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HISTORY OF THE OFFICE OF MEDICAL HISTORY
SKIN DISEASES IN VIETNAM, 1965-72
Diseases of the skin constitute an important but often underrated source of discomfort and disability among military forces in wartime. This is especially true in the Tropics where environmental factors such as heat, humidity, torrential rainfall, biting insects, and sharp-edged vegetation can damage the skin or reduce its natural resistance to infection. Additional contributory factors include the low levels of sanitation and hygiene that prevail under field Conditions and the difficulties involved in seeking early diagnosis and treatment.
Before the war in Vietnam, skin diseases were not generally recognized as a major cause of disability among soldiers in combat. Reasons for this lack of awareness included the absence of deaths, inaccurate or misleading morbidity statistics, and the often trivial nature of the individual case. In Vietnam, the sheer weight of numbers of cases at last forced recognition of the importance of skin diseases in military medicine.
During American involvement in the Vietnam war, conditions were uniquely favorable for collecting information and advancing knowledge concerning skin diseases of military importance. The limited scope and protracted nature of the war permitted expenditure of resources in sufficient quantity to amass an unparalleled amount of clinical and epidemiological data. The extremely high rates of disability from skin infections focused command attention on dermatologjcai problems and insured full cooperation between field units and medical investigators. Teams composed of civilian consultants and military medical researchers combined to identify and investigate high priority problem areas, such as bacterial and fungal infections. In this they were aided by newly developed field methods in microbiology and by rapid means of transportation and communication between Vietnam and the United States.
Although much new information about skin diseases was collected during the war in Vietnam, a great deal of effort was expended in relearning the lessons of previous conflicts. Therefore, a principal aim in compiling this history has been to emphasize those aspects of the Vietnam conflict that had features in common with the experiences of other wars and other armies. It is hoped that this will provide the kind of information which can be of greatest use in the future. Accordingly, nearly all of the material that follows has been devoted to common skin disorders which
historically have been the predominant causes of discomfort and disability in the ordinary soldier. By the same token, there has been little attempt to provide an account of the unusual or the exotic-the so-called "interesting cases"-that have been militarily, if not dermatologically, unimportant.
Past history provides useful insights into the role that skin diseases came to play in the Vietnam conflict. In Vietnam, official and professional attitudes toward this class of disease were much the same as they had been in previous wars-essentially benign neglect until experience revealed that these apparently trivial conditions could cause an enormous amount of disability and create a substantial drain on medical resources.1
Unlike other diseases which are strongly associated with the exposures and living conditions of soldiers at war, such as malaria and dysentery, those affecting the skin were not recognized as serious military medical problems until the 20th century. In fact, not until the Second World War was the military importance of skin diseases first realized.2 Until then, skin diseases had been considered so unimportant in the military that there was not a single qualified dermatologist in the entire U.S. Army, and no Army hospital included a department of dermatology. By the end of the war, however, trained dermatologists were assigned to all major commands, most large general hospitals, and a number of large dispensaries. In addition, a consultant in dermatology was installed in the Army Surgeon General's Office.3
Many of the difficulties faced by the U.S. Army in World War II4 reappeared in Vietnam. The most important of these were that the medical statistical system failed to reveal the size of the cutaneous disease problem; well-trained and highly motivated physicians often were unable to properly diagnose and treat the most common skin disorders; educational programs and materials concerning militarily important skin diseases were grossly inadequate; research and development programs were not appropriately focused and supported until after skin disease had been a serious problem; and a system for provision of consultant coverage was not devised at the start of the war, as it had been for other classes of disease, but was instituted only after the situation had reached epidemic proportions.
World War II
Accounts of the dermatologic problems faced by the various Allied forces during World War II are strikingly similar.5-10 From these accounts a pattern emerges that transcends national and geographic boundaries, variations in customs, and differences in living standards. None of the Allied armies of the English-speaking countries correctly anticipated the caseload volume and amount of disability that would result from skin diseases. Hospital beds, clinic facilities, and trained medical staffs were universally inadequate to cope with the number of skin disease cases that occurred. With few exceptions, the important disease entities were the same in each army. These included bacterial pyodermas, superficial fungal infections, miliaria, scabies, crab lice, drug sensitization, and the adverse effects of overtreatment of an underlying dermatosis.
Since the 1939-45 war was global in scope and involved people of many races and nationalities in a wide variety of environments, an opportunity was presented to discover the effect of these factors on the type, incidence, and severity of common skin disorders. Disability from skin diseases varied according to climate and hygienic conditions Hot, humid climates and poor hygiene were conducive to the development of severe skin diseases. For example, the admission rate for cutaneous diseases in the U.S. Army during 1944 was 55 per 1,000 per year for troops in the Zone of Interior, whereas in the Southwest Pacific it was 103 per 1,000 per year.11 Soldiers engaged in active ground combat had much higher rates of skin disease than did those who functioned in a rear area support capacity.
Among New Zealand forces in the Pacific, skin diseases caused more unfitness and more time lost from duty than any other type of disease.12 Twenty-eight percent of the medical admissions in that area were on account of skin diseases alone. This was similar to the situation among U.S. Army forces in the Southwest Pacific during 1944-45, where skin diseases accounted for approximately 75 percent of all patients seeking dispensary
care, 20 percent of hospital admissions, and 15 percent of all evacuations to the United States.13
Problems of an administrative nature.-In a paper published in 1947, Dr. Donald M. Pillsbury and Dr. Clarence S. Livingood14 recounted the U.S. Army's experiences with military dermatology during the Second World War. Their observations were drawn upon their wartime experiences. Their most important observations, particularly as they pertain to what would later happen in Vietnam, were those of a critical nature. The salient points were as follows:
The entire group of "rare" dermatoses was of no significance in the total disability. It was a common complaint of dermatologists overseas that a major portion of the published dermatologic papers were of no practical value and little interest to them because the reports dealt at length with diseases which would be seen with great infrequency. * * * a disproportionate amount of time is spent in investigation of diseases which are responsible for an infinitesimal proportion of the total disability from dermatologic disease.
* * * * * * *
* * * little attention was paid by the Army or its civilian advisory board, the National Research Council, to this problem [military dermatology] until late in the war. The only exceptions were the projects of the Office of Scientific Research and Development on dermatophytosis, * * *
* * * many physicians have had so little opportunity for dermatologic training in medical school and internship that they are unable to arrive at a diagnosis of even the simplest conditions of the skin. Working alone in isolated stations, they required help in arriving at a reasonable working diagnosis and proper simple treatment in any given case. * * *
In view of the large-scale studies which were initiated on many special problems in other fields of medicine and surgery, it was a matter of some surprise to us that more studies were not undertaken in certain aspects of dermatology which had proved to be important sources of disability in other armies. These included * * * scabies, * * * drug sensitization, * * * pyogenic infections, * * * contact sensitization, [and] the effects of a warm environment on the skin. * * * there was no correlated study of superficial pyogenic infections until the summer of 1945. * * * there was nothing even remotely comparable to the scope of official studies initiated on a wide variety of other diseases and hazards, many of which proved to be of far less significance as a source of disability than cutaneous diseases. * * *
* * * * * * *
Another striking feature of the management of cutaneous diseases in the Army was the incontrovertible fact that many students graduate from medical schools in the United States with only the haziest knowledge of dermatologic diagnosis and treatment.
They have no real understanding of the ten or twelve groups of diseases of the skin which constitute over 95 percent of the general practice of dermatology. * * *
* * * * * * *
* * * Because of the lack of appreciation by many administrators (particularly surgeons of armies in the field) and other physicians of the extreme importance of an accurate diagnosis and adequate early care of a patient with a disease of the skin, it was too often impossible to provide good treatment before the eruption had reached a phase which might require weeks or months of hospitalization before the soldier could be returned to duty. * * *
Not all the points were of a critical nature. Despite the deficiencies, the U.S. Army had significantly advanced in care of skin diseases during World War II. Advances included:
1. Representation by a full-time dermatology consultant in the Office of the Surgeon General.
2. Separation of responsibilities for dermatology and venereology so that care of one type of patient did not conflict with care required by another type of patient.
3. Removal of dermatologists from the urology sections of hospitals and according their specialty separate departmental status.
Advances in diagnosis, treatment, and prevention.-Dermatologic diagnosis, treatment, and prevention advanced significantly during the Second World War.15 The most outstanding advances were:
1. A lichenoid eruption which occurred with appreciable frequency among troops in the Tropics was found to be a reaction to quinacrine (Atabrine), a drug widely used in the prophylaxis and treatment of malaria.
2. Diphtheria of the skin was found to be a common infection among troops in the Southwest Pacific and China-Burma-India theaters. It was thought to be responsible for an appreciable amount of disability and a few deaths. The proper management was found to be similar to that for faucial diphtheria.
3. The mode of transmission of scabies in epidemic situations was established. A superior treatment modality, benzyl benzoate, was introduced.
4. Penicillin was introduced in the treatment of pyogenic dermatoses. Its local use was found to be accompanied by a considerable incidence of contact sensitivity reactions.
5. Concepts concerning the transmission, prevention, and treatment of superficial fungal infections underwent a marked change. Attempts to prevent infection by sterilizing footwear and using hypochlorite footbaths were found to be useless. Use of powders containing nonirritating higher fatty acids (such as undecylenic acid) was determined to be an effective
15See footnote 2, p. 2.
method of suppressive treatment. Simple hygienic measures and air drying of the skin were established as the most reliable preventive measures.
6. DDT (dichlorodiphenyltrichloroethane) was introduced for treatment of body lice, and pediculosis corporis became almost nonexistent in soldiers.
Unresolved problems.-Although a number of significant advances were made in the prevention and treatment of militarily important skin diseases during World War II, most of the cutaneous disease problems went unresolved.16 Penicillin was useful in the treatment of the common bacterial infections of the skin, but nothing was available for prevention. For dermatophytic (ringworm) infections, neither treatment nor preventive measures were available that were practical and effective under field conditions. There was no means of controlling disorders involving the sweat glands, particularly miliaria rubra. Little was known about the cause of chronic eczematous eruptions of the hands and feet, and practically nothing was available for symptomatic relief of itching, excessive sweating, and the irritation caused by nonspecific inflammatory reactions. In short, the experiences of the Second World War served better to identify than to resolve problems relating to military dermatology.
British Experience in Malaya
In the late 1940's and well into the 1950's, British forces were actively engaged in counterinsurgency operations in the jungles of Malaya. This experience afforded a chance to observe militarily important skin diseases under circumstances similar to those that would later prevail in Vietnam.
A Royal Army dermatological research team surveyed British troops, Ghurkhas, and locally enlisted personnel in Malaya during the late 1940's.17 This was before counterinsurgency operations had begun in earnest. In the British troops, three conditions predominated: ringworm, tropical bullous impetigo, and prickly heat. The team noted that information obtained from men reporting sick was misleading. Cited as an example was an instance wherein 43 (57 percent) of 75 men were found to have body ringworm on a routine examination, yet unit medical records showed only 17 (40 percent) of the 43 with infections had reported sick with skin disease at any time during the preceding 3 months. The investigators expressed the opinion that the incidence of prickly heat exaggerated its importance and noted that most of the cases of acne seen were relatively trivial. Bullous impetigo was thought to be a greater problem because of the discomfort it caused in its usual location in the groin or the axilla.
The dominant condition was fungus infection. It was found on the
body of one man in three.18 Physical evidence of foot infections (tinea pedis) was present in 80 percent of the men. Body and groin ringworm infections were widespread and inflammatory. Sixty-one percent of the infections were caused by a zoophilic strain of Trichophyton mentagrophytes.
Skin diseases were much less common in Asian troops living under nearly identical conditions The predominant ringworm pathogen in Asians was T. rubrum.
The source of the zoophilic T. mentagrophytes infections among British troops was thought to be the toewebs of the affected individual.19 It was postulated that latent toeweb infections became active under the influence of the tropical climate in Malaya and spread to other parts of the body. As a corollary, it was believed that relatively avirulent anthropophilic strains of T. mentagrophytes, which were prevalent in England at the time, underwent a conversion to the virulent zoophilic form under tropical conditions. Maceration of the skin caused by unevaporated sweat was thought to be an important contributing factor in the pathogenesis of dermatophytosis in the Tropics. The low incidence of T. mentagrophytes infections in Asian personnel was not explained; however, the possibility of specific immunity was considered.
In addition to the research team, a Royal Army medical officer reported on skin diseases in Malaya. This officer, who was a medical researcher but not a dermatologist, accompanied infantry units on jungle operations against the insurgents. In his report, which covered all medical problems of the operational infantryman in Malaya,20 he concluded that the predominant disease was tropical skin infection. He found that infection of the skin was nearly universal in operational units and was aggravated by jungle operations. It was noted that skin diseases made up the largest single cause of hospital admissions (46 per 1,000 per year), and that practically every man suffered from skin disease of sufficient severity to require treatment at least once during the first year of service in Malaya. Most soldiers needed only outpatient treatment; few required hospitalization.
The most common infections were ringworm, secondary pyogenic infection of abrasions or insect bites, and bullous impetigo. The incidence of skin disease was higher in flat, muddy, swampy areas than in hill country.
The only prophylactic measures available were early treatment, daily washing, and the use of foot and body powder to dry the skin. It was
stressed that these measures were insufficient even if concientiously carried out, which was seldom possible under operational conditions.
Three other factors were believed to contribute to the incidence of skin disease: these were the type of socks worn, the standard footwear issued for use when not in the jungle, and the living conditions. The standard army sock was woolen. It shrank easily and was difficult to get clean. It was worn with leather boots, woolen tops, and woolen puttees when outside the jungle, and "a hotter covering for the foot is difficult to imagine." Only cold water showers and local hand laundry were available to maintain hygiene, and these were present only in base camp. Consequently, a bare minimum of hygiene and skin care was made even more difficult to achieve by existing circumstances, some of which were potentially amenable to change.
French Forces in Vietnam
An account of the health aspects of the French campaign in Indochina (1945-54) by the Surgeon General of the French forces stated that diseases of the skin created an enormous drain on manpower and caused a great deal of suffering.21 Fungal infections were most frequent and these were followed in precedence by staphylococcal infections. Streptococcal infections were said to be rarer. There was no effective means of preventing these conditions.
Swampfox II Operation in Panama
In 1962, the U.S. Army Transportation Corps conducted a 3-month training exercise in the Panamanian jungle to test human and equipment factors related to military effectiveness in a hot, humid, dirty environment. The training operation was designated "Swampfox II." A small team of civilian dermatologists studied the 150 men involved both before and after departure from the United States. They reported that tinea corporis, candidiasis, and staphylococcal skin infections increased in the jungle, whereas the prevalence of tinea pedis and erythrasma of the feet remained unchanged.22
The dermatologic research team concluded that skin diseases associated with military service in the Tropics are principally caused by infection by bacteria, yeasts, and fungi, each requiring specific diagnosis and treat
ment. Obtaining a correct diagnosis is frequently difficult, particularly for the physician with limited training in dermatology. Effective prophylaxis was recognized as the ideal solution to these problems, and it was suggested that incorporation of antibacterial, antifungal, anticandidal, and perhaps even insect-repellent agents into a bar soap would be the most desirable approach.23
GEOGRAPHY AND MILITARY OPERATIONS
The prevalence, severity, and type of skin diseases among U.S. Army personnel in Southeast Asia were heavily influenced by geographic and military factors. Accordingly, a brief account is given of the most important of these factors.
South Vietnam is a tropic al country whose northern boundary, the 17th parallel, lies well below the Tropic of Cancer. It is a long, narrow country which occupies the eastern edge of the Indochinese Peninsula, thus having a long coastal boundary facing the Gulf of Siam and the South China Sea. Inland, it is bordered in the north by North Vietnam and on the west by Laos and Cambodia. It occupies 66,000 square miles, about the size of the State of Washington, and can be divided conveniently into three major geographical areas: the Mekong Delta in the south, the coastal lowlands facing the South China Sea, and the highlands occupying the area west of the lowlands (map 1).
The Mekong Delta is named for the Mekong River, whose five branches terminate there. The entire delta area consists of silt deposited by the Mekong and three smaller rivers to the north and is seldom more than a few feet above sea level. It is an extremely fertile alluvial plain extensively cultivated for rice and other vegetables. Its potential productivity is so great that it has been referred to as the rice bowl of Asia. The delta is crisscrossed by a system of canals and irrigation ditches, and a large proportion is underwater, especially during the rainy season, which lasts from May until November. In flooded areas, the only dry land is that on the banks of the canals and rivers, the paddy dikes, and the mounds on which the homes sit. The weather is hot and humid. Average annual temperatures range between 25° and 33° C; relative humidities range
between 50 and 90 percent, depending chiefly on the time of day. The average annual rainfall in Saigon is 80 inches.
The central coastal lowlands vary in width from a maximum of 40 miles to a minimum of less than a mile. The southern portion is rather barren and dry, but the northern area is fertile and wet, much like the Mekong Delta. The amount of rainfall is greatest here, reaching 128 inches per year at Hue. The rainy season occurs at a different time of the year than in the delta, generally lasting from September to February.
The highlands consist of a mountain chain with peaks ranging in height from 5,000 to 8,500 feet. The northern part of the highlands varies in mean altitude between 600 and 1,600 feet and is covered mainly with bamboo and tropical forest. The southern part, located below Ban Me Thuot, contains many areas over 3,000 feet above sea level and is covered largely with evergreen forest. The climate is much cooler in the highlands than in other parts of South Vietnam, the temperature falling as low as 12° C in some areas during the night.
The population of South Vietnam, estimated at 16.1 million in 1965, consists mainly of ethnic Vietnamese, a people similar in physical characteristics and culture to the Chinese. Significant minority groups include the Chinese, the Cambodians (Khmers), and approximately 30 tribes of primitive people known collectively as Montagnards The bulk of the population lives in the fertile lowland areas of the central coastal plain and the Mekong Delta; the highlands are sparsely populated. The Chinese tend to concentrate in the cities, the Cambodians along the Cambodian border, and the Montagnards in villages scattered across the highlands.
South Vietnam is a predominantly rural country with a traditional family-oriented society. Agriculture and fishing are the major industries. Except for the small proportion of the population in the upper and middle classes, the standard of living is low. Sanitation and hygiene are generally poor by Western standards. Physicians are scarce (less than 1 per 100,000 people), leaving medical treatment in the hands of pharmacists and herbalists. Indiscriminate use of antibiotics purchased over the counter is common.
In terms of numbers of men involved, United States military involvement in the war in Southeast Asia began in earnest in April 1965, with President Lyndon B. Johnson's announcement that a major U.S. commitment would be made to stem North Vietnamese aggression. By the end of 1965, there were 185,000 U.S. troops in South Vietnam, of which 117,000 were U.S. Army personnel. Peak troop strength was reached by mid-1968; by January 1969, 366,000 were Army personnel. Thereafter, phased with-
drawals began, so that by mid-1972 only 22,000 American soldiers remained in Vietnam and these were gone by the spring of 1973.24
U.S. Army forces in Vietnam were engaged primarily in a counterinsurgency effort directed against North Vietnamese Army regulars who infiltrated south down the so-called Ho Chi Minh trail through Laos and Cambodia, or who crossed the demilitarized zone established by the 1954 Geneva agreement at the 17th parallel, and against the indigenous South Vietnamese insurgents, generally referred to as VC (Vietcong).
There was no "frontline," as in conventional warfare, since enemy units employed "hit and run" tactics when fighting, and otherwise remained dispersed, hidden in jungles, swamps, and small, friendly villages while preparing for future attacks. In a sense, it was a static war because U.S. and allied forces remained relatively fixed in their area of operations, and progress could not be measured in terms of movement of the front.
In this situation the U.S. Army played a dual role: First, it placed combat units in all parts of the country and gave them the mission of searching out and destroying the enemy and his supplies. Second, it established a logistical system which provided the majority of supplies and sophisticated maintenance for both U.S. and allied forces.
This dual role had important implications. A maximum ground combat troop strength was required to find and close on the enemy. At the same time, a large number of troops was required to man the logistical and combat support system. The logistical burden was added to by a large number of sophisticated weapons systems and other devices intended to minimize losses of friendly personnel.
Ground fighting was conducted by infantry maneuver battalions whose average strength was 800 to 850 men. These were the "cutting edge" of the figurative sword the United States wielded in Vietnam. Since armor, artillery, and air strikes were relatively ineffective against a dispersed and hidden enemy, successful conduct of the war depended upon the ability of the infantrymen to fight; and this was in turn strongly influenced by combat-available troop strength in the maneuver battalions.
As a result of unprecedented demands for logistical support, the ratio of support troops to infantrymen was higher than in any previous conflict. It has been estimated that seven support troops were required for every infantryman in the field, and this estimate may have been conservative. Consequently, the "cutting edge" was relatively small in relation to the overall number of troops in Vietnam, a fact of utmost importance in considering the impact of skin diseases on the fighting strength.
Both combat and support troops spent a yearlong tour of duty in Vietnam, and during this time they were always well fed and had adequate clothing. Infantrymen conducted patrols in mountains, jungles, or swampy
terrain, depending on the region in which their unit was operating. During the rainy season, they were exposed to torrential rains and flooded terrain (fig. 1). They were often unable to get completely dry for days at a time.
Opportunities for bathing were infrequent and skin hygiene was poor. Skin infections were rampant under these circumstances and many infantrymen were temporarily disabled as a result (fig. 2).
Support troops, on the other hand, and those in the other combat arms (such as armor, artillery, and combat engineers) were seldom exposed to water, mud, insect bites, and scratches in the same manner as were infantrymen. They had frequent opportunities to bathe and generally were
FIGURE 2.-Foot soldier taking time out from a patrol to examine his feet. Bacterial and fungal infections involving the skin of the feet and ankles were a major cause of temporary disability among U.S. combat forces in Vietnam.
able to keep dry, except for the effects of perspiration. Thus, in terms of cutaneous hygiene, infantrymen and support troops lived in two nearly separate worlds. As a consequence, support troops had few serious problems with skin infections and other disabling dermatoses.