Papilledema

CPT Andrew C. Carr was the second neurologist to be assigned to Vietnam during the early years of the war. Soon after his return, he prepared a commentary on the practice of neurology under field conditions, providing a vivid account of the practice of good neurology under bad conditions.

Introduction

During the Vietnam War, military neurologists practiced within the combat zone for the first time since World War II. Daroff, the first neurologist to be assigned to Vietnam, recorded his experiences as a member of the 935th KO Team attached to the 93rd Evacuation Hospital in Long Binh from December 1965 to November 1966.1 Gunderson and Daroff traced 17 neurologists who later served in Vietnam.2 Among these was CPT Andrew C. Carr (Fig. 1).

Carr arrived in Nha Trang with the 98th KO Team (a neuropsychiatrie specialty team) in June 1966, where the team was attached to the 8th Field Hospital. As in Daroffs experience at the 935th, there was no electroencephalogram (EEG) or electromyogram capability. However, there was a neurosurgical "K team" at the 8th Field Hospital that helped Carr with necessary radiological studies. Carr kept a notebook record of his patients from his arrival until November 1966. Starting in August 1966, he began submitting the "U.S. Army Vietnam Psychiatry and Neurology Morbidity Report" monthly. He retained copies ofthat report from August 1966 to March 1967.

Later, Carr prepared a commentary from these records. This commentary follows in its entirety. Minor editorial additions are in brackets. Spelling and grammar have not been changed. Table I summarizes the diagnoses of those patients he evacuated to Japan. Carr corrected some numbers at a later date; these appear in parenthesis. Attempts at reconciling these inconsistencies based on available documents after 37 years were futile. However, these inconsistencies detract little from the thrust of his commentary.

CPT Carr's Commentary

Epilepsy

"Seizures were a major reason for referrals. The first problem was to determine if the event was indeed a seizure. This was often difficult. The referral card, which came with the patient, was frequently the totality of the medical information available. The patient usually only remembers passing out. It the patient had evidence of many bruises or contusions about the arms or face, if he had bitten his tongue or if he gave a history of incontinence, I assumed it was as a real seizure and treated it accordingly."

"My policy was to admit all first seizures and do a lumbar puncture and skull x-rays in addition to a detailed neurological exam. There was no EEG available in Viet Nam, so if the exam and the above two tests were negative I placed the patient on a P3 Profile and returned to duty on medication. I did not evacuate any patients to Japan or the Philippines solely to obtain an EEG."

"For known seizure patients who were on meds and had another seizure, I would evaluate their drug regimen and if I felt that meds were below average in amount, I would increase the dose and return to duty, If the standard dose was inadequate, I would evacuate without further adjustments. Anyone with status or a "first focal seizure" I would evacuate."

"If I judged the seizure related to another disease, encephalitis etc. I would not treat or evacuate. I did not treat or evacuate seizures I termed "alcoholic withdrawal seizures."

"In no case did any patient who I had returned to duty ever come back with anything other than a seizure, i.e., tumor."

"It is interesting to note that of the 50 patients sent to me who have had multiple seizures in the past, only 21 of them had been placed on a profile [Table II]. Most of these were in draftees or new recruits, and in most cases the history of the black out spells was raised at time of induction or during basic training."

"Of the 11 patients evacuated for seizures, I had psychomotor epilepsy and a severe personality disorder and simply could not be used in his unit, 4 had been on previous profile and had become uncontrolled, and 2 of these I had good reason to believe were altering their medication to induce seizures. Three were first seizures I had place on medications but continued to have seizures. One, although controlled, could not be used while on profile and was evacuated. Two were in status and although one recovered completely, they were both first seizures and I felt should be worked up further."

"Eleven of the 85 seizure patients clearly had their seizure related to sleep deprivation. This became apparent when I noticed that a number of patients were referred to me from replacement companies and with the time difference and discomfort of a long flight, many were going without sleep for 18 to 40 hours. Two of the patients went without sleep due to nighttime attacks or mortar barrage. I did not start to note this association till late,' in my tour of duty, so feel that there may well have been others who had seizures in association with sleep deprivation. I feel this may well be a significant factor causing seizures in a War Zone, especially because the advent of long cross-oceanic flights and into radically different time zones. Also, often associated with the sleep deprivation is food deprivation, as many of these men had missed one or more meals. This association may account for my high "cure rate" as none of the patients had another visit for seizures. It was assumed that if the circumstance did not recur, the seizures would not."

Neurological Manifestations of Tropical Diseases

"At the 8th Field Hospital, as elsewhere, the majority of patients were admitted for medical diseases. Some of these diseases had neurological complications."

"Four cases of scrub typhus were sent to me directly for neurological evaluation because of severe headache, and it was not known at the time of referral that the patient had scrub typhus. Leptospirosis was also a common disease in that part of the country and a cause for neurological referral because of severe headache, stiff neck and blurring of vision. Malaria was the hospitals single most frequent diagnosis. Twenty patients were seen during the year with neurological complications of malarial. Nineteen, which could be called "cerebral malaria." These could present as coma, dementia, ataxia, seizures, or more focal neurological deficits."

"Twenty-three cases of encephalitis were seen. Most were very mild, but there was one death in this group. The exact type was undetermined, but was known for sure not to be Japanese B as acute and convalescent sera were typed for this" [Table III].

"The clinical picture ranged from slight drowsiness and mild headache to coma, decerebrate posturing and death. Most cases however presented with severe headache and excessive sleeping. Usually the history dated about 1 week before they sought medical aid for the headache. The headache was rather characteristic, beginning as a myalgia type headache with pain on movement of the eyes, that later became very severe and associated with movement of the head. They would often walk in with their head held stiffly and walking very softly so as not to jar the head. Stiff neck was common and they would often be thought to have a subarachnoid hemorrhage. Fever was not prominent and they rarely had temperatures above 99 to 100. Reversal of sleep pattern was prominent and excessive sleeping was common. There were no cases of overt hostility or hyperactive behavior, although case 11 became completely disoriented and required restraints."

"Seizures were not a common finding, but were seen in 5 cases and the presenting complaint in 2, although not the only finding or complaint. Only 3 required evacuation. It was usually a very mild self limiting disease and responded well to rest and conservative treatment."

Neurological Manifestations of Malaria

"Although in Vietnam I saw 22 cases of malaria with neurological complications and have spoken at great length with Bob Daroff, who has seen 19 others."

"Reading the literature published heretofore one would get a false impression about the disease. For instance, in the literature it says that the neurological symptoms usually appear in the second or third week of the illness (untreated) but they may be the presenting symptom. The onset of cerebral symptoms has no relationship to the height of the fever. Headache, photophobia, vertigo, convulsions, delirium and coma are the most common symptoms. There may be stiffness of the neck, transient paralysis, and aphasia. Negativeness or combativeness are present in a large percentage of cases. The mortality rate is approximately 39 to 40%in all cases of cerebral malaria. It is highest (80%) when there is a combination of coma and convulsions."

'This is probably true as far as it goes, except for the mortality rate. Of the 22 cases I saw and the 19 that Bob Daroff saw, none died. First of all, they all had P. Faciparum with no exceptions. Of the cases I saw, 6 presented with their cerebral malaria in a relapse. The average day of relapse from the onset of the disease was 36 days with the range from 25 to 60 (the day 60 was probably a second attack rather than a relapse, because he had been returned to duty and was in an endemic area, Tuy Hoa)."

"The clinical syndrome was varied from very severe with decerebrate postures to very mild with only an occasional seizure and the only central nervous system manifestation. Even although the clinical syndrome was varied, certain things can be said in making the diagnosis" [Table IV].

Treatment. 1. In all cases prompt and strong therapy with antimalarials. 2. If they have papilledema, treat with steroids. Decadron 10 mg at once and 6 mg every 6 hours. Be very careful with pneumonia and any complicating factor."

"Cure rate. All recovered. The first to clear is the coma and the neurological signs, the last to clear is the memory and the psychiatric signs. My worst case apparently recovered completely."

"Pathology. None available. But I do feel that the plugging of the capillaries is the major pathology as many of the men with this had few circulating parasites. In fact some had none at all. There is practically no cerebrospinal fluid cell count and most importantly, when they recover there are no residual neurological deficits."

Peripheral Nerve Injury

"Peripheral nerve injury, as was to be expected, was a major reason for referral. However, the acute type of nerve injury as seen with wounds was not a problem that I often saw. Although there were numerous high and low velocity missile wounds to nerves, the concomitant bone and soft tissue injury precluded the careful examination needed for neurological evaluation. The patient usually went directly to surgery from the battlefield and following surgery evaluation was impossible because of the dressings or casts. If there was nerve injury or extensive tissue injury, the patient was evacuated out the theater in a few days. So this type of acute injury problem is best seen and dealt with in a more rear hospital."

"There were, however, 76 cases of nerve injury seen by me. Fifty of these were of the upper extremity, 19 of the lower, and the rest scattered. The most common was ulnar neuropathy with 40. There were 9 radial neuropathy and 13 peroneal nerve neuropathies. Of special interest, were 5 cases of isolated paralysis of the long thoracic nerve (hod carrier's palsy). In most of these cases a history of carrying heavy material on the shoulder of the affected side could be elicited. The most common cause of the ulnar palsy seemed to be in truck drivers who left their arm for long periods of time on the door of their cab while riding over rough roads. The other most common cause of peripheral nerve palsy was sleeping on the ground. It was of interest to note that in nearly all the cases I saw there was a history of excessive weight loss, above and beyond that seen routinely in a combat zone. This ranged between 18 and 30 pounds, which led me to speculate that the loss of fat left the nerves more exposed to trauma in most cases, especially the ones with peroneal palsy and a nerve unusually easy to palpate."

'The treatment was usually conservative with a cock up splint for the radial nerve palsies and watchful waiting for the rest, as leg braces were not available. The patient was placed on limited duty and reevaluated in one month. Most recovered uneventfully. The hod carrier's palsies did the worst and two had to be evacuated. None of them showed much recovery, but 2 of the 4 could be used in their job with the limitation imposed by the condition."

Headaches

"Headaches were the single largest category of patients seen by me in Vietnam. I saw 239 [ 185] patients with chief complaint of headache who had no other disease process going on to account for the headache. (Often a patient would be sent to see me and turn out to have leptospirosis or scrub typhus as the basic disease causing the headache.) Of these, 183 (104) had "tension type headaches" and 46 (64) had typical vascular headaches, either migraine or "histamine cephalgia." Many of the headaches listed under tension could better be called headache of unknown etiology, as a clear history of tension could not always be elicited nor was every headache typical of that syndrome. In most cases, the headache patients in this group had been tried on all available medication in the theater and continued to show up for sick call, so in desperation or as a "last resort" they were sent to me. After careful evaluation and examination I usually had little to add in the way of a diagnosis or therapy, but having ruled out treatable or progressive organic disease, I would usually instruct them to live with the headache and sent them back to duty. If the patient was able to work effectively with the headache, then he would stay on duty from then on. If, however, he was found to not be working effectively we would try to find a solution within his unit. Rarely I had to evacuate one of these "nonorganic headaches."

"The vascular type headaches were tried on the various types of vasoconstrictor medications, usually in the hospital if he was from a field unit, or on an outpatient basis if within easy reach of a medical facility. These types of headaches responded well, but on occasion evacuation was necessary and at times a profile was necessary, especially if there was a hemiplegic or organic neurological component to the migraine. Only six (2) patients were evacuated out of the country for intractable headaches [Table I]. One was evaluated twice after being sent back to duty the first time, but still unable to perform his duty. In no case did a headache patient sent back to duty ever return with a different diagnosis. Thirty-six of these patients with headache were admitted for a more extensive evaluation."

Conversion Reaction

"Eighty-five (83) patients were diagnosed as having conversion reaction. Some of these may have in reality been malingering, but it would be most difficult to tell in most cases, and at most I suspected it in only a handful (5-10 at the most). These were not the only conversion reactions seen in the Republic of Vietnam as many were referred directly to psychiatry or seen on other services. Of the 85 cases referred to the neurologist, Eleven (12) presented in a fugue state or convulsive like episode; 12 (10) presented with visual difficulty, manifested by double vision, blurred vision, dimness of vision or actual blindness; thirteen (3) presented with ataxia or tremor (cerebellar like signs); thirty (31) came in with weakness, numbness, or both in one or more extremities; and six (3) presented with amnesia or memory problems."

"Sixty two were returned to duty at once with no further diagnostic or therapeutic help other than re-assurance and occasionally a mild tranquilizer in very small doses to act more as a placebo. Twenty-three required hospitalization either because they would not accept return to the unit or because their symptom was severe enough so that they couldn't function. Of these 23, 4 were severe enough to require more specialized treatment on the Psychiatry Ward. Of these, 2 were evacuated eventually. Only one other was evacuated with the mistaken diagnosis of a cerebellar lesion. He was later (two weeks) returned to the Republic of Vietnam and resumed full duty. All of the rest were returned to duty. The average hospital stay was 5 days. The longest hospital stay was two weeks. They all resumed full duty with no limitation."

"Three patients returned with conversion reaction again as a chief complaint. Two had the same complaint and one with a different complaint. Five cases had a clear-cut diagnosis in the health record of conversion reaction. Many of them had functional sounding complaints in their charts, which were very suspicious of previous conversion type symptoms. A high percentage were related to real or near real injury (i.e., a wound which was minor but resulted in a functional deficit or a grenade or mine exploding nearby causing no bodily injury but resulting in a functional problem)."

"My policy was to try not to admit unless completely unable to function. This resulted in my sending some men back to duty with rather marked weakness, but with the reassurance that it would be better in day or two. In most cases there was complete clearing of symptoms. I found that it was much better to give strong reassurance that the condition was not serious, and to reinforce eventual improvement, even though none was apparent on the first day or so. I did not confront them with the fact that the condition was functional, nor did I overtly try to trick them. Referral to Psychiatry was made only in refractory cases so as not to over burden the already busy psychiatry service."

Acute Anxiety

"Another major diagnosis seen by a neurologist in Vietnam was acute anxiety attacks presenting as "blackout spells" and headache with numbness or weakness. These were usually associated with overt hyperventilation. All of these cases had their particular symptoms reproduced in the office by 30 to 60 seconds of hyperventilation, either in part or their entirety. If I could not reproduce the symptoms with hyperventilation then I did not make the diagnosis. At no time could I bring out symptoms from other conditions with hyperventilation. In the year's time I diagnosed this condition 62 times. 5 required admission for passing out spells and it was later discovered that anxiety was the problem with hyperventilation. All were returned to duty. Via personal communication, I have been told that a large number of these patients continued to have anxiety attacks but were better able to be handled at the aid station level. I found that the greatest benefit to diagnosis and therapy was to reproduce the attack by forced hyperventilation. It not only made the diagnosis, but gives the patient insight as to the cause. Also to have the doctor treat it while in the office with bag breathing or breath holding gives the patient confidence in his own ability to control the attacks. Sometimes just this knowledge is enough to prevent further attacks. However if the Military Occupational Specialty of the patient warranted it, and the attacks were frequent, the use of a mild tranquilizer was of benefit."

[Other Matters]

"Of interest, of all the patients I saw in the year in Vietnam, only 48 were diagnosed as having no neurological disease. This meaning that I could either find nothing on the patient or that what I did find had no relation to a neurological condition, (i.e., a medical or orthopedic problem)."

Of note also is the striking absence of war wound type of neurology, such as fragment wounds of the head and neck. It isn't that these didn't occur, but we had a neurosurgical team at the hospital and they took care of this type of injury. Although I saw many fragment wounds, I did not include them in my statistics as the diagnosis and management was done primarily by the neurosurgeons."

Treatment of Civilian Personnel

"Of great interest and personal satisfaction was the treatment of civilian personnel in Vietnam."

"In the area in which I was stationed, there was a civilian Provincial Hospital, a large Vietnamese Army Hospital, a leprosarium, and a smaller Missionary Hospital. Very close associations were established with the Provincial Hospital and the 8th Field Hospital. Although the hospitals were well staffed with civilian, USARV, AMA volunteer doctors, and well-trained Vietnamese doctors, they did lack support in some of the medical and surgical specialties. It was my pleasure to fill the need in neurology. It afforded me an opportunity to see some of the rarer types of tropical diseases seen in that part of the world. Among the cases seen were cerebral malaria, plague meningitis, central nervous system rabies, which is not all that rare in that area, and leprosy. Peripheral neuritis was almost universal, likely on a dietary basis as the severe cases seem to do well on vitamins alone. Decreased ankle jerks are very common in most Vietnamese adults."

Comments

"Although I arrived in Vietnam in the middle of June 1966,1 had only 10 patients sent to me that month, only 60 in the month of July, and 80 in August. In fact, it was not until the month of October that I was seeing over a hundred. This may reflect the length of time it takes for a new service to make itself known. Even then, I had met many doctors in Vietnam who did not know that neurological consultation service was available. Perhaps an up to date list of all consultations and their location should be submitted to the doctors as they process into the country. This could help to relieve this problem."

"I feel there were a significant number of seizures due to sleep and food deprivation. I feel this could be relieved to some extent my making extra efforts to allow adequate sleep time after first arrival in country and by requiring a mandatory rest period when processing out of the Army after returning from Vietnam."

"According to my statistics, there are a great many persons with a clear history of seizures being sent to Vietnam in a combat zone where this could be particularly hazardous to the patient and his unit and the mission of that unit."

"Neurology in Vietnam also on rare occasions had its hazards as the following case shows. A 22-year-old Korean infantryman was brought in by a dust off helicopter with the notation on his card "eye injury" sustained in combat. There was also something written in Korean. The patient was deeply comatose and had a fixed dilated pupil on the right. The left eye was absent due to the trauma. On stimulation he assumed a cerebrate posture. The patient had an immediate tracheotomy because of respiratory difficulty. Vital signs were stable. He was then take to x-ray and the above pictures were obtained. Mer pulling out an extraneous artifact, the patient was immediately isolated and sandbagged, and the ordinance expert was called. They confirmed our suspicion that this was an unexploded rifle grenade. The patient expired 4 hours later."

Discussion

Carr's experience with epilepsy correlates well with more recent evidence pointing to the benign nature of initial seizures in young adults3 and Gunderson's experience with 35 new onset seizure patients at Fort Bragg in the early 1960s.4 Eleven of Carr's first seizure patients were severely sleep deprived and may have had a lower seizure threshold to sleep deprivation. Sleep deprivation has been incriminated as a precipitating factor for seizures in some young soldiers.5

Carr was convinced that his encephalitis patients did not have Japanese B encephalitis. Later, annual epidemics of encephalitis occurred that were believed to be caused by the Japanese B virus. In the summer of 1969, the 935th became the treatment center for encephalitis. Ketel and Ognibene6 described 57 symptomatic cases presenting in that year. The diagnosis of Japanese B encephalitis could be verified by titers on acute and convalescent serum or viral isolation in only 10 patients. This absence of serologic evidence may have led Carr to reject the diagnosis.

Conclusion

The experience of the military neurologists in Vietnam illustrates the simple principle that except for tropical diseases, soldiers and airmen in combat zones display the same sort of neurological problems that they do in garrison. A competent neurologist can play a significant role in diagnosing and treating neurological problems and in limiting unnecessary evacuation even with little to aid him but experience and training.

References

1. Daroff RB: Neurology in a combat zone: Viet Nam 1996. J Neurol Sci 1999; 170: 131-7.

2. Gunderson CH, Daroff, RB: Vietnam. Arch Neurol 2002; 59: 141-6.

3. Hauser WA, Rich SS, Lee JR, Anderson VE: Risk of recurrent seizures after two unprovoked seizures. N Engl J Med 1998; 338: 429-34.

4. Gunderson CH: Management of the soldier's "first" seizure. Milit Med 1968; 133: 208-10.

5. Gunderson CH, Dunne PB, Feher TL: Sleep deprivation seizures. Neurology 1973; 23: 678-86.

6. Ketel WB, Ognibene AJ: Japanese B encephalitis in Vietnam. Am J Med Sci 1971; 261:271-9.

Guarantor; COL Carl H. Gunderson, MC USA (Ret.)

Contributors: COL Carl H. Gunderson, MC USA (Ret.)*; Robert B. Daroff, MD[dagger]; Andrew C. Carr, MD (Ret.)[double dagger]

1Department of Neurology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 208144799.

[dagger] Chief of Staff and Senior Vice President for Academic Affairs, University Hospitals of Cleveland, Cleveland, OH 44106.

[double dagger] Clinical Professor, Department of Neurology, University of California, Irvine, CA 92697.

The data presented in this article are the private views of the authors and should not be construed as the views of the United States Army, the Department of Defense, or the Uniformed Services University of the Health Sciences.

This manuscript was received for review in February 2003. The revised manuscript was accepted for publication in July 2003.

Reprint & Copyright © by Association of Military Surgeons of U.S., 2004.

Copyright Association of Military Surgeons of the United States Oct 2004
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