Chapter 10
General Medicine
Brigadier General Andre J. Ognibene, MC, USA
The classic confrontation between diseases inherent in large populations and men of science and knowledge surfaces in times of war. In November 1888, in his address at the opening of the institute which bears his name, Louis Pasteur said (Hume 1943, pp. 216-17):
Two opposing laws seem to me now in contest. The one law of blood and death, opening out each day new modes of destruction, forces nations to be always ready for battle. The other, a law of peace, work and health, whose only aim is to deliver man from the calamities which beset him. The one seeks violent conquests, the other the relief of mankind. The one places a single life above victories, the other sacrifices hundreds of thousands of lives. The law of which we are the instruments strives even through the carnage to cure wounds due to the law of war. Treatment by our antiseptic methods may preserve the lives of thousands of soldiers. Which of these two laws will prevail, only God knows. But of this we may be sure, that science, in obeying the law of humanity, will always labor to enlarge the frontiers of life.
The medical effort in Vietnam was dedicated to enlarging "the frontiers of life" for American soldiers there. Medical experience in Southeast Asia encompassed the breadth of internal medicine and provided the internist with a challenge equivalent to his skills and ingenuity. It would be impossible to review in depth the difficult and complex parade of patients, both American and Vietnamese, who passed through the portals of medical wards in Vietnam. Many physicians were exposed for the first time to the rigors of tetanus and rabies on the one hand and the management of an acute myocardial infarction without a CCU (coronary care unit) on the other. The challenge was immense and the response genuine. Those returning from a year of medical service in Vietnam felt a significant sense of fulfillment and contribution. Some left newfound knowledge in publications and theses to those who followed. In all, it was an effort characterized by rewards and successes in a time and place where rewards were few indeed.
DISEASES OF GENERAL MEDICAL SIGNIFICANCE
Under the pressure of combat casualties, malaria, and hepatitis, the continued presence of general medical diseases in a large troop population often is forgotten. A review of the medical consultants` reports gives testimony to the broad range of problems encountered in internal medicine practice in Vietnam. Reports in 1965 and 1966 were preoccupied with the serious threat to field
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operations posed by malaria. However, in late 1966, indications appeared that the practice of internal medicine in Vietnam was not limited to malaria, typhus, and other exotic diseases. For example, a report in November 1966 referred to a merchant marine seaman with severe emphysema and pneumonia who developed bronchospasm unresponsive to steroids; he ultimately bled from a stress ulcer and died at the 3d Field Hospital(Blohm 1966).
In the ensuing years, reports were filled with references to complex and catastrophic disease states encompassing all subspecialties of medicine. The 3d and 8th Field Hospitals in successive weeks admitted two patients with acute myelogenous leukemia. Both patients died from subarachnoid hemorrhage before further evacuation (Ognibene 1969a-Jan.) Hemolytic anemia caused by G6PD (glucose-6-phosphate dehydrogenase) deficiency and agranulocytosis related to dapsone usage were also part of the large group of hematologic disorders occurring in the troop population.
Intravascular coagulopathy was an ever-present problem in infected and wounded patients. The laboratory support necessary to delineate specific clotting disturbances was not available, and documentation of diagnosis was impossible. Heparin was given empirically to patients with infection and thrombopenia (Ognibene 1969b). Patients with oozing and bleeding wounds were given fresh frozen plasma and heparin in the hope that dilution of clotting factors and consumption could be corrected concurrently. The need for organized hematologic interest in coagulation problems of infection and wounding was obvious. Belated efforts by the renal unit in Saigon in 1969 and the surgical research unit in Long Binh in 1970 did not produce tangible results before the withdrawal of troops and the cessation of hostilities.
The major endocrine dysfunction addressed by the internist was diabetes. As was noted in World War II, those diabetic patients who were encountered, although relatively few in number, presented significant problems in diagnosis, treatment, and disposition. In Vietnam, increased exposure to skin infections, fungus disorders, and infectious diseases of many varieties posed additional risks for the diabetic patient. In January 1969 the 93d Evacuation Hospital reported a patient with diabetic ketoacidosis who had been serving in Vietnam while on insulin. Studies of the dark mucoid material which drained from his nose revealed hyphae and spores of mucormycosis. He died despite surgical and medical therapy (Koch 1969).
Diabetes per se did not disqualify one from military service in Vietnam, and many individuals were retained on active duty despite significant insulin requirements. Most insulin-dependent patients found it difficult to maintain control because of the variability of diet and activity; in addition, the requirement for refrigeration of insulin supplies was often neglected. It became quite clear that insulin-dependent patients should have been excluded from service in a combat zone and that the exclusion of all diabetic patients from tropical combat theaters should have been seriously considered.
The neurologist encountered Japanese B encephalitis, ingestion of C-4 plastic explosive (cyclonite, 91 percent; polyisobutylene, 2.1 percent; motor oil, 1.6 percent; and di(2-ethylhexyl) sebacate), cerebral malaria, and drug overdose,
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all characteristic of Vietnam experience. In addition, however, patients presented for therapy with disorders unrelated to the tropical environment. Stroke, epilepsy, and unclassified seizure disorders were common. In 1969, the 93d Evacuation Hospital reported a 23-year-old soldier with periodic hypokalemic paralysis (Koch 1969) and, in 1971, a 20-year-old soldier died of Guillain-Barre syndrome at the same hospital (Davis 1971). All of the acute neurologic emergencies which a population of 500,000 can generate were seen at the medical services in Vietnam.
The neurologic centers at Long Binh and Nha Trang were barely adequate to provide the consultative support required. Most basic neurologic practice was handled by the internist at fixed USARV (U.S. Army, Vietnam) hospitals but, because of the ever-present difficult or unusual case and the requirement for EEG interpretation, the neurologist had a critical role. The allocation of one neurologist to each medical group was a realistic and effective solution. Ready consultation for hard-pressed medical services was maintained within medical group hospitals and patients with significant neurologic dysfunction were concentrated at a neurology center where subspecialty expertise could be focused.
As evacuation channels developed and more patients were taken to USARV hospital facilities, field and evacuation hospitals had to modernize. In the early years of the war, portable field defibrillators were found only in large hospitals. In addition, most internists in USARV hospitals were handicapped by the absence of cardiac monitoring equipment, a facility for blood gas analysis, and rapid serum and urine electrolyte determinations. By 1969, these impediments had been surmounted. All medical services in USARV hospitals were required by the USARV medical consultant to have monitoring and defibrillating equipment. In addition, a six-bed centralized CCU was established at the 3d Field Hospital. This facility was required because a large population of MACV (Military Assistance Command, Vietnam) Headquarters personnel was being supported and because the average age of the troop population supported was thus raised. With the opening of the CCU in 1969 (fig. 67) in association with medical intensive care and the renal unit, the 3d Field Hospital provided the best in intensive medical therapeutics in Southeast Asia. Patients with any variety of renal, cardiac, or other medical illness could be stabilized there until transfer was safe and practical. In the first 6 months of operation, the CCU achieved 18 successful cardiac resuscitations and provided extensive monitoring support to critically ill patients undergoing hemodialysis (Paletta 1969).
Of particular concern to the internist and the cardiologist alike was the presence of individuals with prior myocardial infarction. Those on anticoagulation therapy for any reason were difficult, if not impossible, to maintain in country. Under combat conditions, such patients were of little value to their organization and presented a burden to the medical command. Attempts to exclude from military service those people who were incapable of worldwide service precluded some of these difficulties, but errors continued to occur as exemplified by the following description of a patient at the 3d Field Hospital (Davis 1971).
A 39-year-old enlisted man with a P4 profile (unfitting) and a waiver to re-
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FIGURE 67.-Cardiac monitoring equipment in 3dField Hospital coronary care unit, Saigon, 1969.
main on active duty had suffered two previous myocardial infarctions. He arrived in Vietnam in 1970 while on chronic anticoagulation. Some weeks after arrival, he suffered acute chest pain and was brought to the 3d Field Hospital. Despite efforts at resuscitation, the patient died.???
The establishment of coronary care facilities at the 3d Field Hospital and the continued presence of patients with coronary disease on USARV hospital wards prompted a study of the incidence of coronary artery disease in combat casualties. The presence of a significant degree of coronary artery disease in the troop population in Vietnam was established by postmortem studies. Coronary angiography and cardiac dissection were performed on 105 U.S. soldiers killed in action, ranging in age from 18 to 37 years. Some evidence of atherosclerosis was
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found in 45 percent, and 5 percent had gross evidence of severe coronary atherosclerosis (McNamara et al. 1971). According to these data, the incidence of coronary artery disease in this young age group in Vietnam was somewhat less than that reported in a similar series in the Korean war (Enos, Holmes, and Beyer 1953); nevertheless, it was significant. Older individuals in staff positions and advisory capacities added to the population in which clinical coronary artery disease surfaced. A significant incidence was noted at all hospitals, not just those supporting headquarters areas.
The need for resuscitation equipment and facilities for patients with cardiac arrhythmias (both postoperative surgical patients and intensive care medical patients) was realized early in the conflict. Such specialized equipment for support of fixed hospital installations must be standardized in future TOE (table of organization and equipment) or TD (table of distribution) units.
Although it was an immense burden in World War II, duodenal ulcer disease never became of medical significance in the Vietnam war. In Palmer`s summary (1970) of military experience with ulcer disease, he notes that in 1941, 31 percent of all medical patients in the British Army had peptic ulcer and between 1942 and 1945, 53,450 men were separated from the U.S. Army because of gastroduodenal ulcer. Review of the USARV medical consultant`s records of 1969, when there were approximately 500,000 troops in Vietnam, reveals only 10 patients per month requiring evacuation out of country because of ulcer disease (Ognibene 1969a). Selective Service data for 1942-43 indicate that 5.8 per 1,000 individuals, 17 to 37 years old, had ulcer disease (Palmer 1970). If this rate remained valid, approximately 3,000 ulcer patients were on duty in Vietnam in 1969.
Rounds at USARV hospitals rarely revealed a patient occupying a bed because of ulcer disease. This sharp contrast with previous conflicts was a result of the medical era`s relaxation of rigid therapy for ulcer patients. Special diets were not prescribed in Vietnam; the medical policy encouraged selection of standard mess hall foods and even more strongly recommended the use of combat rations. Profile limitations applied in the United States were, in general, removed on arrival in Vietnam. If antacids were considered necessary by the patient or physician, the chewable tablet could be carried in the standard combat uniform. The emphasis on effective performance without any limitation was rigidly adhered to. Thoughts similar to the following (Palmer 1970, p. 876) were kept in the minds of all physicians by constant official reminder.
Some patients seem unable to respond to treatment until they have been successful in manipulating a release from an unwanted job or from military service. But to emphasize the administrative trap that is involved, all will agree that, as soon as the presence of an ulcer is permitted to become either a handy medical excuse for getting rid of an unwanted employee or a personal excuse to get out of an unwanted job, a farce is created.
Hospitalization was not part of therapy unless a complication was documented. Hemorrhage, perforation, or obstruction resulted in early evacuation from country for follow up therapy in the United States. The policy of management of routine therapy on an outpatient basis with no restrictions on any activity resulted in an incalculable manpower savings. Those patients who were
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admitted for therapy found themselves at the 6th Convalescent Center doing calisthenics or filling sandbags and generally requested early return to their units.
The policy of encouragement, motivation, and removal of secondary gain, while successful in maintaining troop strength, was never formalized or carefully documented, nor were the results ever tabulated. Future endeavors in this area should begin with formal directives followed by documented study of results, favorable and unfavorable, in relation to both patients` and units` requirements. The dramatic difference between the impact of ulcer disease in Vietnam and that in World War II should be scientifically secured since application to civilian practice can have far-reaching economic impact.
The significant number of soldiers with allergies or asthma led to the clarification of treatment and evacuation policy. In general, it was believed that patients with allergic disorders were fit for duty in USARV. Individuals undergoing desensitization provided their serum and their supporting medical unit administered it. If an individual had received serum from an Army allergy clinic, his unit physician could simply request resupplies through military channels. However, primary allergy evaluations had to be deferred until the individual returned to CONUS (continental United States). Insect allergy did not preclude duty in South Vietnam. A vaccine for various stinging insects, prepared by the allergy clinic of Walter Reed General Hospital, was available through the medical consultant. Skin testing in this condition was not warranted before the institution of hyposensitization, which was based strictly on the history obtained from the patient. Specific instructions were published in the USARV Medical Bulletin in January 1969 and delivered to all unit physicians. Under these policies, there was significantly less difficulty in managing patients with allergic disorders in Vietnam than in previous conflicts.
Despite recommendations following World War II that "irrespective of the cause or causes, tropical service appears to be contraindicated for individuals giving a history or presenting symptoms of asthma" (MD-IM3, p.185), no ab solute restriction applied to the Vietnam conflict. Patients with asthma generally were fit for duty in Vietnam; however, if repeated hospitalization was required or if the patient failed to respond to conventional therapy, medical evacuation was considered. The consulting internist`s findings and documentation provided by the unit physician were the basis for the decision. In the absence of this documentation, it was often difficult for a consulting internist to decide on the appropriate disposition of the case. With the establishment of communication under the MEDCON (Operation Medical Consultant) concept, asthmatic attacks were better documented in health records in unit-level medical services.
A major portion of the evacuations from Vietnam in the chest disease category were for asthma; at the peak of troop concentration, at least 15 patients monthly were removed from duty there because of it (Ognibene 1969a). If induction rates of 1 per 1,000 for asthma in World War II (Gold and Basemore 1944) remained valid, approximately 500 asthmatics were on duty in Vietnam during 1969 and approximately 320 completed their tour. Whether the 320 addi-
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tions to troop strength justified the medical effort expended on the 180 evacuees is difficult to ascertain, but the Vietnam experience may provide a basis for further decisions about asthma and the combat soldier.
Patients with urolithiasis were not included in evacuation breakdowns for the medical consultants since most of them were evacuated from urology services. Studies of the actual incidence of urolithiasis and associated diseases are not available. However, an analysis of admissions to the 568th Medical Company, which supported 15,000 American soldiers, is available (Scott, Ardison, and Wells 1967). Of the 2,050 admissions during the 1-year period, 54 were for urolithiasis; 51 patients were white, 2 were black, and 1 was Vietnamese. During the period of study, blacks represented approximately 18 percent of total hospital admissions, although their incidence of admission for renal stone was low. No significant seasonal variation was noted in the Cam Ranh Bay area, and there seemed to be no relation of the disease to time served in Vietnam. Three individuals were in their first month in Vietnam. Of the 54 patients, 10 gave a previous history of urolithiasis, and in 5 a positive family history of the disease was obtained.
The clinical picture was remarkably similar in the majority of patients. Most presented a classical picture of sudden onset of severe unilateral costovertebral angle pain with radiation along the ureteral pathways. Attempts to correlate the incidence of urolithiasis with an acute diarrheal state were unsuccessful, and there were not sufficient data to document a state of dehydration. Unrecognized systemic illness manifesting as urolithiasis has been demonstrated in other studies, but in the evaluation of the 568th Medical Company patients, no primary diagnosis of gout, hyperparathyroidism, or other systemic illness could be found. Forty-four of the patients were returned directly to duty after a short period, while 10 were hospitalized in urology services of various supporting hospitals.
SNAKES AND LEECHES
A discussion of problems in general medicine in Vietnam could not be considered complete without reference to snakes and leeches. Although they posed only a minor medical problem, the psychological impact of unwarranted fear made a significant number of troops ineffective in tropical terrain. Leeches were, on the whole, less likely to promote noneffectiveness, although infestation with the nasal leech Dinobdella ferox (Blanchard) produced nosebleeds and hemoptysis (Keegan, Radke, and Murphy (1970). Snakes, on the other hand, were capable of inducing fear out of proportion to reality. Maj. Herschel H. Flowers, VC (fig. 68), and Capt. Frederick G. Berlinger, MC (1973), summarized the problem:
The authors found, upon interviewing troops in Vietnam, that the majority believed that poisonous snakes were to be found in abundance there and that few persons survived a bite. Soldiers from rattlesnake infested areas in the United States harbored little fear of these reptiles but were deathly afraid of the "bamboo vipers" of Vietnam. In actuality the "bamboo viper" is a small snake which
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seldom injects sufficient venom to inflict a serious bite, whereas rattlesnakes are capable of producing death or permanent injury in victims. Almost all of the persons questioned had heard of the "cigarette snakes" (when you are bitten you only have time for one cigarette); or the "two-step snake" (no explanation necessary), but were not cognizant that only one snakebite death had occurred in US forces since United States involvement there.
Other misconceptions were that no antiserum existed for some of the snakes, and snakebites were very common. Studies indicated only 25-50 snakebite incidents occurred annually in US forces. Of these, only a few necessitated intensive therapy. Capitalizing on the average American`s fear, the Viet Cong frequently left snakes in caves and bunkers to harass our troops and to impede their progress. In each case, great publicity was given the incident and fears were perpetuated. As a result, some soldiers refused to search tunnels, and some incidents of refusal to stand perimeter guard in a dark bunker were recorded. Incidents also occurred where positions were given away at night when a snake entered a foxhole.
There are three large categories of medically important snakes in Vietnam. The Elapidae family are the neurotoxic snakes, including cobras, kraits, and coral snakes; of these the Asian cobra and banded krait were significant. The sea snakes, of which there are 15 species, have a highly lethal myotoxic venom but were of little or no medical significance to U.S. troops. Of the pit vipers, which have a hemotoxic venom, the white-lipped bamboo viper and Malayan pit viper were most important. The most common venomous bite was from the arboreal white-lipped bamboo viper, but such a bite was never lethal for an American soldier (Berlinger and Flowers 1973) (fig. 69).
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FIGURE 69.-Green coloring of the bamboo viper was excellent camouflage for its arboreal existence.
The commonest symptom of snakebite is fear, which can be easily overcome by authoritative reassurance and education programs. Treatment in the field or at an aid station was discouraged in favor of evacuation. General treatment measures included tetanus toxoid and analgesics, plus sedation and antibiotics when indicated.
Systemic treatment depends upon the type of snake involved; in all cases, specific antivenin should be used. For cobra bites, Cobra-Kraft Polyvalent Antivenin (made by the Haffkine Institute, Bombay, India) was used immediately. For krait bites, the same antivenin was used, but treatment usually could be delayed until the patient was evacuated to a snakebite treatment center or until neurotoxicity became apparent. For viper bites, serial clotting times were followed but treatment did not begin until hemorrhagic signs became manifest. With bamboo vipers, the drug of choice was Polyvalent Crotaline Antivenin (Wyeth), while with Malayan pit vipers it was Thai Red Cross Anti-Malayan Pit Viper Antivenin.
Most bites were not by venomous snakes, however, and few of those which were caused systemic envenomation. Even fewer required any systemic therapy.
STAFFING REQUIREMENTS
Medical consultants maintained a deep and abiding interest in the flow of medical patients to hospitals and through the evacuation system. The records
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they compiled are testimony to the magnitude of the medical effort. Although the actual practice of general internal medicine fell to those 40 to 50 internists in USARV hospitals, the need for medical expertise spread beyond the confines of the combat area. There were those whose abilities were exercised in hospitals in Japan and those who were required to provide additional staff support to medical services in CONUS. Just how many more physicians with a basic 3139 (internist) or medical subspecialty designation were actually required to render specialty care to an Army of one-half million in the field is difficult to estimate. For direct support only, 50 to 70 were appropriate estimates for Vietnam with up to 20 additional internists in Japan. However, another 50 to 70 individuals would be required in CONUS hospitals, bringing the total additional requirement, conservatively, to 120 to 160 internists. The conservatism of this estimate can be verified by a review of the medical admissions in Vietnam, tabulated by the USARV medical consultant (Edgett) for the calendar year 1970 from feeder reports sent him by the chiefs of medicine in USARV hospitals. That year there were 41,328 medical admissions. The peak year, 1969, produced even more, as was shown in chapter 3. The following is a partial breakdown of the categories of medical admissions in 1970:
Malaria, total - 8,216
Falciparum - 4,635
Vivax and mixed - 3,581
Amebiasis - 246
Hepatitis - 1,666
Typhoid and parathyroid - 38
Encephalitis - 61
Drug-related disorders - 397
Shigellosis - 401
Agranulocytosis - 9
In addition, 556 hemodialyses were performed and 11 malaria deaths occurred. In December 1970, the medical consultant`s final monthly tally was carefully recorded (table 36), a practice ultimately discontinued with the wind down of troop strength. Admissions had fallen to one-half the 1969 monthly peak but still constituted a significant volume of patients.
TABLE 36.- Admissions for medical causes to USARV hospitals, December 1970
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The documentation of the effort in internal medicine, except for the continuation of the drug abuse program, ended in the ensuing months. A broad, sustained, and productive era in Army medicine had closed.
REFERENCES
Berlinger, F. G., and Flowers, H. H. 1973. Some observations on the treatment of snakebites in Vietnam. Mil Med. 138:139-43.
Blohm, Col. Raymond W., Jr., MC, USARV Medical Consultant. 1966. Monthly report to USARV surgeon, Nov. 66.
Davis, Maj. Michael A., MC, Chief of Medicine, 93d Evacuation Hospital. 1971. Report to USARV medical consultant, 8 Jan. 71.
Edgett, Lt. Col. Joseph W., Jr., MC,USARV Medical Consultant. 1970 yearly admissions tabulations. Report, undated.
Enos, W.; Holmes, R. H.; and Beyer,J.1953. Coronary disease among United States soldier skilled in action in Korea. J.A.M.A. 152: 1090-93.
Flowers, H. H., and Berlinger, F. G. 1973. The psychological importance of snakes to the combat soldier. Mil. Med.138: 144-45.
Gold, E. M., and Bazemore, J.M. 1944. Significance of allergy in military medicine; report of incidence of allergic diseases in large station hospital and method of preinduction evaluation of allergic state. J. Allergy 15: 279-82.
Hume, E. E. 1943. Victories of Army medicine: Scientific accomplishments of the Medical Department of the United States Army. Philadelphia: J. B. Lippincott Co.
Infectious diseases and general medicine, Internal Medicine in World War II. SeeMD-IM3.
Keegan, H. L.; Radke, M. G.; and Murphy, D. A. 1970. Nasal leech infestation in man. Am. J. Trop. Med. 19:1029-30.
Koch, L. W. 1969. Diabetes and mucormycosis. Presentation at USARV Internal Medicine Conference, 31 Jan. 69, 3d Field Hospital, Saigon.
McNamara, J. J.; Molot, M. A.; Stremple, J. F.; and Cutting, R. T. 1971. Coronary artery disease in combat casualties in Vietnam. JA.M.A. 216: 1185-87.
MD-IM3-Medical Department, U.S. Army.1968. Infectious diseases and general medicine. Internal Medicine in World War II, vol. III. Washington: Government Printing Office.
Ognibene, Col. Andre J., MC, USARV Medical Consultant. 1969a. Monthly reports to USARV surgeon, Jan.-Oct. 69.
Ognibene, A. J. 1969b. Use of blood and blood products in Vietnam. USARV M. Bull (USARV Pam 40-13), Jan.-Feb., p. 45. Copy in Joint Medical Library, Office of the Surgeons General.
Paletta, T. L. 1969. Cardiac arrest. USARV M. Bull (USARV Pam 40-15), May-June, pp. 30-39.Copy in Joint Medical Library, Office of the Surgeons General.
Palmer, E. D. 1970. Military experience with ulcer disease: a review. Mil Med. 135: 871-77.
Scott, N. R.; Ardison, G.; and Wells, R. F. 1967. Urolithiasis in Vietnam. USARV M. Bull(USARV Pam 40-6), Nov.-Dec.; pp. 62-66. Copy in Joint Medical Library, Office of the Surgeons General.
