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Books and Documents

MEDICAL DEPARTMENT, UNITED STATES ARMY

INTERNAL MEDICINE IN VIETNAM

Volume II

GENERAL MEDICINE AND INFECTIOUS DISEASES

Editors for Internal Medicine

Brigadier General ANDRE J. OGNIBENE, MC, USA, and Colonel O'NEILL BARRETT, Jr., MC, USA (Ret.)

OFFICE OF THE SURGEON GENERAL AND CENTER OF MILITARY HISTORY UNITED STATES ARMY
WASHINGTON, D.C., 1982


Library of Congress Cataloging in Publication Data Main entry under title        

General medicine and infectious diseases.

(Internal medicine in Vietnam; v. 2)

At head of title: Medical Department, United States Army in Vietnam. Includes bibliographies and index.

Supt. of Docs. no.: D 104.11/2:In8/v. 2

1. Communicable diseases-Vietnam. 2. Communicable diseases-Vietnam Statistics. 3. Vietnam Conflict, 1961-1975-Medical and sanitary aspects. 4. Tropical medicine-Vietnam. I. Ognibene, Andre J. II. Barrett, O'Neill. III. United States. Surgeon General's Office. IV. Center of Military History (U.S.) V. United States. Army Medical Dept. VI. Series. [DNLM: 1. Military medicine-United States. 2. Internal medicine-Vietnam. 3. Communicable diseases-Occurrence-Vietnam. 4. Tropical medicine-Vietnam. WB 115 B274g]


INTERNAL MEDICINE IN VIETNAM

Advisory Editorial Board for the History of the U.S Army Medical Department in Vietnam and Southeast Asia

Major General JAMES A. WIER, USA (Ret.), Chairman

Major General SPURGEON H. NEEL, Jr., USA (Ret).

Major General EDWARD H. VOGEL, Jr., USA (Ret.)

Major General ROBERT E. BLOUNT, USA (Ret.)

Major General JAMES T. MCGIBONY, USA (Ret.)

Major General WILLIAM H. MONCRIEF, USA (Ret.)

Brigadier General OSCAR P. HAMPTON, Jr., USAR (Ret.)

Colonel HINTON J. BAKER, USA (Ret.)

Colonel JESSE N. BUTLER, USA (Ret.)

Colonel THOMAS P. CAITO, USA (Ret.)

Colonel ROBERT P. CAMPBELL, USA (Ret.)

Colonel JENNIE L. CAYLOR, USA (Ret.)

Colonel HERSCHEL E. GRIFFIN, USA (Ret.)

Colonel ARNOLD W. JOHNSON, USA (Ret.)

Colonel CHRIS J. D. ZARAFONETIS, USAR (Ret.)

CHARLES J. SIMPSON

Advisory Editorial Committee on the History of Internal Medicine

Brigadier General ANDRE J. OGNIBENE, MC, Chairman

Colonel ALFRED M. ALLEN, MC

Colonel O'NEILL BARRETT, Jr., USA (Ret.)

Colonel RONALD R. BLANCK, MC

Colonel RAYMOND W. BLOHM, Jr., USA (deceased)

Colonel NICHOLAS F. CONTE, USA (Ret.)

Colonel JOHN J. DELLER, Jr., USA (Ret.)

Colonel NORMAN W. REAM, MC

Center of Military History

Brigadier General JAMES L. COLLINS, Jr., Chief of Military History

MAURICE MATLOFF, Chief Historian

CHARLES J. SIMPSON, Director, Clinical History Program

Colonel ROBERT N. WAGGONER, Chief, Historical Services Division

Colonel JAMES W. DUNN, Chief, Histories Division


MEDICAL DEPARTMENT, UNITED STATES ARMY

The volumes comprising the official history of the Medical Department of the United States Army in Vietnam are prepared by the U.S. Army Center of Military History and published under the direction of Lieutenant General Charles C. Pixley, The Surgeon General, and Brigadier General James L. Collins, Jr., Chief of Military History. These volumes are divided into two series: (1) the professional, or clinical and technical, series; and (2) a series devoted to medically related subjects. This is the second volume of the former series; the first volume is entitled "Skin Diseases in Vietnam, 1965-72."


It should be the duty of every soldier to reflect on the experiences of the past, in the endeavor to discover improvements, in his particular sphere of action, which are practicable in the immediate future.

-B. H. Liddell Hart (Thoughts on War, 1944)


Authors

O'NEILL BARRETT, Jr., M.D.

Colonel, MC , USA (Ret.). Professor of Medicine and Assistant Dean for Academic Affairs, University of South Carolina School of Medicine , Colombia . Chief, Medical Service, and Chief, Professional Services, 8th Field Hospital, Nha Trang, Vietnam, 1962-63; Chief, Department of Medicine, Tripler General Hospital, and USARPAC Medical Consultant, 1968-71; Chief, Depart­ment of Medicine, Walter Reed Army Medical Center, 1971-73.

RAYMOND W. BLOHM, Jr., M.D. (Deceased)

Colonel, MC , USA . Formerly Chief, Professional Services, Fitzsimons General Hospital . USARV Medical Consultant, Vietnam, 1966-67; Assistant Chief, Department of Medicine, Walter Reed General Hospital, 1967-69; Chief, Department of Medicine, Walter Reed General Hospital, 1969-71; Clinical Associate Professor of Medicine, Georgetown and Howard Univer­sities, 1969-77.

FRANCIS C. CADIGAN, Jr., M.D.

Colonel, MC , USA . U.S. Army Medical Liaison Officer to British Military Medical Services, London ; Lecturer in Military Medicine, Uniformed Services University of the Health Sciences. Deputy Director, SEATO Medical Research Laboratory, Bangkok, Thailand, 1964-67; Director, U.S. Army Medical Research Unit, Kuala Lumpur, Malaysia, 1969-72; Director of Medical Research, U.S. Army Medical Research and Development Command, Washington, D.C., 1972-76; Director, Biomedical Laboratory, Edgewood, Md., 1976-79.

DONALD CATING, M.D.

Adjunct Assistant Professor of Clinical Medicine and Community Medicine, Dartmouth Medical School, Hanover, N.H.; Chief of Internal Medicine, New London Hospital, New London, N.H. Formerly Captain, MC, USAR. Member , U.S. Army Medical Research Team, WRAIR, Vietnam , 1967-68.

DAN C. CAVANAUGH, Ph.D.

Colonel, MSC , USA (Ret.). Member, Expert Panel, Bacterial Diseases (Plague), World Health Organization. Chief, Plague Section, Medical Research Team, WRAIR, Vietnam , 1964-65; Chief, Department of Hazardous Microorganisms, Walter Reed Army Institute of Research , 1973-81.

EDWARD J. COLWELL, M.D.

Attending physician, Internal Medicine, Peninsula General Hospital , Salisbury , Md. Formerly Lieutenant Colonel, MC , USA . Member, U.S. Army Medical Research Team, WRAIR, Vietnam, 1967-68; Deputy Director, SEATO Medical Research Laboratory, Bangkok, Thailand , 1970-72; Member, Departments of Immunochemistry and Virology, Walter Reed Army Institute of Research, 1969 and 1973.

NICHOLAS F. CONTE, M.D.

Colonel, MC , USA (Ret.). Consultant in Internal Medicine to the Surgeon, USARV, 1967-68; Ar­my Liaison Representative, Endocrinology Study Group, National Institutes of Health, 1969-72; Chief Medical Consultant to The Surgeon General, 1972-75; Governor (Army), American College of Physicians, 1972-75.

JOE A. DEAN, M.D.

Gastroenterologist, Medical and Surgical Clinic, Wichita Falls, Tex. Formerly Lieutenant Col­onel, MC, USAR. Formerly Chief, Gastroenterology Service, Brooke Army Medical Center ; Chief, Army Medical Re-evaluation Program for Prisoners of War, Vietnam.

JOHN J. DELLER, Jr., M.D.

Colonel, MC , USA (Ret.). Director of Education and Research, Eisenhower Medical Center, Ran­cho Mirage, Calif. Chief, Department of Medicine, Letterman Army Medical Center, Presidio of San Francisco, 1969-76.

JAMES V. DONADIO, Jr., M.D.

Professor of Medicine, Mayo Medical School, and Chairman, Division of Nephrology, Depart­ment of Internal Medicine, Mayo Clinic, Rochester, Minn. Formerly Captain, MC, USAR. Co­director, 629th Medical Detachment (Renal), Saigon , Vietnam , 1966-67; Member, Department of Medicine, Walter Reed General Hospital , 1967-68.

DAVID T. ENGLISH, M.D.

Associate Clinical Professor of Medicine, Department of Dermatology, University of Washington School of Medicine , Seattle . Formerly Major, MC, USAR.

RONALD P. FISHER, M.D.

Chairman, Departments of Surgery and Emergency Medicine and Trauma, Kino Community Hospital, Tucson, Ariz.; Adjunct Professor, University of Arizona Health Sciences Center, Tuc­son. Formerly Lieutenant Colonel, MC, AUS. Surgeon, 3d Field Hospital, and Surgeon, U.S. Army Dialysis Center, Vietnam, 1969; Chief, Department of Human Studies, Division of Surgery, Walter Reed Army Institute of Research, 1969-71.

LAYNE O. GENTRY, M.D.

Associate Professor of Internal Medicine, Microbiology, and Immunology, Baylor College of Medicine, Houston, Tex. Formerly Lieutenant Colonel, MC, USAR. Assistant Chief, Infectious Disease Service, Brooke Army Medical Center , 1971-74.

CARL R. GUITON, M.D.

Assistant Professor of Medicine, University of Minnesota Medical School , Minneapolis . Former­ly Lieutenant Colonel, MC, AUS. Assistant Chief, Pulmonary Disease Service, Fitzsimons Army Medical Center , 1970-72; Chief, Professional Services, USAH, Saigon , Vietnam , 1972-73.

JAMES E. HANCHETT, M.D.

Assistant Professor of Clinical Medicine, University of Pittsburgh School of Medicine, Pitts­burgh, Pa.; Director, ESRD Unit, Veterans Administration Medical Center, Pittsburgh. Former­ly Captain, MC, USAFR. Member, Medical and Hemodialysis Service , U.S. Air Force Hospital , Tachikawa , Japan , 1965 68.

KENNETH W. HEDLUND, M.D.

Colonel, MC , USA . Chief, Division of Bacteriology, U.S. Army Medical Research Institute of In­fectious Diseases, Fort Detrick, Md.

JAMES H. KNEPSHIELD, M.D.

Associate Clinical Professor of Medicine, Georgetown University School of Medicine; Co­director, Hemodialysis, Hemoperfusion, and Transplantation Service, Georgetown University Hospital; Co-director, Metropolitan Washington Renal Dialysis Centers, Washington, D.C. Formerly Lieutenant Colonel, MC, USA. Chief, Medical Service, 3d Field Hospital, and Corn-

XI

mander, 629th Medical Detachment (Renal), Saigon, Vietnam, 1968-69; Chief, Renal Dialysis Service, Walter Reed General Hospital, 1969-72; Chief, Nephrology Service, Walter Reed General Hospital, 1971-72; Consultant in Renal Disease to The Surgeon General, 1971-72.

LLEWELLYN J. LEGTERS, M.D., M.P.H.

Colonel, MC , USA (Ret.). Professor and Chairman, Department of Preventive Medicine and Biometrics, School of Medicine , Uniformed Services University of the Health Sciences. Chief, U.S. Army Special Forces-WRAIR Field Epidemiologic Survey Team (Airborne), 1966-68; Preventive Medicine Officer and Deputy Post Surgeon, U.S. Army Training Center, Fort Ord, 1968-70; Chief, Training Evaluation Group, Directorate of Plans and Training, Fort Ord, 1971-72; Chief, Ambulatory Health Services, Silas B. Hays Army Hospital, Fort Ord, 1972-74.

DANIEL L. MACKEN, M.D.

Assistant Clinical Professor of Medicine, Colombia University College of Physicians and Surgeons, New York , N.Y. Formerly Lieutenant Colonel, MC, USAR.

JOHN D. MARSHALL, Jr.

Colonel, MSC , USA . Commander/Director, Letterman Army Institute of Research, Presidio of San Francisco , Calif.

WILLIAM E. MILLER, M.D.

Chief, Nephrology Section, Wilmington Medical Center, Wilmington, Del. Formerly Clinical Pro­fessor of Medicine, Thomas Jefferson University, Philadelphia, Pa.; Consultant in Nephrology, St. Francis Hospital, Wilmington; Kent General Hospital, Dover, Del.

WILLIAM L. MOORE. Jr., M.D.

Colonel, MC , USA . Chief, Department of Medicine, Eisenhower Army Medical Center , Fort Gordon , Ga. ; Clinical Professor of Medicine, Medical College of Georgia . Commander, 156th Medical Detachment, Southeast Asia Action Force, 1965; Assistant Chief, Department of Medicine, Brooke Army Medical Center , 1970-74.

ANDRE J. OGNIBENE, M.D.

Brigadier General, MC , USA . Commander, Brooke Army Medical Center, Fort Sam Houston, Tex.; Clinical Professor of Medicine, The University of Texas Health Science Center, San An­tonio, Tex. USARV Medical Consultant, Vietnam, 1969; Assistant Chief, Department of Medicine, Walter Reed General Hospital, 1969-72; Chief, Department of Medicine, Brooke Army Medical Center, 1972-76.

ROBERT F. PROCTOR, M.D.

Formerly Lieutenant Colonel, MC, AUS. Chief, Medical Section , U.S. Army Medical Research Team, WRAIR, Vietnam , 1966-67; Chief, General Medicine Service, Martin Army Hospital , 1968.

ADOLF E. RAHM, Jr., M.D., M.P.H.

Colonel, MC , USA . Chief, Department of Medicine, Darnall Army Community Hospital, and Director, Brooke Army Medical Center Affiliated Internal Medicine Residency and Intern Training Program, Fort Hood, Tex. Commander, 20th Preventive Medicine Unit, and Assistant USARV Preventive Medicine Consultant, Vietnam, 1969-70.

PHILIP K. RUSSELL, M.D.

Colonel, MC , USA . Director, Walter Reed Army Institute of Research. Chief, Virology Depart­ment , U.S. Army Medical Component, SEATO, Bangkok , Thailand , 1965-68; Chief, Department of Virus Diseases, Walter Reed Army Institute of Research , 1968-73.

JAY P. SANFORD, M.D.

Professor of Medicine and Dean, School of Medicine , Uniformed Services University of the Health Sciences. Civilian Consultant in Medicine to The Surgeon General, U.S. Air Force, 1963-75; Civilian Consultant in Medicine, Brooke Army Medical Center , 1964-75.

DALLAS E. SMITH, M.D.

Assistant Professor of Medicine, Eastern Virginia Medical School, Norfolk; Consultant in Rheumatology, Kecoughtan Veterans Hospital, Virginia; Lecturer in Rheumatology, Portsmouth Naval Hospital, Virginia. Formerly Major, MC, USAR.

EDWARD G. SOUTH WICK, M.D.

Clinical Instructor, Division of Dermatology, University of Utah School of Medicine , Salt Lake City . Formerly Lieutenant Colonel, MC, USAR.

FRED R. STARK, M.D.

Colonel, MC , USA . Chief, Department of Medicine, Letterman Army Medical Center, San Fran­cisco, Calif.; Associate Clinical Professor of Medicine, University of California, San Francisco.

WILLIAM J. STONE, M.D.

Professor of Medicine, Vanderbilt University School of Medicine, Nashville, Tenn. Formerly Ma­jor, MC, AUS. Member, 629th Medical Detachment (Renal), Saigon , Vietnam , 1968-69.

RALPH F. WELLS, M.D.

Colonel, MC , USA (Ret.). Clinical Professor of Medicine, University of Texas Health Sciences Center, San Antonio, Tex. Commander, 61st Medical Battalion, 1967; Commander, 17th Field Hospital, 1968; Consultant in Internal Medicine to the Surgeon, USARV, 1968; Chief, Gastroenterology Service, Brooke Army Medical Center, 1968-76.

JAMES E. WILLIAMS, Ph.D.

Major, MSC , USA . Chief, Plague Section, Department of Hazardous Microorganisms, Walter Reed Army Institute of Research.

ANDREW WHELTON, M.D.

Associate Professor of Medicine, The Johns Hopkins University School of Medicine. Formerly Major, MC, USAR. Co-director, 629th Medical Detachment (Renal), Saigon , Vietnam , 1966-67; Civilian Consultant in Renal Disease to The Surgeon General, U.S. Air Force, 1971-76.


Contents

FOREWORD

PREFACE

Part I. BACKGROUND

Chapter

1 Setting (Colonel O'Neill Barrett, Jr., MC, USA Ret.)

Geography and People

Vietnamese and French Medical Experience

2 U.S. Medicine in Vietnam: The Early Years (Colonel O'Neill Barrett, Jr., MC USA (Ret.))
    8th Field Hospital
    Administration and Patient Evacuation <>   
    Hospital Construction
    Laboratory and Radiology Support

Medical Problems

Summary

3 Full-Scale Operations (Brigadier General Andre J. Ognibene, MC, USA)

Command Structure

The Consultant System

Problems of Area Medical Service

Education and Training

Hospitalization and Evacuation

Scope of Disease

Part II. CLINICAL DISORDERS: INFECTIOUS DISEASES AND GENERAL MEDICINE

4 Fever of Undetermined Origin (Colonel John J. Deller, Jr., MC, USA Ret.)

History and Military Significance

Incidence and Epidemiology

Hindrances to Early Specific Diagnoses

The Spectrum of FUO

Clinical Conditions Presenting as FUO

Lessons Learned

5 Group B Arboviruses (Colonel Philip K. Russell, MC, USA, and Brigadier General Andre J. Ognibene, MC, USA)

Section I. Dengue and Dengue Shock Syndrome

  History

  Epidemiology

  Etiology

  Pathogenesis

  Clinical Features

  Laboratory Diagnosis_

  Prevention and Treatment

  New Advances

Section II. Japanese B Encephalitis

 Materials and Methods

 Clinical Data

Discussion

6 Other Viral Diseases (Jay P. Sanford M.D., and Colonel Adolf E. Rahm, Jr., MC, USA)

Section I. Acute Respiratory Disease

 Historical Perspective

 ARD Overview

 ARD in Vietnam

 Lessons Learned

Section II. Infectious Mononucleosis

 Etiology

 Vietnam Experiences

 Lessons Learned

Section III. Rabies

7 Rickettsial Diseases and Leptospirosis (Colonel O'Neill Barrett, Jr., MC, USA (Ret.), and Colonel Fred R. Stark, MC, USA)

Section I. Scrub Typhus (Tsutsugamushi Fever)

 History and Military Significance

 Epidemiology

 Etiology, Pathogenesis, and Pathology

 Clinical Manifestations

 Laboratory Diagnosis

 Treatment

 Prevention

 Summary 

Section II. Murine Typhus

 History and Military Significance

 Epidemiology

 Clinical Manifestations

 Treatment and Chemoprophylactic Measures

Section III. Leptospirosis

 Incidence and Epidemiology

 Clinical Features

 Laboratory Diagnosis

 Prevention and Treatment

 Conclusion

8 Bacterial Diseases (Colonel Dan C. Cavanaugh, MSC, USA (Ret.), Colonel Francis C. Cadigan, Jr., MC, USA, Major James E. Williams, MSC USA, Colonel John D. Marshall, Jr., MSC USA, Colonel William L. Moore, Jr., MC, USA, Carl R. Guiton, M.D., Colonel O'Neill Barrett, Jr., MC, USA (Ret.), and Brigadier General Andre J. Ognibene, MC, USA)

Section I. Plague

 History and Military Significance

 Etiology and Pathogenesis

 Incidence and Epidemiology

 Clinical Features and Treatment

 Laboratory Diagnosis

 Prevention

 Vietnam Experiences

 Lessons Learned

Section II. Melioidosis

 History and Military Significance

 Incidence and Epidemiology

 Etiology, Pathogenesis, and Pathology

 Clinical Manifestations

 Laboratory Diagnosis

 Prevention and Treatment

 New Advances

Section III. Tuberculosis

 History and Military Significance

 Incidence and Epidemiology

 Clinical Features, Complications, and Treatment

 Summary

Section IV. Gram-Negative Infection

 Serratia marcescens

    Chromobacterium violaceum (janthinum)

    Neisseria meningitidis

9 Venereal Diseases (Colonel John J. Deller, Jr., MC, USA (Re t.), Dallas E. Smith, M.D., David T. English, M.D., and Edward G. Southwick, M.D.)

  History and Incidence

  Control of Disease

  Clinical Spectrum

  Section I. Urethritis Syndromes

 Gonorrhea

 Postgonococcal Urethritis

 Nonspecific Urethritis

 Reiter's Syndrome

  Section II. Nonurethritis Syndromes

 Lymphogranuloma Venereum

 Chancroid

 Syphilis

10 General Medicine (Brigadier General Andre J. Ognibene, MC, USA)

Diseases of General Medical Significance

Snakes and Leeches

Staffing Requirements

Part I. CLINICAL DISORDERS: MALARIA

11 Malaria: Introduction and Background (Brigadier General Andre J. Ognibene, MC, USA, and Colonel O'Neill Barrett, Jr., MC, USA (Ret.) )

12 Malaria: Epidemiology (Colonel O'Neill Barrett, Jr., MC, USA (Ret.))

Species and Vectors in Vietnam

Incidence in American Troops in Vietnam

Malaria in Enemy Troops

Malaria in the United States

13 Malaria: The Clinical Disease (Colonel O'Neill Barrett, Jr., MC, USA (Ret.), and Colonel Raymond W. Blohm, Jr., MC, USA)

Clinical Manifestations

Diagnosis

14 Malaria: Chemotherapy (Brigadier General Andre J. Ognibene, MC, USA, and Colonel Nicholas F. Conte, MC, USA (Ret.))

  Initial Experiences, 1960-65

  Experiences With Quinine-Pyrimethamine-Dapsone Therapy, 1966-68

  Vivax Malaria

Treatment of Malaria, 1968-72

Part IV. CLINICAL DISORDERS: GASTROINTESTINAL DISEASES

15 Gastrointestinal Diseases: Background and Buildup (Colonel Ralph F. Wells, MC, USA (Ret.))

History and Military Significance

Gastrointestinal Diseases in Vietnam

16 Bacterial Diarrheal Diseases (Layne 0. Gentry, M.D., Colonel Kenneth W. Hedlund, MC, USA, Colonel Ralph F. Wells, MC, USA (Ret.), and Brigadier General Andre J. Ognibene, MC, USA)  

Section I. Shigellosis

 History and Military Significance

 Epidemiology

 Etiology and Pathogenesis

 Clinical Features, Course, and Complications

 Summary

Section II. Typhoid Fever and Other Salmonelloses

 Typhoid Fever

 Other Salmonelloses

Section III. Cholera and Vibrio parahemolyticus Gastroenteritis

 Cholera

    Vibrio parahemolyticus Gastroenteritis

Section IV. Pathogenic Escherichia coli Diarrhea

 History and Military Significance

 Incidence and Epidemiology

 Etiology and Pathogenesis

 Clinical Features, Course, and Complications

 Laboratory Diagnosis

 Prevention and Treatment

 New Advances and Lessons Learned

17 Amebiasis and Other Parasitic Diseases (Brigadier General Andre J. Ognibene, MC, USA, Colonel Ralph F. Wells, MC, USA (Ret.), and Colonel Oneill Barrett, Jr., MC, USA (Ret.))

Section I. Amebiasis

 History and Military Significance

 Incidence and Epidemiology

 Etiology and Pathogenesis

 Clinical Features, Course, and Complications

Section II. Other Parasitic Diseases

 Incidence

 Hookworm

 Filariasis

 Other Parasites

 Treatment

18 Hepatitis (Joe A. Dean, M.D., and Brigadier General Andre J. Ognibene, MC, USA)

History

Etiology

Epidemiology

Clinical Features

Complications

Chronic Hepatitis

Vietnam Experience

19 Tropical Sprue (Brigadier General Andre J Ognibene, MC, USA, Donald Catino, M.D., Robert F. Proctor, M.D., Colonel Llewellyn J Legters, MC, USA (Ret.), Edward J Colwell, M.D., and Joe A. Dean, M.D. )

History and Background

Pathology

Etiology

Radiology

Diagnosis and Treatment

Vietnam Studies

Part V. CLINICAL DISORDERS: RENAL DISEASES

20 Renal Care (Daniel L. Macken, M.D., James H. Knepshield, M.D., James V. Donadio, Jr., M.D., and Andrew Whelton, M.D.)

Section I. The 629th Medical Detachment (Renal)

Section II. Renal Center Operation in a Combat Zone

  Location

Personnel

Clinical Results

 Summary

21 Posttraumatic Acute Renal Insufficiency (William J. Stone, M.D., and James H. Knepshield, M.D.)

Materials and Methods

Results

Discussion

22 Medical Causes of Acute Renal Insufficiency (William J. Stone, M.D., James E. Hanchett, M.D., and James H. Knepshield, M.D.)

Section I. Acute Renal Insufficiency From Falciparum Malaria

Materials and Methods 

Results

 Discussion

Section II. Acute Renal Insufficiency in Other Medical Disorders

Section III. Toxic Effects Following Ingestion of C-4 Plastic Explosive

23 Renal Transplantation in Vietnam (Daniel L. Macken, M.D., Ronald P. Fischer, M.D., William E. Miller, M.D., and James H. Knepshield M.D.)

GLOSSARY

INDEX (NOT POSTED)

Illustrations

Figure

1 Can Tho, a principal city of the Vietnam Delta

2 Aerial view of flooded rice paddies in the Mekong Delta

3 Grazing cattle on the open plains near Pleiku in the Central Highlands

4 Small fishing village near Nha Trang, nestled to the east of the Chaîne Annamitique

5 Nha Trang, situated along the east coast of the fertile lowlands

6 Aerial views of Saigon: Natural access to the sea along the Saigon River; example of congestion in major cities

7 Typical dwelling on a levee in the Mekong Delta; sampans

8 Commercial activity on crowded Cho Lon street

9 Typical Montagnard tribesman seen in Central Highlands village

10 Leprosy patients: Characteristic leonine facies; deformed hands of lepromatous leprosy

11 Christian Mission Alliance Hospital, Nha Trang, 1963

12 HU-IA aeromedical helicopter of the 57th Medical Detachment, Nha Trang, 1963

13 U.S. Air Force C-123 cargo plane used for aeromedical evacuation in-country

14 U-1 Otter of the 20th Aviation Company, Nha Trang, 1963

15 Headquarters area of the 8th Field Hospital "under canvas" in 1962

16 Aerial photograph, 8th Field Hospital, 1963

17 Wood and screen facility near Headquarters, 8th Field Hospital, 1963

18 The 8th Field Hospital, 1965: Typical ward unit; messhall and walkway

19 The 8th Field Hospital, 1965: Aerial view of the permanent construction of the hospital

20 Province Hospital, Nha Trang

21 Severely injured child being attended in a U.S. medical facility

22 A makeshift croupette at the 24th Evacuation Hospital

23 Vietnamese child with advanced cirrhosis of unknown cause brought to a U.S. military medical facility

24 Dustoff arriving at the 24th Evacuation Hospital helipad

25 Typical aid station supporting a fire base; aid station in an advanced area

26 The 45th Surgical Hospital, Tay Ninh

27 Evacuation hospitals in South Vietnam: The 12th, at Cu Chi; the 29th, at Can Tho; the 67th, at Qui Nhon; the 71st, at Pleiku

28 Aerial view of the 3d Field Hospital complex

29 Aerial view of the 6th Convalescent Center on the beach of the South China Sea at Cam Ranh Bay

30 Patients arriving for rehabilitation at the 6th Convalescent Center

31 Patients exercising at the 6th Convalescent Center: Calisthenics on the beach; pushups in front of ward buildings

32 The evacuation process: Patients await loading on buses; ambulance bus after loading patients; unloading patients directly into MAC aircraft; four-deep loading technique

32 The evacuation process continued

33 Aeromedical evacuation is accomplished with onramp loading in a Sikorsky helicopter HH

34 The 24th Evacuation Hospital dedicated a Quonset but to ambulatory outpatient care

35 X-ray reception center at the 24th Evacuation Hospital

36 Typical hospital-support laboratory

37 Typical aid station or clearing company pharmacy cabinet

38 Patient with Japanese B encephalitis under therapy at the 93d Evacuation Hospital

39 Animal brain removed for examination in the 9th Medical Laboratory for evidence of rabies infection

40 Terrain showing U.S. Army patrol in high grass in mountainous area of Vietnam, where the trombiculid mite proliferated

41 Characteristic spiking or sawtooth temperature pattern in scrub typhus

42 Typical temperature response to tetracycline therapy in scrub typhus

43 Typical eschar seen in scrub typhus

44 Maculopapular rash showing dull red, discrete macular eruptions

45 Rattus norvegicus, the typical reservoir host for the Oriental rat flea, Xenopsylla cheopis

46 Typical femoral bubo as observed in Vietnam; femoral bubo showing drainage and early healing

47 Axillary bubo observed in acutely ill Vietnamese patient

48 Bloody sputum in advanced pneumonic plague

49 Lesion in plague purpura, low power magnification; skin lesion in plague purpura, high power magnification

50 Plague bacilli in clinical specimen of peripheral blood

51 Typical culture appearance of Pseudomonas pseudomallei on blood agar plate, 48 hours 52 Histopathologic material from a lung showing inflammatory cell infiltration in the area of an abscess

52 Histopathologic material from a lung showing inflammator cell infilgraion in the area of an abscess.

53 Typical X-ray of cavitary melioidosis

54 Extensive pulmonary melioidosis of left upper lobe with widespread infiltration and multiple small cavities

55 Inflammatory cell infiltration causing microabscess formation in the myocardium

56 Typical microabscesses in the brain

57 Inflammatory cell infiltrate in the pectoralis muscle causing abscess formation

58 Initial X-ray in a case of pulmonary melioidosis, untreated

59 X-ray showing sequential improvement in a case of pulmonary melioidosis, partially resolved on tetracycline therapy

60 Final X-ray showing improvement in a case of pulmonary melioidosis, near complete resolution following tetracycline therapy

61 Typical urethral discharge, gonococcal urethritis

62 Typical desquamation of the scrotal and penile areas in Reiter's syndrome

63 Typical scaling and nail changes of Reiter's syndrome: feet; hands

64 Typical inguinal bubo in a patient with lymphogranuloma venereum

65 Typical penile ulcer in a patient with chancroid

66 Typical cutaneous lesions of secondary syphilis; typical palmar lesions of secondary syphilis

67 Cardiac monitoring equipment in 3d Field Hospital coronary care unit, Saigon, 1969

68 Maj. Herschel Flowers, VC, presenting to the 3d Field Hospital staff lecture on snakes and snakebites

69 Green coloring of the bamboo viper

70 Malaria experience, 1st Cavalry Division, September 1965-December 1966

71 Entamoeba histolytica in stool sample, low power magnification, and with ingested red cell, high power magnification

72 Trophozoites of Entamoeba histolytica invading intestinal wall

73 Anteroposterior and lateral films of the abdomen demonstrating a large pericolic abscess of the ascending colon

74 Anteroposterior film of chest and upper abdomen demonstrating elevated right hemidiaphragm; lateral view of chest showing subdiaphragmatic abscesses with fluid levels 75 Anterior and right lateral views of the liver using colloidal gold scanning

75 Anterior (top) and right lateral ( bottom views of the liver using collodial gold scanning at Camp Zama, Japan

76 The Dane particle

77 High power microscopic views of hepatic parenchyma in acute viral hepatitis

78 Liver of patient dying of fulminant viral hepatitis; high power microscopic view of hepatic parenchyma in late fulminant hepatitis

79 High power microscopic view of hepatic parenchyma in chronic persistent hepatitis; same, with Masson stain

80 High power microscopic view of hepatic parenchyma in chronic active hepatitis; low power view of same

81 Low power microscopic view of postnecrotic (macronodular) cirrhosis

82 Mucosa from proximal jejunum of a patient with tropical sprue

83 Mucosal biopsy from jejunum of more severely ill tropical sprue patient

84 Barium radiographs from a patient with tropical sprue

85 View of the 629th Medical Detachment, 3d Field Hospital, 1969

86 U.S. Army Sergeant Osborn, ARVN Sergeant Chew, and Maj. James H. Knepshield with patient

87 The Teflon-Silastic arteriovenous shunt used by the 629th Medical Detachment

88 Modernization of the 629th Medical Detachment in 1969 and 1970 included acquisition of a Travenol RSP artificial kidney

89 Typical wounded patient in shock with renal failure; treatment with immobilization and pressure dressings

90 Cross section of lung obtained at necropsy

91 Renal tissue obtained at necropsy from patient with falciparum malaria

92 Chemical structure of RDX

93 Rounds of 105 mm white phosphorus placed on top of C-4 explosive at an ammunition dump

94 Saigon Hospital, scene of the first U.S. military participation in a renal transplantation

95 The renal transplantation team

Charts

Number

1 Comparison of causes of admission of active-duty Army patients at U.S. Army medical facilities in Vietnam, 1967

2 Number of cases of group B arbovirus, leptospirosis, melioidosis, scrub typhus, and murine typhus in Vietnam, January-December 1969

3 Seasonal occurrence of meningoencephalitis and group B arbovirus infections in Vietnam, 1967

4 Mental status of Japanese B encephalitis patients in Vietnam, 1969

5 Reported incidence of acute (common) respiratory diseases in USARV,1965-70

6 Reported incidence of common respiratory diseases at Fort Bragg, N.C., and for the Army in CONUS, October 1942-November 1945

7 Incidence of acute respiratory disease in USARV, 9th Infantry Division, 1st Cavalry Division, and 173d Airborne Brigade, 1967

8 Incidence of human plague in the Republic of Vietnam, 1906 to 1 September 1967

9 Major plague outbreaks in the Republic of Vietnam, 1962-67

10 Relationship between the occurrence of plague and climatic factors in the coastal lowlands of the Republic of Vietnam, 1962-66

11 Drug sensitivity of sixty-one Pseudomonas pseudomallei isolates studied in Vietnam,1969

12 Cases of malaria reported in the United States, 1935-60

13 Admissions to hospital and quarters for malaria among U.S. Army personnel in Vietnam, 1965-69

14 Morbidity from malaria by date of onset, related to activities of one indigenous company, Vietnam, November-December 1966

15 Cases of malaria in the military and civilian populations, United States, 1959-70

16 Distribution of total leukocyte count in 404 cases of malaria

17 Response of primaquine-sensitive patient to a single C-P tablet

18 Mean hematocrit values of falciparum malaria patients treated with supplemental folates or placebo

19 Mean white blood cell counts of falciparum malaria patients treated with supplemental folates or placebo

20. Mean platelet counts of falciparum malaria patients treated with supplemental folates or placebo

21 Incidence rate per month of falciparum and vivax malaria, USARV,1965-71

22 Number of cases per month of falciparum and vivax malaria, USARV,1965-71

23 Course of typhoid fever of a previously immunized American patient in Vietnam

24 Relative frequencies with which blood, urine, and stool cultures and serum agglutination tests are positive in typhoid fever

25 Monthly diarrheal disease rates, U.S. Army in Vietnam, January 1966-December 1968

26 Courses of acute viral hepatitis

27 Hepatitis incidence rates during the Vietnam war

28 d-Xylose excretion and 5-hour urine volume at initial examination of Americans in Vietnam

29 Annual mortality of patients with acute renal insufficiency from falciparum malaria in Vietnam, 1965-69

Maps

1 U.S. Army hospitals in South Vietnam, 31 December 1968

2 Geographic distribution of scrub typhus, 1964

3 Known and probable foci and areas of plague, 1969
3 Known and probably foci and areas of plague, 1969 continued

4 Extension of the human plague epidemic in the Republic of Vietnam, 1962

5 Extension of the human plague epidemic in the Republic of Vietnam, 1967

6 Distribution of proven and suspected malaria vectors in Vietnam

7 Geographical occurrence of malaria, 29 February 1968

8 Relative malaria endemicity in Vietnam, 1966

9 Locations where United States and allied military personnel contracted drug-resistant falciparum malaria in Southeast Asia, 1965

Tables

1 Incidence of amebiasis by race and combat status, French forces, 1945-54

2 Venereal diseases in French troops in Vietnam, 1946-54

3 Data pertaining to U.S. Army medical and surgical patients in the 6th Convalescent Center, FY 1969

4 Data pertaining to Army medical and surgical patients in U.S. Army hospitals in South Vietnam, FY 1969

5 U.S. Army medical and surgical patient evacuations from South Vietnam to Japan, 1966-70

6 Final dispositions of active-duty Army patients initially admitted to hospital in Vietnam, 1965-70

7 Total noneffective days of active-duty Army patients initially admitted to hospital, dispensary, or quarters in Vietnam, 1965-70

8 Probability of acute febrile disease acquisition by American soldiers in Vietnam

9 Results of five FUO studies in Vietnam, 1966-68

10 Miscellaneous diagnoses recorded in FUO studies in Vietnam, 1966-68

11 Differential features of patients having dengue, chikungunya, scrub typhus, leptospirosis, and malaria in five FUO studies in Vietnam

12 Serological diagnoses of FUO cases in Vietnam, by month, 1969

13 History and symptoms of serologically confirmed FUO cases in Vietnam, 1969
13 History and symptoms of serologically confirmed FUO cases in Vietnam, 1969 continued

14 FUO cases, by medical facility and diagnosis, Vietnam, 1969

15 Summary of clinical signs and laboratory findings in 55 dengue patients in Bangkok hospitals, 1971

16 Clinical and serologic findings in eight patients with clinically diagnosed hemorrhagic fever, Saigon, 1963

17 Clinical and laboratory data of ten confirmed Japanese B encephalitis patients in Vietnam, 1969

18 Clinical and laboratory data of four suspected Japanese B encephalitis patients in Vietnam, 1969

19 General pattern of the epidemiology of acute respiratory disease in U.S. military populations stationed in temperate climates

20 Review of 553 Special Forces troops with fever of undetermined origin, Vietnam, 1963

21 Heterophil and monospot tests for infectious mononucleosis performed by the 9th Medical Laboratory, Vietnam, 1966-69

22 Animal bite cases and antirabies treatment, USARV,1969 and 1970

23 Areas of known occurrence of scrub typhus with identified hosts and vectors

24 Incidence of scrub typhus among cases of fever of undetermined origin in Vietnam, 1966-67

25 Comparison of clinical manifestations of scrub typhus from five studies

26 Comparison of clinical features of murine typhus from three studies in Texas and Vietnam

27 Melioidosis in Vietnam,1965-71

28 Incidence of positive tuberculin skin test in personnel on first tour in Vietnam and personnel who had previous tours, 1970

29 Serratia marcescens infection in eight patients in Vietnam

30 Sensitivity of Neisseria meningitidis strains from Vietnam

31 Incidence rates for all venereal diseases among U.S. Army personnel, 1963-June 1972

32 Incidence rates for types of venereal disease among U.S. Army personnel in Vietnam,1963-June 1972

33 Admission rates for all venereal diseases among U.S. Army personnel, 1963-June 1972 34 Gonorrhea treatment schedules given clinical trials by the U.S. Army in Vietnam

34 Gonorrheal treatment schedules given clinical trials by the U. S. Army in Vietnam

35 Relative efficacy of various schedules of therapy in aborting incubating syphilis

36 Admissions for medical causes to USARV hospitals, December 1970

37 Comparative incidence of relapse in treatment of Korean vivax malaria, 1951-52

38 Deaths from infectious diseases in South Vietnam, 1955-65

39 Distribution and relative importance of Anopheles species as malaria vectors in Vietnam

40 Total cases and deaths caused by malaria, U.S. Army, 1965-70

41 Malaria in military personnel returning from Vietnam to the United States, 1970

42 Results of malaria chemoprophylaxis survey in 671 U.S. servicemen returned from Vietnam

43 Reasons given by 470 U.S. servicemen returned from Vietnam for failure to complete therapy in malaria chemoprophylaxis survey

44 Summary of symptoms, signs, and laboratory data in 621 cases of malaria acquired in Vietnam

45 Distribution of leukocyte count, by patient source, in 404 cases of malaria

46 Comparison of the responses of five strains of Plasmodium falciparum to antimalarial drugs administered at normally curative doses

47 Evaluation of five drug regimens for Plasmodium falciparum in U.S. Army troops in Vietnam, 1965

48 Relapses occurring in three different malaria treatments, Tripler General Hospital, October-December 1965

49 Reduction in major complications from Plasmodium falciparum by standardized therapy, October 1965-July 1966

50 Malaria admissions, 85th Evacuation Hospital, September 1966-August 1967

51 Complications of falciparum malaria and therapy in 2,003 cases, 85th Evacuation Hospital, September 1966-August 1967

52 A comparison of 10- and 14-day quinine in multidrug therapy for acute falciparum malaria

53 Results of treatment of Plasmodium falciparum malaria from Vietnam with trimethoprim and sulfalene

54 Recrudescence rates in treatment of Plasmodium falciparum infections in U.S. military personnel, Vietnam, 1965-70

55 Relapse rates in malaria patients, by hospital and geographic area of troop deployment, Vietnam

56 Therapy of patients who had one relapse after treatment of falciparum malaria

57 Weekly disease admissions, Army Task Force 201, Lebanon, 1958

58 Diarrheal disease admissions, U.S. military personnel in Vietnam, January-July 1965

59 Enteric pathogens cultured from 176 U.S. military personnel with acute diarrheal disease in Vietnam, September 1965

60 Antibiotic sensitivity of Shigella strains isolated in 176 military personnel in Vietnam, September 1965

61 Admissions to hospital or quarters, U.S. Army active-duty personnel in Vietnam, January 1965-March 1966

62 Number of diarrheal cases reported to USARV medical consultant, January-March 1966

63 Shigella classification

64 Antibiotic resistance of 505 Shigella strains, Vietnam, 1968-69

65 Admissions and deaths from typhoid fever during the Spanish-American War and World War I

66 Salmonella infections, active-duty Army, 1942-45 and 1950-53

67 Incidence of typhoid fever and salmonellosis in U.S. Army troops in Vietnam, 1965-70

68 Relation of Salmonella species and representative serotypes to human disease

69 Incidence of paratyphoid fever in the U.S. Army, by area and year, 1942-45

70 Composition of intestinal fluid

71 Laboratory test used to distinguish classical from El Tor biotypes of Vibrio cholerae

72 Effect of tetracycline on stool volume in cholera patients, 1963 study

73 Monthly diarrheal disease rates, U.S. Army, Vietnam, January 1966-December 1970

74 Site of action of amebicides used for acute amebic colitis in Vietnam

75 Clinical findings in 42 patients with amebic liver abscess, Camp Zama, Japan, 15 July 1968-3 April 1969

76 Laboratory findings in 42 patients with amebic liver abscess, Camp Zama, Japan, 15July 1968-3 April 1969

77 Estimated liver size on first hepatoscan in 42 patients with amebic liver abscess, Camp Zama, Japan, 15 July 1968-3 April 1969

78 Treatment schedule for amebic disorders caused by Entamoeba histolytica

79 Incidence of intestinal parasites in 75 American servicemen returning from Vietnam

80 Treatment schedule for parasitic infestations in Vietnam, 1971
80 Treatment schedule for parasitic infestations in Vietnam, 1971 continued

81 New cases of hepatitis, by month, among active-duty Army personnel in Vietnam, 1965-72

82 Clinical findings among 175 American servicemen in Vietnam with acute viral hepatitis, August-December 1970

83 Prevalence of hepatitis B surface antigen and relative frequency of HB3 Ag subtypes in various populations in Southeast Asia

84 Jejunal mucosal measurements of 48 Americans on arrival in Vietnam

85 Quantitative jejunal bacteriology of tropical sprue patients versus patients newly arrived in Vietnam

86 Qualitative jejunal bacteriology of tropical sprue patients versus patients newly arrived in Vietnam

87 Incidence of tropical sprue in Vietnam

88 Symptoms during the 3-month interval before diagnosis of sprue versus symptoms of patients without sprue

89 Clinical picture and laboratory data of 13 tropical sprue patients, Vietnam

90 Findings in 12 patients with tropical sprue, 12th USAF Hospital, Cam Ranh Bay, January 1968-January 1969

91 Dialysis procedures, 629th Medical Detachment, September 1966-September 1967

92 Causes of acute renal insufficiency in Vietnam, 629th Medical Detachment, September 1966-September 1967

93 Patient population with posttraumatic acute renal insufficiency, 629th Medical Detachment, August 1967-February 1969

94 Types of trauma in patients with posttraumatic acute renal insufficiency, 629th Medical Detachment, August 1967-February 1969

95 Organs or organ systems injured, 629th Medical Detachment, August 1967-February1969

96 Causes of posttraumatic acute renal insufficiency, 629th Medical Detachment, August 1967-February 1969

97 Selected statistics, 629th Medical Detachment, August 1967-February 1969

98 Presenting symptoms and signs of 42 patients with acute renal insufficiency from falciparum malaria, July 1965-June 1969

99 Admission laboratory data of 42 patients with acute renal insufficiency from falciparum malaria, July 1965-June 1969

100 Parasite index of 31 patients with acute renal insufficiency from falciparum malaria, July 1965-June 1969

101 Coagulation disorders of seven patients with acute renal insufficiency from falciparum malaria, July 1965-June 1969

102 Renal pathology in 16 cases of acute renal insufficiency from falciparum malaria, July1965-June 1969

102 Renal pathology in 16 cases of acute renal insufficiency from falciparum malaria, July1965-June 1969 continued

103 Survival rate of patients with acute renal insufficiency of medical etiology, 629th Medical Detachment

104 Symptoms and signs of six patients with C-4 intoxication

105 Laboratory data of patients with C-4 intoxication