Chapter 2
U.S. Medicine in Vietnam: The Early Years
Colonel O`Neill Barrett, Jr., MC, USA (Ret)
Our God and the soldier we alike adore
Ev`n at the brink of danger, not before:
After deliverance, both alike requited,
God is forgotten, and the soldiers lighted.
-Quarles, 1635
Francis Quarles might also have commented upon the diseases which soldiers encounter in time of war and which are likewise all too quickly slighted or forgotten. As Lt. Col. (later Col.) Robert H. Moser (1965) noted: "Disease is woven intricately into the fabric of war. The story of one cannot be told without the other. Yet each succeeding generation, soldier and scholar alike, seems reticent to concede to the microbe its historical role as an awesome factor in the wars of man." So it was in Vietnam, where the involvement of the U.S. Army exposed an unprepared generation of physicians to diseases which for them were but vague recollections from a dreary course in tropical medicine, mercifully brief, in an already overcrowded medical school curriculum. This despite the prophecies of such military medical visionaries as Col. (later Brig. Gen.) William D. Tigertt, MC (1966), who predicted the problem of drug-resistant malaria in early 1962.
Before 1962, the total American troop strength in Vietnam was small and composed primarily of MAAGV (Military Assistance Advisory Group, Vietnam) personnel. American medical care in Saigon was available through a small State Department dispensary; hospitalization, when required, was provided at the local Seventh Day Adventist Hospital or the Swedish Hospital. In late 1961, as a consequence of the decision by President John F. Kennedy to increase support to RVNAF (Republic of Vietnam Armed Forces), a significant buildup of U.S. Army combat advisory support took place. Overall support of this activity was provided by the USARYIS (U.S. Army, Ryukyu Islands) Support Group (Provisional), under the command of Col. Marvin H. Merchant; the medical section consisted of one Medical Service Corps officer, Maj. (later Lt. Col.) Frank Filtsch, and an enlisted clerk.
The information in this chapter, unless otherwise noted, is from the personal observations and records of the author or from Neel, S. 1973. Medical support of the U.S. Army in Vietnam, 1965-1970. Vietnam Studies. Washington: Government Printing Office.
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In March 1962, the USARYIS activity was redesignated USASGV (U.S. Army Support Group, Vietnam) and placed under the command of Brig. Gen. Joseph W. Stilwell, Jr. The USASGV and MAAGV units were, in turn, placed under control of MACV (Military Assistance Command, Vietnam), commanded by Lt. Gen. Paul D. Harkins. The first MACV surgeon was Cmdr. (later Capt.) Paul G. Bamberg, MC, USN, who served in this capacity for several months and was replaced by Col. (later Maj. Gen.) William Moncrief, Jr., MC. Medical support for this 1961-62 troop buildup was provided by three OA* medical detachments, located respectively at Tan Son Nhut (Saigon), Qui Nhon, and Nha Trang. These detachments were able to provide minor surgical and outpatient medical services. The detachment in Nha Trang was inactivated following the arrival of the 8th Field Hospital in that city.
Based on the anticipated increase in troop strength, the need for greater medical support was recognized. As a consequence, the 8th Field Hospital, part of the 43d Medical Group stationed at Fort Lewis, Wash., was alerted for movement. This hospital was in a training status, minus professional complement, under the competent command of Maj. Jack D. A. Dickey, MSC, who served as the executive officer of the unit in Vietnam. Command of the hospital was given to Lt. Col. (later Col.) Carl A. Fischer, MC, who had served as a corps surgeon during the Korean conflict. Other key staff members included Maj. (later Col.) O`Neill Barrett, Jr., MC, Chief of Medical Service and coordinator for professional activities; Maj. (later Col.) Ariel Rodriguez, MC, Chief of Surgical Service; Maj. (later Col.) Louise F. Bitter, ANC, Chief Nurse; and M. Sgt. Chester Spain, sergeant major.
Several weeks before the anticipated deployment of the unit, an advance party, consisting of Major Barrett, Maj. Paul E. Hartenstein, MC, Major Dickey, and Maj. (later Lt. Col.) Murray Lieberman, DC, departed for Saigon. En route this team was briefed by the USARPAC (U.S. Army, Pacific) surgeon and his staff in Hawaii and by the USARYIS surgeon in Okinawa. Following discussions with the USARYIS Support Group commander in Saigon, the group flew to Nha Trang, the designated location for the hospital. It is perhaps symbolic that this city was chosen as the site for the first United States hospital in Vietnam, for there Alexander Yersin, the discoverer of plague who died while studying the disease, is buried. Preparation for the receipt and installation of the hospital was made there. The remaining hospital personnel soon arrived by air, but all equipment and supplies were delayed several weeks by a shipping error which caused the equipment to be delivered to the Philippine Islands rather than Vietnam. By 18 April 1962, however, the 8th Field Hospital, consisting of a headquarters and one hospitalization unit (100 beds), became operational and was to be the major treatment center in the country until the establishment of a U.S. Navy dispensary in Saigon in October 1963. The next U.S. Army hospital was not to arrive in country until 26 April 1965, when the 3d Field Hospital was opened in Saigon.
*TOE (table of organization and equipment) designation for medical detachments with one Medical Corps officer and eight enlisted personnel.
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Area medical support during this time was provided by medical detachment (OA) teams whose locations included:
Vung Tau - 91st Medical Detachment
Bien Hoa - 93d Medical Detachment
Pleiku - 94th Medical Detachment
Tan Son Nhut - 129th Medical Detachment
Tan Son Nhut - 45th Transportation Battalion(Medical Section)
Qui Nhon - 130th Medical Detachment
Soc Trang - 134th Medical Detachment
During the period of March 1962 to November 1965, no medical consultant was assigned formally under the USARV (U.S. Army, Vietnam) surgeon. Informal medical consultation for both American and Vietnamese medical units was provided by the internist serving as chief of the Medical Service, 8th Field Hospital. Subsequently, medical consultants were assigned formally to the USARV surgeon. The following individuals served as medical consultants, 1962-71:
Maj. (later Col.) O`Neill Barrett, Jr * - March 1962-February 1963
Maj. (later Lt. Col.) Walter Dawson Durden,Jr.* - February 1963-March 1964
(Consultant unknown) * - March 1964-February1965
(Consultant unknown) * - March 1965-October1965
Lt. Col. Thomas W. Sheehys * * -November1965-May 1966
Lt. Col. (later Col.) Raymond W. Blohm, Jr. -April 1966-June 1967
Lt. Col. (later Col.) Nicholas F. Conte -June 1967-June 1968
Lt. Col. (later Col.) Ralph F. Wells -June1968-July 1968
Lt. Col. (later Col.) Samuel C. Jefferson -July 1968-January 1969
Lt. Col. (later Brig. Gen.) Andre J. Ognibene- January 1969-November 1969
Lt. Col. Thomas A. Verdon - November1969-July 1970
Lt. Col. Joseph W. Edgett, Jr. - July1970-March 1971
Col. Joseph E. Kmiecik - March1971-June 1971
Col. John J. Castellot, Sr. - July1971-December 1971
* Primary duty as chief, Medical Service, 8th Field Hospital.
* * First fulltime medical consultant, USARV.
The 8th Field Hospital commander and the hospital staff served in multiple roles during this early period, carrying the responsibility of daily care and supply for all Army medical units and future planning for the Vietnam medical mission.
8TH FIELD HOSPITAL
In 1962, in addition to the basic medical and general surgical capability of the field hospital, several medical detachments were attached for command but not operational control. These included the 44th Medical Detachment (KB), an orthopedic team, commanded by Maj. (later Col.) Spencer Walton, MC; the 66th Medical Detachment (KF), a thoracic surgery team, commanded by Maj. (later Lt. Col.) Paul Thomas, MC; and the 41st Medical Detachment (KE), a neurosurgical unit, commanded by Capt. Michael Mason, MC. A large efficient dental unit, the 36th Medical Detachment (KJ), commanded by Lt. Col. John Rudisill, DC, and the 57th Medical Detachment (RA), a helicopter ambulance
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unit, commanded by Capt. (later Lt. Col.) John Temperilli, MSC, were also originally included in this medical center. Later in the year, the 7th Medical Laboratory, a general laboratory unit, and the 20th Medical Laboratory, a preventive medicine unit, were added. Much of the early history of Army medicine in Vietnam is, therefore, the story of the 8th Field Hospital and its attached units.
Unfortunately, the potential of this organization far exceeded the professional demands placed upon it, especially during the first year. The lack of challenge, primarily to the highly skilled surgical teams, had a negative effect on morale. Therefore, with the recommendations of both USASGV and MACV surgeons, two specialty teams were moved from Nha Trang. The thoracic surgery team was relocated to the ARVN (Army, Republic of Vietnam) General Hospital, Cong Hoa, in Saigon. Here it provided outstanding care to Vietnamese soldiers with thoracic injuries and also offered continuing thoracic surgery training to members of the local hospital surgical staff. The neurosurgical team was moved out of country and assigned to the U.S. Air Force hospital at Clark Air Force Base, Philippine Islands. This unit was thus able to provide a previously lacking neurosurgical capability for this hospital and also served as a regional neurosurgical referral center for all of Southeast Asia until its return to Walter Reed Army Medical Center the following year.
An important and unique medical contribution during this early period was made by the orthopedic surgical team. Its commander, Major Walton, was an energetic and aggressive surgeon not content with the prospect of an idle year. The remainder of the group, who shared this attitude, included an anesthesiologist, a surgical nurse, and several enlisted technicians. This unit became, in fact, a traveling medicine show reminiscent of the patent medicine shows of the 19th century U.S. frontier. With the approval of USASGV Headquarters, and through arrangements with Air Force and Army flight detachments, Major Walton managed to travel extensively through the II Corps area visiting American military and Vietnamese military and civilian hospitals. Orthopedic surgical procedures were performed at the ARVN Hospital and Province Hospital in Nha Trang and at the ARVN Hospital, Province Hospital, and Holy Family Hospital at Qui Nhon. The team made two trips to the Province Hospital at Quang Ngai. On each occasion, they remained for a week and performed a large number of major and minor operations. In addition, the team made at least a weekly visit to the Christian Mission Alliance Hospital in Nha Trang (fig.11). This remarkable little hospital received special interest and support from the entire professional staff of the 8th Field Hospital.
While the care of patients was an important contribution in its own right, the team also furthered the education of the Vietnamese physicians, teaching them basic orthopedic principles and procedures. Introduction of the "hanging cast" technique for treatment of humeral fractures was a simple but extremely important contribution, for example. While handling the usual problems of orthopedic trauma, congenital lesions, and residual deformity from poliomyelitis, the team also encountered several serious problems common in Vietnam but unusual in American surgical experience. Pott`s disease (tuberculosis of the
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FIGURE 11.- Christian Mission Alliance Hospital, Nha Trang, 1963.
spine) was especially tragic because patients were seen late in the course of the disease when spinal cord compression and paraplegia had developed. Acute osteomyelitis, especially of the lower extremities, was also frequent, as was extensive joint destruction caused by leprosy.
In addition to providing orthopedic care to Vietnamese military and civilian hospitalized patients, the team made a series of field trips to refugee camps in the II Corps area. Here they were able to treat a wide variety of minor illnesses and in some instances provided immunization, especially for plague, which had become a serious problem in some areas. In one such camp, 40 kilometers west of Tuy Hoa, they saw 250 patients during a 14-hour period. On another occasion, they visited a camp in the "ambush alley" sector just outside Qui Nhon and treated 400 patients. This camp was attacked and completely destroyed by Vietcong troops 2 months later. Although modest in its overall impact on disease in Vietnam, the orthopedic surgical team nonetheless established an informal program of medical care, a pioneer effort antedating the formal programs later provided through the Agency for International Development and the Military Provincial Health Assistance Program.
ADMINISTRATION AND PATIENT EVACUATION
While the professional requirements of the 8th Field Hospital were easily handled, the administrative and logistical burdens were too great to be managed
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FIGURE 12. - HU-1A aeromedical helicopter of the 57th Medical Detachment, Nha Trang,1963.
adequately by the small hospital administrative staff. Few of the attached medical detachments had intrinsic administrative support, so their requirements were added to those of the hospital. Also, because of the distance from Nha Trang to Saigon and the difficulty of travel between these two areas, much of the administrative work of the USASGV surgeon`s office had to be performed by the 8th Field Hospital staff, further compounding the administrative burden. In addition, the hospital was designated as the central medical supply point for all Army medical units in Vietnam. At this time, the supply section of the hospital consisted of one MSC (Medical Service Corps) lieutenant, the supply officer, and one supply sergeant. With insufficient manpower, no clerical support, and an erratic supply line from USARYIS, this activity was and remained a serious weakness in the medical support system in Vietnam for several years. Medical supply support improved somewhat with deployment of the 32d Medical Depot to Vietnam in October 1965.
Although the 8th Field Hospital was placed in Nha Trang because of its strategic central location in the country, movement of patients to this area was difficult at best and frequently impossible. No formal air evacuation system was established in-country until 1967.
The 57th Medical Detachment, based in Nha Trang, provided excellent air ambulance support, especially in moving nearby emergency cases to the hospital. The effectiveness of this unit was impaired, however, by the relatively short range of the HU-1A helicopters (fig.12), recurrent maintenance problems, lack of repair parts, problems associated with dispersing JP-4 fuel, and lack of
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FIGURE 13.- U.S. Air Force C-123 cargo plane used for aeromedical evacuation in-country.
an adequate communications system. The unit was also required to transfer two of its helicopters to Saigon for tactical use, further restricting its effectiveness.
In general, patients who required attention at the 8th Field Hospital arrived as "hitchhikers" on aircraft flying tactical missions into Nha Trang. This resulted in frequent delays of patients getting to the hospital. Return of patients to duty from Nha Trang was an even greater problem as a low priority was given to these individuals. An entirely new unit was finally established within the hospital area to house discharged patients until transportation could be arranged. Transportation was most often accomplished via Air Force C-123 aircraft (fig. 13) or by U-1 Otter aircraft of air transportation companies located throughout Vietnam (fig. 14). In Nha Trang, the 18th Aviation Company, commanded by Capt. (later Maj.) Robert Felix, was especially helpful in this regard. When emergency evacuation of patients from Nha Trang to Clark Air Force Base was required, the Air Force responded in splendid fashion and was always able to provide a C-130 for such missions. Only the most severe weather prevented individual movement of such patients. In 1967, a formal in-country aeromedical evacuation system was established and operated by the 903d Aeromedical Evacuation Squadron. By early 1968, C-118 cargo aircraft, specifically modified for medical evacuation, were in use.
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FIGURE 14.- U-1 Otter of the 20th Aviation Company, Nha Trang, 1963.
HOSPITAL CONSTRUCTION
The original 8th Field Hospital was established under canvas on a large, soft, sandy area immediately adjacent to the Nha Trang airport (fig.15). Fortunately, the USARYIS Support Group engineers anticipated the requirement for solid floors and poured concrete slabs over which the tents were placed. On the other hand, original wiring for the compound was done through a local contractor using Vietnamese electrical wire which malfunctioned when attached to the American generators. Subsequent rewiring was accomplished with American material; two 100-kW and two 60-kW generators were installed and there was never a shortage of power thereafter.
The unsuitability of the canvas-covered hospital for the local geographic conditions became immediately apparent (fig.16). Tents could not be adequately ventilated, and the intense heat made the patients extremely uncomfortable. In the operating suite, temperatures under the operating room drapes frequently exceeded 110° F. The USASGV supply section immediately provided two large air conditioning units for the operating room area. This area was specially constructed with a wood frame for the canvas cover and an asbestos cement roof. However, the tents, despite reinforcement liners, could not withstand the high winds which accompanied local tropical storms. On one occasion, patients were moved into temporary quarters in two nearby villas in anticipation of one such storm. Although damage to the hospital was slight, two patient care areas and the supply tent were blown down. Later in 1963, construction of a semi permanent wood and screen facility for the patient care areas was begun; it was completed in November 1963 (fig.17).
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FIGURE 15.- Headquarters area of the 8thField Hospital "under canvas" in 1962.
Support areas, including pharmacy, X-ray, and laboratory, as well as some of the administrative buildings, also were constructed in this manner. This type of construction was used until 1965 when a permanent, completely air conditioned cement block hospital was completed (figs.18 and 19). This structure was subsequently turned over to RVNAF in 1970, and the 8th Field Hospital was inactivated except for a small detachment which remained in Tuy Hoa.
LABORATORY AND RADIOLOGY SUPPORT
Intrinsic laboratory and radiology support for the field hospital in 1962 was spartan at best. Laboratory capability included one laboratory technician with enough equipment to perform routine blood counts and urinalyses, and radiologic equipment consisted originally of a single 30-kV field X-ray unit. One radiologist, Capt. (later Maj.) Bert Sosnow, MC, and one radiology technician were assigned to the hospital. Completion of a small but completely airconditioned building and acquisition of a 100-kV unit subsequently provided more radiologic support. With the arrival of the 7th Medical Laboratory in May 1962, extensive support was available, including blood chemistry, electrolyte, bacteriologic, and parasitic studies, as well as histologic tissue processing. One serious drawback, which persisted until late 1966, was the lack of serologic diagnostic capability in-country. All serums were processed by the 406th
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FIGURE 16.-Aerial photograph, 8th Field Hospital, 1963. (Courtesy, Spencer Walton, M.D.)
Medical Laboratory in Japan. Service was frequently slow and erratic and, in several instances, there was apparent disparity between clinical experience and reported laboratory results. Much of this difficulty was eliminated by the arrival of the 9th Medical Laboratory in-country in 1966.
In September 1963, a mobile laboratory unit of the 406th Medical Laboratory, Japan, was attached to USASGV. This unit replaced and absorbed the personnel and equipment of the 7th Medical Laboratory. Throughout the Vietnam conflict, this unit remained under command of USARJ (U.S. Army, Japan) but was attached to, and generally controlled by, various in-country medical headquarters. On 1 August 1966, the 9th Medical Laboratory became operational and acted as the control element for all medical laboratories in Vietnam, including the mobile unit of the 406th Medical Laboratory.
Despite its own intrinsic surgical capability and the addition of the three surgical specialty teams, the hospital had no blood bank capability, in terms of either equipment or a trained blood bank technician. Fortunately the internist, Major Barrett, had had training in clinical hematology, and both he and the assigned laboratory technician had received training in blood bank techniques at Madigan General Hospital before going to Southeast Asia. Typing serums and plastic containers for storing blood were obtained from the Madigan Army Hospital supply section and added to the 8th Field Hospital supply stock.*
* The value of this preparation was to be shortly demonstrated. Less than 3 weeks after becoming operational, the 8th Field Hospital received its first American combat casualty, a helicopter pilot who sustained serious gunshot wounds of the left hip, bladder,
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FIGURE 17.- Wood and screen facility near Headquarters, 8th Field Hospital, 1963.
It became immediately obvious that hospital personnel could not be used as a primary source of blood donations. Therefore, the 8th Field Hospital commander contacted all unit commanders of organizations in Nha Trang, requesting volunteers to have themselves blood-typed and registered in a "walking blood bank." The response was gratifying, and several hundred donors were available whenever blood was required. In late 1962, arrangements were made with the 406th Medical Laboratory in Japan, and five units of fresh, type 0, low titer blood were flown to Nha Trang from Tokyo on a weekly basis. This supplement assured that a small reserve was always immediately available. Outdated blood was given to either the Vietnamese military or the Province Hospital in Nha Trang and was always used to good advantage for Vietnamese patients. This was an especially important contribution to these hospitals since the Vietnamese had a remarkable reluctance to serve as blood donors even for seriously injured Vietnamese casualties. Several cases are recorded in which American military personnel served as donors for Vietnamese patients because their own troops refused to donate. The dramatic story of the blood program in Vietnam which developed in subsequent years will be told in another volume.
and left ureter. During surgery, he required 19 units of whole blood, all of which was drawn from hospital personnel. Because of his extensive injuries, he was evacuated to Walter Reed General Hospital. Here an ironically fortuitous complication, a uretero cutaneous fistula, was found. During preoperative evaluation for fistula repair, an asymptomatic carcinoma of the left kidney was discovered and removed without difficulty.
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FIGURE 18.- The 8th Field Hospital,1965. Top: Typical ward unit. Bottom: Mess hall and walkway.
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FIGURE 19.-The 8th Field Hospital, 1965. Aerial view of the permanent construction of the hospital.
MEDICAL PROBLEMS
American Troops
During 1962, the general health of the troops assigned to Vietnam was quite good. Most of the hospital admissions were for combat and noncombat trauma, upper respiratory infections, and nonspecific gastroenteritis. Stool cultures were obtained in most cases of diarrhea and reports generally revealed no pathogenic organism; the clinical disorders were mild to moderate in severity and required only supportive therapy. One outbreak of shigellosis which occurred in Qui Nhon affected 30 individuals, all of whom had uncomplicated disease. No other epidemic occurrences were recorded that year.
The most serious gastrointestinal disorder seen was amebic colitis. The occurrence was sporadic and noted primarily in troops who served as advisers to
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Vietnamese units and who usually ate local food. While most cases had a typical clinical course, less severe manifestations were noted. Frequently, these patients complained of persistent diarrhea, some weight loss, and fatigue, but not of hematochezia, severe abdominal cramping, or temperature elevation. As there was concern about serious diarrhea for which no obvious cause could be found despite appropriate direct stool examination and culture, a program of routine sigmoidoscopy for such cases was instituted with rewarding results. Since diagnosis of acute amebic dysentery depended on the demonstration of motile trophozoites in the stool, freshly collected specimens were examined promptly for parasite identification. The frequency of diagnosis increased when smears were obtained directly from the base of ulcerated bowel lesions through the sigmoidoscope with the stool examination being done immediately.
All cases of amebic colitis, approximately 25 in that first year, responded to standard Diodoquin-tetracycline therapy. Despite awareness of liver abscess as a potential complication, no classic cases were observed. One patient, a 22-year-old white male, was admitted to the 8th Field Hospital with high fever, weight loss, marked jaundice, hepatomegaly, and a large abdominal mass with signs of intestinal obstruction. He was operated upon shortly after admission and the large mass in the transverse colon was resected and found to be an ameboma. Despite intensive therapy, he died shortly thereafter. At autopsy, the liver was diffusely involved with amebiasis, but no discrete abscess was found.
Perhaps the most ominous medical warning which was sounded in 1962 dealt with malaria. In 1922, Santayana admonished that "Those who cannot remember the past are condemned to repeat it." Unfortunately, he did not specifically mention malaria in his discourse. The discovery of the aminoquinolines, which were proven effective as early as 1943, produced a false sense of security concerning drug control of malaria despite isolated case reports of chloroquine-resistant falciparum malaria from New Guinea, Colombia, and Thailand (Young et al. 1963).
From March 1962 until February 1963, 20 cases of malaria were diagnosed and treated at the 8th Field Hospital. Nineteen of these were caused by Plasmodium falciparum, and all but one responded to the standard chloroquine regimen. Captain Sn., a 34-year-old Marine Corps officer, had served as an adviser for almost 1 year with Vietnamese troops in an endemic malaria area. He had routinely taken the weekly chloroquine prophylaxis tablet. On 27 August 1962, he was admitted to the hospital and found to have falciparum malaria; he was treated with chloroquine and responded well. He remained asymptomatic until 20 September when he was rehospitalized with typical symptoms and was found to have falciparum parasitemia and evidence of moderate hemolysis. He again responded to chloroquine therapy, given for a total of 6 days. Hematocrit rose to normal and he remained afebrile and asymptomatic for 14 days, but then developed recurrent chills, fever, and falciparum parasitemia. Since the problem of drug-resistant falciparum disease had been anticipated, arrangements were quickly made through the efforts of Colonel Tigertt, and the patient was evacuated by air to the Army Medical Research Project at the University of Chicago. Here, under the direction of Dr. Alf S. Alving, the first malaria case
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caused by a chloroquine-resistant falciparum strain from Vietnam, the Sn. strain was described as was the strain`s response to pyrimethamine (Powell et al. 1964).
Despite mounting evidence of the existence of this new strain of malaria, Colonel Tigertt (1972) reflected: "I was in Southeast Asia during this period and yet it is beyond my capabilities to describe the incredulity with which such reports were received by public health workers. It was equally difficult to gain acceptance of these facts elsewhere in the world." The tremendous impact which this new strain of malaria was to have upon the military effort in Vietnam, as well as its occurrence in Vietnam returnees in the United States (Barrett et al. 1969), is chronicled in Part III of this volume.
The story of the venereal diseases during the early years is an interesting one and reflects the impact of social "reform" upon their occurrence. Before mid-1963, only an occasional case of gonorrhea was treated at the 8th Field Hospital. Following the abrupt passage of the "morality law" sponsored by Madam Nhu, literally thousands of previously gainfully employed young Vietnamese women were suddenly without jobs. Legitimate dancehalls were closed, and the employees either became bar girls or turned openly to prostitution. There was a corresponding and striking rise in the incidence of gonorrhea, far out of proportion to the increase in troop strength within the country. Fortunately, most cases responded well to penicillin therapy. Almost at once, however, an occasional case of apparently penicillin-resistant gonorrhea (a real problem in later years) was observed (Pedersen 1972). Later, with the bacteriologic support of the 7th Medical Laboratory, these cases were shown to be examples of Mima polymorpha urethritis, sensitive to tetracycline. Striking by its absence was syphilis. Despite careful surveillance, examination of all ulcerated penile lesions, and appropriate VDRL (Venereal Disease Research Laboratory) serologic studies, no case of primary syphilis was diagnosed during that first year.
The second most commonly encountered venereal disease was chancroid. Diagnosis was made on the basis of penile ulceration, multiple ulcers often being present, and the demonstration of typical organisms of Haemophilus ducreyi on smear. Response to tetracycline was generally good and most buboes, when present, regressed spontaneously. Occasionally, however, because of a large, painful inflammatory mass in the groin, needle aspiration and even incision and drainage, with predictable slow healing, were required. No cases of lymphogranuloma venereum were diagnosed during this period.
??
"Exotic" infectious diseases, seen in significant numbers in later years, were encountered only occasionally in this early period. Two cases of typical scrub typhus were treated, but no murine typhus was diagnosed. Ten cases of febrile disease clinically compatible with dengue fever were observed, but no serologic diagnosis was available at that time. Subsequently, however, dengue fever was a recognized cause of FUO (fever of undetermined origin) in Vietnam. No cases of encephalitis were observed, although Japanese B encephalitis was also to become a serious problem in later years. Melioidosis was not recognized during this early period.
36 Vietnamese Patients
Physicians of the 8th Field Hospital had the remarkable opportunity to observe and treat a wide variety of diseases in the Vietnamese population. Admission of selected Vietnamese patients to the 8th Field Hospital was authorized by the MACV commander. The internist, Major Barrett, and the general surgeons, Major Rodriguez and Major Hartenstein, served as consultants both to the military hospital in Nha Trang and to the Cong Hoa Military Hospital in Saigon. They also visited the Province Hospital in Nha Trang and the Christian Mission Alliance Hospital just outside that city. In addition, each general surgeon spent a month at the Province Hospital at Quang Ngai.
While many of the cases seen were those ordinarily encountered by American physicians, others occurred only in the Vietnamese population and posed unusual and challenging problems. Tuberculosis was both a clinical and a public health problem. Extrapulmonary forms of the disease were common, especially bone and joint involvement, as was tuberculous meningitis in infants. Lepromatous leprosy was frequently seen, and while there were several leprosariums in the areas, most patients either were seen as outpatients or received no treatment at all. Trachoma was the cause of blindness in a large number of patients, and although a few corneal transplants were performed by local physicians, most patients suffered permanent visual impairment.
Bubonic plague has been endemic in Vietnam for centuries, and epidemic outbreaks are not uncommon. In 1962, several outbreaks were reported from surrounding provinces, although this was denied both at the province level and by the central government in Saigon. Late that year, 10 cases of plague occurred in civilians who were hospitalized and treated in the Province Hospital in Nha Trang (fig. 20). All cases were typical clinically, had characteristic gram-negative pleomorphic rod-shaped organisms on smear of aspirates from buboes, and responded well to streptomycin therapy. Although reported to the province government officials, the occurrence of the disease in Nha Trang was never officially recognized. Rats trapped within Army compounds, including the 8th Field Hospital, were found to carry plague, but no cases were reported in United States personnel. Vaccination for plague was required for all American troops in Vietnam.
Typhoid fever was another serious problem in the civilian population, and the mortality rate was high because of bowel perforation. During their visits to Quang Ngai, 8th Field Hospital surgeons operated upon 12 patients with this complication. Early recognition of peritonitis, use of chloramphenicol, and prompt externalization of the perforation, with or without subsequent bowel resection, were highly effective and this approach was subsequently adopted by Vietnamese physicians. No cases of typhoid fever were seen in American military personnel during this early period.
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FIGURE 20.- Province Hospital, Nha Trang.
SUMMARY
The early years of medicine in Vietnam were a combination of frustration and great professional satisfaction. The challenge of establishing medical support for widely scattered American forces throughout Vietnam was met by the dedicated effort of both medical and nonmedical support troops. Shortages of supplies, inadequate communication, and a poor patient evacuation system coupled with an administrative and logistic burden too great for 8th Field Hospital facilities caused many problems. Innovation, improvisation, and total dedication to care of the sick soldier resulted in outstanding patient care despite these difficulties and set the stage for the unfolding drama of combat medicine in Vietnam which is subsequently described.
REFERENCES
Barrett, 0., Jr.; Skrzypek, G.; Datel, W.; and Goldstein, J. D. 1969. Malaria imported to the United States from Vietnam. Chemoprophylaxis evaluated in returning soldiers. Am. J. Trop. Med. 18: 495-99.
Moser, R. H. 1965. Of plagues and pennants. Mil Rev. 45: 71-84.
Neel, S. 1973. Medical support of the U.S. Army in Vietnam, 1965-1970. Vietnam Studies. Washington: Government Printing Office.
Pedersen, A. H. B.; Wiesner, P. J.; Holmes, K. K.; Johnson, C. J.; and Turck, M. 1972. Spectinomycin and penicillin G in the treatment of gonorrhea: A comparative evaluation. J.A.M.A.220: 205-8.
Powell, R. D.; Brewer, G. J.; DeGowin, R. I.; and Alving, A. S.1964. Studies on a strain of chloroquine resistant Plasmodium falciparum from Viet-Nam. Bull World Health Organ. 31: 379-92.
Tigertt, W. D. 1966.Present and potential malaria problem. Mil. Med. 131: 853-56.
_______1972. The malaria problem: Past, present, and future. Arch. Int. Med 129: 604-6.
Young, M. D.; Contacos, P. G.; Stitcher, J. E.; and Millar, J. W. 1963. Drug resistance in Plasmodiumfalciparum from Thailand. Am. J. Trop. Med 12: 304-14.
