tal in late December 1965 several weeks after its opening Courtesy of Robert Daroff

Fig 3 The 93rd Evacuation Hospital in the summer of 1966 which includ-ed the hospital the helicopter pad on the left and tents behind it which were reserved for the 616th Clearing Company as well as for housing for the enlisted personnel of the hospi-tal and the 935th Medical Detach-ment Neuropsychiatry Team In the foreground across the road was an Army of the Republic of Vietnam base In the background are the am-munition and petroleum dumps that surrounded the hospital Courtesy of Robert Daroff

Tatu L Bogousslavsky J (eds) War NeurologyFront Neurol Neurosci Basel Karger 2016 vol 38 pp 201ndash213 (DOI 101159000442657) D

ownl

oade

d by

V

erla

g S

KA

RG

ER

AG

BA

SE

L

17

216

61

07 -

54

201

6 8

485

8 A

M

206 Gunderson Daroff

ington DC and at Letterman Army Medical Center in San Francisco California USA During the war years Walter Reed graduated approxi-mately 19 adult and child neurologists while Let-terman produced approximately nine

Most of the graduates of the Army residency programs staffed the Armyrsquos six Medical Centers including not only Walter Reed and Letterman but also Tripler Army Medical Center (Hono-lulu Hawaii USA) Fitzsimmons Army Hospital (Denver Colo USA) Madigan Army Medical Center (Tacoma Wash USA) Brooke Army Medical Center (San Antonio Tex USA) and William Beaumont Army Medical Center (El Paso Tex USA) Berry Plan neurologists were usually assigned to staff positions at large base hospitals including those at Fort Bragg Fort Ben-ning Fort Hood Fort Ord Fort Knox and Fort Carson as well as Army hospitals in Korea and West Germany Those few reserve officers who stayed beyond their obligatory 2 years became available as backfill for the more popular assign-ments at the Medical Centers Once the war be-gan two to three drafted Army or Air Force re-serve neurologists were sent to Vietnam usually for their first year of obligated duty They were

often given their choice of assignments for their second year Only one Army-trained career neu-rologist Lieutenant Colonel Nick Keller served in Vietnam He was assigned as the Psychiatry and Neurology Consultant (a senior staff posi-tion)

Providing Neurologic Services in Vietnam During most of the war neurologists in the 935th and the 98th KO Teams were practicing solo Lat-er there was some overlap at the 935th KO Team ( table 1 ) Few had any clinical experience beyond residency Since these were the years before brain imaging was developed most diagnoses depend-ed upon clinical skills The only available diag-nostic tools were lumbar puncture plain x-rays and EEG with the latter only available after 1968 for the 935th KO Team The first EEG machine to be delivered was severely rusted unusable and said to have been lsquodropped in the Bayrsquo [2] More sophisticated procedures such as angiography and pneumoencephalography were not available except in facilities that also had a neurosurgeon The conditions under which the neurologists worked were quite varied When Captain Daroff arrived at the 93rd Evacuation Hospital in Long

Fig 4 Entrance to the Neurology Clinic of the 93rd Evacuation Hospi-tal in 1970 Courtesy of Leon Menzur MD

Tatu L Bogousslavsky J (eds) War NeurologyFront Neurol Neurosci Basel Karger 2016 vol 38 pp 201ndash213 (DOI 101159000442657) D

ownl

oade

d by

V

erla

g S

KA

RG

ER

AG

BA

SE

L

17

216

61

07 -

54

201

6 8

485

8 A

M

Neurology in the Vietnam War 207

Binh it was a collection of tents and Quonsethuts in the middle of a rubber plantation ( fig 2 ) In contrast when Captain Carr arrived at Nha Trang it was lovely resort city with air-condi-tioned housing and clinics for the medical staff [5] The 93rd Evacuation Hospital ambience im-proved somewhat over the ensuing months ( fig 3 ) but remained rather primitive through-out the conflict ( fig 4 ) The many experiences of the succeeding neurologists were described by Gunderson amp Daroff [2]

In November 1967 the Air Force opened a neurology service at Cam Ranh Bay a large and well-protected installation that they maintained for 3 years The 400-bed hospital was second only to Wilford Hall Medical Center in San Antonio as the Air Forcersquos largest hospital As might be ex-pected these neurologists as well as those as-signed to Army units were used as consultants at other Army and Air Force installations [2]

Types of Patients Seen by the Military Neurologists in Vietnam Patients were referred from the other military medical units and consisted mostly of American

and allied armed forces but there were also a number of civilians in the mix Headaches trau-matic neuropathies epilepsy and psychogenic disorders constituted the most common reasons for referral If additional workup was required the patients were evacuated to military facilities in Japan or the Philippines

Daroff [3] logged 621 new patients and 153 re-turn visits during his year in Vietnam The major-ity of cases were similar to those seen in young soldiers outside of combat zones these cases in-cluded headaches epilepsy single seizures and peripheral nerve injuries with only occasionally more serious problems such as 19 cases of cere-bral malaria and five cases of stroke ( table 2 ) He was not asked to treat any enemy soldiers As op-posed to the Middle Eastern wars of the 21st cen-tury head injury was seen much less commonly The importance of concussion had not yet been fully appreciated and more serious head injuries went directly to surgical units Most neurologists had little experience with tropical diseases but were now faced with cerebral malaria and season-al epidemics of encephalitis

Scientific Opportunities and Issues Presented

by the War

Head Injury The Caveness Study The William Caveness Head Injury Study was the most ambitious and long-lasting neurological re-search enterprise of the Vietnam War and re-mains ongoing in 2015 Over the years it has un-dergone a number of name changes and is pres-ently the Defense and Veterans Head Injury Center based in Silver Spring Maryland Dr Caveness a neurologist and the original principal investigator had served in the Navy for 23 months in Korea and Japan during the Korean War In 1969 he submitted a report to the Office of Naval Research summarizing the activity of the lsquoCom-bat Head Injury Projectrsquo from 15 May 1953 to 30 September 1969 lsquoIn the spring of 1953 the Bu-

Table 2 Patients seen by Daroff during his year in Viet-nam [3]

Disorder Number

Headache 120Neuropathy 112Seizures 75Psychogenic disorders 70Neck and back pain 44Syncope 40Head trauma-related disorders 29No disease 21Cerebral malaria 19Cerebrovascular disorders 12Movement disorders 8Intoxicationspoisoning 8Vertigo 6Sleep disorders 5Stroke 5

Tatu L Bogousslavsky J (eds) War NeurologyFront Neurol Neurosci Basel Karger 2016 vol 38 pp 201ndash213 (DOI 101159000442657) D

ownl

oade

d by

V

erla

g S

KA

RG

ER

AG

BA

SE

L

17

216

61

07 -

54

201

6 8

485

8 A

M

208 Gunderson Daroff

reau of Medicine and Surgery US Navy initi-ated a prospective study of head injuries and their sequelae The material has been or was to be de-rived from cerebral trauma associated with com-bat and supporting activitiesrsquo The methodology included establishing a neurological team to par-ticipate in the care of head trauma during the acute phase a clinical service at the Naval Hospi-tal in Yokosuka Japan and a research unit at the Neurological Institute of Columbia University College of Physicians and Surgeons in New York to provide follow-up care [6]

Caveness [7] described the project during the Vietnam War years in the Journal of Neurosur-gery in 1979 lsquoDuring the Vietnam War 1967ndash1970 a roster of 1221 head injured men was de-veloped by military surgeons Through the com-pletion of Registry Forms subjects were selected for future study The injured received definitive care within an average of 6 hours after injury The forms four-fifths of which were completed by personnel trained in Neurological Surgery pro-vided a uniform assessment of the initial neuro-logic status particularly as regards to level of con-sciousness and location and extent of cranio-ce-rebral damage not previously reported in military or civilian populations of head injured patientsrsquo [7]

After initial follow-up examination 1030 cas-es were selected for further study A total of 764 had been injured by missile fragments 163by gunshot wounds and 41 from vehicle acci-dents When the patients arrived at a medical care facility 553 were alert and 201 were re-sponding only to commands Moreover 424 had injuries to a single lobe of the brain while 409 had injuries to multiple lobes [7]

The Caveness Study Epilepsy Post-traumatic seizures were of special interest to Dr Caveness He reported the early Vietnam fol-low-up data in 1979 and compared it with his data from the Korean War By 1979 344 of the 1030 Vietnam study cases had developed sei-

zures Following both conflicts most patients who developed seizures did so within the first6 months after injury and about 9 within the first month Even within this group there was a subgroup that Caveness described as lsquoearlyrsquo hav-ing experienced their first seizure within the first week A total of 279 of the seizures occurred in patients with single-lobe injuries whereas 437 were in those with multiple injured lobes In the Korean group over a 10 year period about one-third had 1ndash3 seizures another one-third had 20ndash30 seizures and the remainder had lsquotoo many sei-zures to countrsquo Early in the follow-up of the Viet-nam War patients the seizures persisted in over half of those who had them within the first week after the injury About a quarter of all seizures were partial seizures [7]

In 1980 there was a major follow-up study on 1221 subjects from the Vietnam Head Injury Study performed at the Walter Reed Army Med-ical Center Five hundred and twenty of these men and 85 controls matched for age and service in Vietnam for whom Armed Forces Qualifica-tion Test (a psychometric evaluation performed upon entrance into military service) scores were available were admitted to the hospital for a 1-week reevaluation including lsquoneurologic histo-ry and examination formal visual fields exten-sive neuropsychological battery speech and lan-guage audiology physical rehabilitation batter-ies electroencephalogram (EEG) visual auditory and somatosensory evoked potentials CT rou-tine laboratory and x-rays and an in-home Amer-ican Red Cross conducted family interview of the veterans and familiesrsquo [8]

Head Injury and Neuropsychological Deficits The initial thrust of the Caveness study was the relationship of injury to epilepsy Colonel Andres Salazar [8] published several studies addressing this relationship over the next several years In 1985 Salazar et al [9] reported the clinical corre-lates of the first 421 head-injured subjects 224 had epilepsy and 197 did not There were several

Tatu L Bogousslavsky J (eds) War NeurologyFront Neurol Neurosci Basel Karger 2016 vol 38 pp 201ndash213 (DOI 101159000442657) D

ownl

oade

d by

V

erla

g S

KA

RG

ER

AG

BA

SE

L

17

216

61

07 -

54

201

6 8

485

8 A

M

Neurology in the Vietnam War 209

significant differences between the two groups The epileptic patients had lost more brain vol-ume were more likely to have metal fragments remaining evidence of a hematoma focal neuro-logic signs including initial and residual hemipa-resis and aphasia visual field loss and organic mental disorders (The older terms lsquoorganic men-tal disorderrsquo or lsquoorganic mental syndromersquo en-compassed a variety of conditions commonly re-ferred to as confusional states encephalopathy stupor and dementia among others) There was no difference in the family history of seizures or retrograde or anterograde amnesia The overall frequency of epilepsy was 43 and of those with epilepsy 92 had more than one seizure The av-erage duration of epilepsy was 93 months Sur-prisingly 18 had their first seizure 5 years after injury and 7 had their first seizure ten or more years after injury There was no recognized etio-logical factor to explain the late onset in these pa-tients [9]

After 1980 the Caveness study prompted con-siderable attention to the psychological sequelae of penetrating head injury Tissue loss could now be correlated with CT findings Two papers writ-ten by Grafman et al in 1986 [10] and 1988 [11] summarized these findings The first examined the relationship between pre-injury intelligence the amount of brain tissue loss and lesion local-ization and cognitive deficits in Vietnam Warpatients They found that Armed Forces Quali-fication Test scores accounted for a significant amount of the variance in overall intelligence in-dependent of the volume of brain loss on global cognitive measures Left hemisphere lesions es-pecially those in the frontal and temporal lobes caused the most impairment in performance on verbal tests Temporal lobe lesions were most pre-dictive of impaired performance on the spatial memory test [10 11]

Japanese B Encephalitis Many of the neurologists had some experience with the arthropod-borne virus encephalitides

(Arbor viruses) as these were endemic in por-tions of the United States In Vietnam episodes of viral encephalitis occurred every year between the months of April and September There was no controversy as to whether these were viral en-cephalitides but it was unclear how many were Japanese B encephalitis or were some unidenti-fied virus Control of these diseases required eliminating mosquitoes The neurologist Captain W Bruce Ketel noted three cases in Long Binh occurring in a short period of time He had the base sprayed and stopped the epidemic earning a Bronze Star for preventive medicine [2]

In 1969 the 93rd Evacuation Hospital where the 935th KO team was located was designated as the center for the treatment of encephalitis This allowed Captain Ketel and the Medical Consul-tant Colonel Andre J Ognibene to study 57patients admitted with encephalitis during that summer Immunologic confirmation of Japanese B encephalitis was made in only 10 of the 57 Al-though only one patient died 36 had to be evac-uated from Vietnam due to their persistent en-cephalopathy [12]

Focal neurologic signs were quite varied in these patients and showed little pattern These in-cluded ocular palsies nystagmus aphasia clumsy gait and mild tremor Babinski sign and other evidence of upper motor neuron disorders were seen only in patients who had major motor sei-zures The most common persistent findings were related to mental status [12] Lincoln and Silvertson reported similar results for 201 cases of Japanese B encephalitis in American soldiers in Korea in 1950 [13]

Cerebral Malaria Cerebral malaria was a disorder completely un-known to the American neurologists in Vietnam RBD [14] and his 93rd Evacuation Hospital col-leagues and Captain Carr [5] published their ex-periences whereas Barrett and Blohm [15] de-scribed the countrywide experience Diagnosis of cerebral malaria depended on confirmed parasit-

Tatu L Bogousslavsky J (eds) War NeurologyFront Neurol Neurosci Basel Karger 2016 vol 38 pp 201ndash213 (DOI 101159000442657) D

ownl

oade

d by

V

erla

g S

KA

RG

ER

AG

BA

SE

L

17

216

61

07 -

54

201

6 8

485

8 A

M

210 Gunderson Daroff

emia and neurologic features with no other expla-nation The frequency was about 16 of the total malaria cases and the signs and symptoms were nonspecific In RBDrsquos series of 19 patients eight had disturbances of consciousness ranging from stupor to coma four had encephalopathies mani-festing as confusion and disorientation three had movement disorders three were psychotic and only one had focal signs [14]

In World War II cerebral malaria was often fatal RBD [14] reviewed the literature involving American and allied troops The overall mortality rate was 21 The treatment was fairly standard consisting of quinine either alone or with quina-crine hydrochloride administered intravenously Increased intracranial pressure was treated with therapeutic lumbar puncture

The basic therapy used by the neurologists in Vietnam consisted of quinine sulfate pyrimeth-amine and sulfadiazine RBD arrived at the 93rd Evacuation Hospital when it had been in op-eration for only 2 weeks during which time two American soldiers had died of cerebral malaria He reviewed the records noted that steroids were not used and began using them in patients who were encephalopathic or otherwise seriously im-paired Over the course of his year in Vietnam none of the 19 patients with cerebral malaria died Captain Carr also used steroids in patients with increased intracranial pressure and experienced no deaths [5] Major Robert Blount [16] an inter-nist at the 85th Evacuation Hospital (1966ndash1967) treated every one of the 24 cases at his hospital with steroids and had no deaths Thus the com-bined experience of the three Army hospitals in Vietnam in 1966ndash1967 totaled 62 cerebral malar-ia patients who were liberally treated with ste-roids with no deaths The usefulness of steroids for cerebral malaria was questioned by Worrell et al in 1982 [17] They performed a double-blind series of 100 Thai patients ages 6ndash70 years of age They made no attempt to stratify the patients based upon severity of illness There were eight deaths in the steroid group and nine deaths in

the control group a mortality rate of 17 only slightly less than that observed in military per-sonnel during World War II Clearly this popula-tion was not comparable to those of RBD Carr or Blount RBD addressed additional criticisms of steroid use in 2001 [18] Both Carrrsquos and RBDrsquos patients had only minor residual symp-toms The 93rd Evacuation Hospital team [19 20] used psychometric testing and found that al-though early minor abnormalities could be dem-onstrated in the recovery period these disap-peared on retesting Twenty years after the war Varney et al [21] published a study of 42 Viet-nam veterans who had suffered high fever due to malaria and had at least 24 hours of amnesia as well as 40 Vietnam veterans who had experienced combat injuries Psychological testing uncovered a number of abnormal characteristics that were more common in the malaria patients However lsquosocial functioningrsquo was not different between the two groups with 80 of the malaria patients and 85 of the war-injured patients being employed The malaria patients had held more jobs than the combat-injured individuals and the two groups had similar numbers of marriages [21]

Put in perspective the care provided to pa-tients with cerebral malaria by the neurologists who served in Vietnam was obviously more effec-tive than that used in World War II Given the vascular pathology of cerebral malaria it is not surprising that these patients might show late ef-fects not evident upon immediate recovery

Sleep Deprivation Seizures In the summer of 1967 CHG was transferred from the Medical Field Service School in San An-tonio Texas to become Assistant Service Chief of Neurology at Letterman Army Medical Center in San Francisco On CHGrsquos 1st day of teaching rounds he was shown a patient who had had a seizure the day before at the Oakland Army Base The residents diagnosed him as lsquojust another sleep deprivation seizurersquo Not only had CHG never heard of the entity but also a literature

Tatu L Bogousslavsky J (eds) War NeurologyFront Neurol Neurosci Basel Karger 2016 vol 38 pp 201ndash213 (DOI 101159000442657) D

ownl

oade

d by

V

erla

g S

KA

RG

ER

AG

BA

SE

L

17

216

61

07 -

54

201

6 8

485

8 A

M

Neurology in the Vietnam War 211

search failed to reveal any mention of this asso-ciation CHG later learned that Captain Carr had identified sleep deprivation as a cause of sei-zures in 11 of the 85 seizure patients who he eval-uated while in Vietnam [5]

Letterman was in a unique position to study this phenomenon The San Francisco Bay Area was the staging area for most of the personnel and equipment involved in the Vietnam War Most of the personnel going to or from the war had to pass through the Oakland Army Base across the Bay from San Francisco and Letterman provided neurological support for that base

A research project was started to study the cause of seizures in the Oakland Army Base and elsewhere in the military lsquopipelinersquo to or from Vietnam A search of the discharge records at Letterman identified 78 patients who had been evaluated following a single generalized seizure between 1966 and 1968 Thirty-eight who had no prior seizure history and no other apparent cause were selected for further study Patients with a seizure associated with a closed head in-jury or with a history of chronic alcoholism were excluded [22] During the study period 435000 returning soldiers and 595000 outbound mili-tary personnel passed through the Oakland Ar-my Base

Most of the 38 study patients were returning from Vietnam after a 13-month tour of duty The following quotation summarizes the events they encountered during their returned to the United States lsquoA day or two before they were to leave they were moved to an embarkation point The night before was usually an occasion for celebra-tion often featuring the consumption of a large amount of alcohol and little or no sleep At the embarkation point a number of steps in admin-istrative processing were accomplished so that the soldier might not miss his scheduled flight Processing often was done without interruption on a 24-hour basis usually in stifling heatrsquo

Once the soldiers embarked on the plane the period of sleep deprivation for many had just be-

gun lsquoThe flying time from Southeast Asia to Tra-vis Air Force Base in California ranged between 10 and 18 hours depending on the number of in-termediate stops Some soldiers slept aboard the plane while others did not On arrival at Travis Air Force Base they were taken to the Oakland Army Base terminal by bus another four hour de-layrsquo [22] Processing included medical examina-tions and production of new uniforms for all re-turning soldiers For those going to other bases processing required about four hours For those being discharged from service processing re-quired several hours more Transfer to the San Francisco International Airport took at least an-other hour after which soldiers had to wait for their commercial plane One of the study patients had his first seizure waiting in the San Francisco airport terminal and was sent back to Letterman [22]

It was usually easy to derive a fairly accurate estimate of how long it had been since a soldier had at least four hours of uninterrupted sleep Many could be documented as having been sleep deprived in excess of 48 hours All 38 selected for further study had been sleep deprived for 24 or more hours Most were younger soldiers without a prior history of heavy drinking Many had con-sumed an unaccustomed quantity of alcohol be-fore boarding the plane A control group of re-turning soldiers was identified who showed sub-stantially less sleep deprivation then the study patients [22] A clear correlation between the pe-riod of sleep deprivation and the occurrence of a seizure could be demonstrated

C-4 Encephalitis C-4 is a lsquoplastic explosiversquo widely used in Vietnam in Claymore land mines and standard demolition kits To be used as an explosive it must be set off by a detonator If it is simply ignited it will burn with a hot flame emitting toxic fumes but will not explode Pilfered C-4 was often used in the field for cooking by both soldiers and Vietnam civil-ians When ingested it produced lsquointoxicationrsquo

Tatu L Bogousslavsky J (eds) War NeurologyFront Neurol Neurosci Basel Karger 2016 vol 38 pp 201ndash213 (DOI 101159000442657) D

ownl

oade

d by

V

erla

g S

KA

RG

ER

AG

BA

SE

L

17

216

61

07 -

54

201

6 8

485

8 A

M

212 Gunderson Daroff

similar to alcohol Its principal ingredients are 19 cyclotrimethylenetrinitramine 21 poly-isobutylene 16 motor oil and 53 inert plas-ticizer When injected intravenously into ani-mals it causes seizures

Ketel and Hughes [23] published their clinical experience with C-4 intoxication They saw sev-eral cases per month at the 93rd Evacuation Hos-pital and wrote lsquoC-4 intoxication was suspected when the patients presented with the symptom complex of nausea vomiting generalized sei-zures (single and particularly multiple attacks) prolonged post ictal confusion and amnesia A definitive diagnosis was made when a history of C-4 use could be obtained from the patient or others in his unit or when gastric analysis re-vealed the presence of nitrates The signs and symptoms of C-4 intoxication usually began 8ndash12 hours after exposure Seizures usually only oc-curred during the first 36 hours and could not be controlled with either phenytoin or phenobarbi-tal After the seizures the patients displayed con-fusion lethargy and poor memory which usually cleared within a weekrsquo

Cerebrospinal fluid and liver enzymes were normal in their study but an occasional patient showed evidence of renal damage There was usu-ally a transient elevation of the white blood cell count of up to 29000 per cubic millimeter Many of their patients had myoclonic jerks and the EEGs during these episodes showed bilateral syn-chronous and symmetrical spike and wave com-plexes at 2ndash3 per second which were maximal on the frontal areas with a slow background frequen-cy These EEG signals usually returned to normal within 1ndash3 months [23]

Agent Orange Agent Orange was a mixture of several herbicides that the US military sprayed over Vietnam to re-duce the thick jungle that could conceal enemy forces destroy crops that those forces might de-pend upon and clear areas around US base camps The mixture may have caused toxicity to

exposed veterans and the native Vietnamese This is discussed at length in an 870 page book that is updated every 2 years by the Institute of Medicine of the National Academies [24] A variety of med-ical conditions have been deemed by the US Vet-erans Administration to be secondary to Agent Orange and these lsquoservice connectedrsquo veterans re-ceive compensation from the government Cur-rently the two primary neurological conditions recognized as being service connected are Parkin-sonrsquos disease and peripheral neuropathy provid-ed that the neuropathy was evident within 1 year of herbicide exposure (see wwwpublichealthvagovexposuresagentorangeconditions)

Post-Traumatic Stress Disorder The term post-traumatic stress disorder was first used to describe the psychiatric syndrome mani-fested by many Vietnam veterans It has contin-ued to be used in all subsequent wars involving the USA and indeed for nonmilitary stress reac-tions

The disorder was certainly present but named differently in all previous wars involving the USA since the Civil War in 1891ndash1865 [25] In World War I it was called lsquoshell shockrsquo and in World War II lsquocombat exhaustionrsquo It was not unique to US wars as it was also described in the Boer War [26]

Post-traumatic stress disorder in Vietnam vet-erans was undoubtedly enhanced by the warrsquos un-popularity Whereas previous and subsequent combat veterans were treated as heroes upon their return home many Vietnam veterans were scorned and treated as pariahs However all vet-erans may take solace in Lindrsquos [27] 2002 book (Vietnam The Necessary War) that somewhat convincingly makes the case that the war initiated the series of events that led to the fall of the Soviet Union

Tatu L Bogousslavsky J (eds) War NeurologyFront Neurol Neurosci Basel Karger 2016 vol 38 pp 201ndash213 (DOI 101159000442657) D

ownl

oade

d by

V

erla

g S

KA

RG

ER

AG

BA

SE

L

17

216

61

07 -

54

201

6 8

485

8 A

M

Neurology in the Vietnam War 213

References

1 Summers HG Vietnam War Almanac New York NY Facts On File Publica-tions 1985

2 Gunderson C Daroff RB Vietnam Arch Neurol 2002 59 141ndash146

3 Daroff RB Neurology in a combat zone J Neurol Sci 1999 170 131ndash137

4 National Archives College Park MD RG 112 E1015 Box 57

5 Gunderson CH Daroff RB Carr AC Neurology in Vietnam CPT Carrrsquos pa-tients Mil Med 2004 169 768ndash772

6 Caveness WF Combat head injury proj-ect follow-up phase Statistical studies of combat head injury Office of Naval Research Columbia University New York NY 24 November 1969

7 Caveness WF Meirowsky AM Rish BL et al The nature of posttraumatic epi-lepsy J Neurosurg 1979 50 545ndash553

8 Salazar A Grafman J Jabbari B et al Epilepsy and cognitive loss after pen-etrating head injury in Wolf P Dam W Janz M et al (eds) Advances in Epilep-tology New York Raven Press 1987 pp 267ndash268

9 Salazar A Epilepsy after penetrating head injury I clinical correlates ndash a re-port of the Vietnam Head Injury Study Neurology 1985 35 1406ndash1414

10 Grafman J Salazar A Weingartner H et al The relationship of brain tissue loss and lesion volume location to cognitive deficit J Neurosci 1986 6 301ndash307

11 Grafman J Jonas BS Martin A et al Intellectual function following penetrat-ing head injury in Vietnam veterans Brain 1988 111 169ndash184

12 Ketel WB Ognebine AJ Japanese B en-cephalitis in Vietnam Am J Med Sci 1971 261 271ndash279

13 Lincoln AF Silvertson SE Acute phase of Japanese B encephalitis Two hundred and one cases in American soldiers Ko-rea 1950 J Am Med Assoc 1952 150 268ndash273

14 Daroff RB Deller JJ Jr Kastl AJ Jr et al Cerebral malaria J Am Med Assoc 1967 202 679ndash682

15 Barrett O Blohm RW Malaria The Clinical Disease in Ognebene AJ Bar-rett O (eds) Internal Medicine in Viet-nam Vol II San Antonio TX General Medicine and Infectious Diseases US Government Printing Office 1982 pp 295ndash312

16 Blount RE Jr Acute falciparum malaria field experience with quininepyrimeth-amine combined therapy Ann Intern Med 1969 70 142ndash147

17 Warrell DA Looareesuwan S Warrell MJ et al Dexamethasone proves delete-rious and cerebral malaria New Engl J Med 1982 306 313ndash319

18 Daroff RB Cerebral malaria J Neurol Neurosurg Psychiatry 2001 70 817ndash818

19 Kastl AJ Daroff RB Blocker WW Psy-chological testing of cerebral malaria patients J Nerv Ment Dis 1968 147 553ndash561

20 Blocker WW Jr Kastl AJ Jr Daroff RB The psychiatric manifestations of cere-bral malaria Am J Psychiatry 1968 125 192ndash196

21 Varney NR Roberts RJ Springer JA et al Neuropsychiatric sequelae of cerebral malaria J Nerv Ment Dis 1997 185 695ndash703

22 Gunderson CH Dunne PB Feyer TL Sleep deprivation seizures Neurology 1973 23 678ndash686

23 Ketel WB Hughes JR Toxic encepha-lopathy with seizures secondary to in-gestion of composition C-4 A clinical and electroencephalographic study Neurology 1972 22 871ndash876

24 Committee to Review the Health Effects in Vietnam Veterans of Exposure to Herbicides (Ninth Biennial Update) Veterans and Agent Orange Update 2012 Washington DC National Acad-emies Press March 20 2014

25 Hyams KC Wignall S Roswell R War syndromes and their evaluation From the US Civil War to the Persian Gulf War Ann Intern Med 1996 125 398ndash402

26 Hodgins-Vermaas R McCartney H Everitt B et al Post-combat syndromes from the Boer war to the Gulf war a cluster analysis of their nature and attri-bution BMJ 2002 324 321ndash324

27 Lind M Vietnam The Necessary War A Reinterpretation of Americarsquos Most Di-sastrous Military Conflict New York Simon amp Schuster 2002

Carl H Gunderson MD Department of Neurology Uniformed Services University of the Health Sciences 4301 Jones Bridge Road Bethesda MD 20814 (USA) E-Mail carlgunderson usuhsedu

Tatu L Bogousslavsky J (eds) War NeurologyFront Neurol Neurosci Basel Karger 2016 vol 38 pp 201ndash213 (DOI 101159000442657) D

ownl

oade

d by

V

erla

g S

KA

RG

ER

AG

BA

SE

L

17

216

61

07 -

54

201

6 8

485

8 A

M