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Chapter II

Table of Contents



Trained dermatologists were present in Vietnam from the inception of the major U.S. troop buildup. First to arrive was a U.S. Navy medical officer, Capt. Gustave T. Anderson, MC, who surveyed cutaneous disease problems among Navy and Marine Corps personnel in the northern area of South Vietnam from November 1965 to February 1966. Since this period coincided with the rainy season in the northern (Da Nang) area, Captain Anderson was able to make his observations at a time when the rate and severity of skin diseases were maximal.

Captain Anderson reported that skin diseases among U.S. troops in the Republic of Vietnam represented a morbidity problem of considerable magnitude and that the majority of cases were the same kinds of disease as those seen among similar populations in the Temperate Zone.1 Any differences seemed to be related to climate and lack of skin hygiene. In particular, Captain Anderson noted that skin diseases considered "tropi­cal," or endemic in Vietnam, were not present in U.S. troops.

The most common dermatoses in combat troops were pyoderma, fungus infections, and miliaria. Medical officers in the field indicated a feeling of incompetence in diagnosing and treating even the most ordinary skin disorders and expressed a strong desire for educational materials covering the common disease entities.

In view of his findings, Captain Anderson recommended the following:

1. Assign a dermatologist full time in the I Corps (northern) area of South Vietnam, with a twofold mission: (1) administer a dermatology clinic at the Station Hospital, Da Nang, and (2) act as a dermatology consultant for I Corps, particularly to cut down on the number of patients being evacuated out of country for dermatologic consultation.

2. Fill the need for educational materials in dermatology. Recommended was the production of a compact military handbook of dermatology, similar to the one published during World War II, and the production of short (5-10 minutes) educational films to be used in indoctrination of medical officers in field medical schools. Also suggested were audiovisual briefings on professional problems to be encountered in Vietnam. These, too, were to be given at the field medical schools.

1Anderson, G. T.: Report of Dermatologic Survey of U.S. Marine and Navy Personnel in Republic of Viet Nam. In Annual Report of the Commission on Cutaneous Diseases, AFEB, 1965-1966. Washington: U.S. Army Medical Research & Development Command, pp. 3-8.


3. Carry out problem-oriented investigations to help alleviate the major dermatology problems. Specific suggestions were:

a. Accumulation of data on the differences, kinds and number of resident and transient bacteria and fungi on skin in order to obtain more specific knowledge of microbiologic flora existing in our troops in the tropics and the role these organisms play in the production of disease.

b. Investigations of the possibility of using silicone preparations in the prevention of Wet Foot Syndrome.

c. Search for prophylactic methods to reduce the incidence of pyoderma, miliaria and dermatophytosis. Possible approaches include: (a) the use of antibacterial soaps for pyoderma and miliaria; (b) the use of tetracyclines for pyoderma; and (c) the use of griseofulvin in dermatophytosis.

d. Investigation of new and easier techniques in the laboratory diagnosis of skin disease in the field. Attempts at the University of Miami to develop a simple quick culture method to diagnose fungus infections are a step in the right direction.

e. Investigation of newer and better methods for the treatment and care of the common wart and fungus infections.

f. Search for ways to increase the resistance of the skin to chemical and mechanical trauma.

g. Search for newer and better treatments of bacterial infections of human skin.

Captain Anderson also commented about specific skin and venereal disease entities, including the following excerpts:

Pyoderma-Probably the most common dermatosis and generally secondary to insect bites, abrasions, lacerations, miliaria and dermatophytosis * * *. On a day to day basis this problem is responsible for most of the short term ineffectiveness in the line battalions.

Otitis Externa- * * * a very common problem during warm weather. A substantial percentage of people evacuated from RVN for "consultation" are for this reason.

*          *          *          *          *          *          *

Dermatophytosis-Next to pyoderma, * * * the most prevalent skin disease, seldom seen on the soles-most frequently expressed as T. [tinea] corporis (abdomen, buttocks, anterior legs, and dorsa of feet) and T. [tinea] cruris.

Candida Infections-Crural moniliasis is quite common during hot weather and quite an acute, crippling and distressing disease.

Miliaria Rubra-Very common in hot weather but seldom seen during the monsoon [rainy season]. * * *

*          *          *          *          *          *          *

Tinea Versicolor-Very common and generally much more extensive than those cases seen in our clinics at home.

Acne Vulgaris-Incidence probably no greater than in any dermatology clinic. However,


the disease frequently undergoes startling and profound changes for the worse in this hot, humid climate [of Vietnam].

*          *          *          *          *          *          *

Verruca Vulgaris-  * * * probably no more common than in any * * * clinic, but can be a disabling problem depending on location, e.g., plantar warts in the rifleman, * * *.

*          *          *          *          *          *          *

V.D.- * * * The most prevalent venereal disease seemed to be gonorrhea, followed in order by NSU [nonspecific urethritis] and chancroid, syphilis, and lymphogranuloma [venereum]. * * *

*          *          *          *          *          *          *

Wet Feet Syndrome- (Also called Immersion Foot or Paddy Foot). A potentially serious problem.

Captain Anderson's observations and recommendations, which had been made during a relatively brief survey period in the earliest portion of the major U.S. troop buildup, proved to be remarkably prescient as the Vietnam conflict enlarged in scope and intensity. His comments primarily concerned U.S. naval and Marine Corps personnel in the northernmost area of South Vietnam, but in retrospect it became apparent that they would later apply equally well to U.S. Army forces in the Mekong Delta at the opposite end of the country.


The need in Vietnam for a number of qualified dermatologists was recognized early by the U.S. Army Medical Department. During late 1965 and early 1966, no dermatologists as such were assigned in Vietnam. But in early 1966, an experienced, board-certified dermatologist, Lt. Col. (later Col.) Louis E. Harman, Jr., MC, arrived in Vietnam. Colonel Harman's principal duties were those of a hospital commander, first of the 36th Evacuation Hospital in Vung Tau, later of the 93d Evacuation Hospital at Long Binh. This was a demanding task and one that left little time for other activities, including the practice of dermatology. However, Colonel Harman was able to see a number of cases of skin disease in U.S. troops and in Vietnamese as well, an experience he was later to utilize in contributing a chapter to a book on various skin disease problems.2

The first U.S. Army dermatologist assigned to practice his specialty full time was Capt. Stanley E. Jacobs, MC, who arrived in July 1966.

2Harman, Louis E., Jr.: Skin Diseases in United States Military Personnel Serving in Vietnam. In The Skin (Elson B. Helwig and F. K. Mostofi, editors). Baltimore: Williams & Wilkins Co., 1971, pp. 423-434.


Captain Jacobs was stationed at the 17th Field Hospital in downtown Saigon, where he cared for both clinic and hospitalized patients drawn from several populations. His patients included Vietnamese nationals and U.S. State Department staff members as well as U.S. military personnel. The outpatient caseload at the 17th Field Hospital's dermatology clinic ranged between 704 and 1,334 per month, averaging 950. Six to 10 dermatologic patients were hospitalized at any given time, and 86 were evacuated out of country during the 1-year period from July 1966 through June 1967. Referrals came mainly from the III and IV Corps areas, but a few came from as far away as Qui Nhon.3

As the troop buildup continued in 1966, the USARV (U.S. Army, Vietnam) Medical Consultant, Lt. Col. (later Col.) Raymond W. Blohm, Jr., MC, recognized the need for more trained dermatologists in Vietnam and submitted an official recommendation to this effect to the Medical Consultant, Office of the Surgeon General, in Washington. The recommendation, which appeared in the USARV Medical Consultant's Monthly Report for September 1966,4 read as follows:

A minimum of four dermatologists, full time, are considered necessary for USARV. These should be located in the large support troop concentrations: one in Long Binh; one in Nha Trang; one in Qui Nhon; one in Saigon. At least one of these should be Regular Army and serve an additional duty as consultant in dermatology to the Surgeon, USARV, unless we have a more senior dermatologist serving in staff or command (as LTC Harman) in the country.

The response from Washington was that the situation regarding acquisition of dermatologists for the Army was not good.5 By the summer of 1967, it was anticipated that five dermatologists would come from the Berry (draft deferment) Plan, three from Army residency programs, and an undetermined number from the draft. These acquisitions had to be matched against the loss of 11 or more dermatologists from active duty during the same period. Thus the requirement for dermatologists in Viet­nam came when totals available to the Army were uncertain, if not shrinking.

Despite the scarcity of dermatologists Armywide, four were sent to Vietnam in mid-1967. Because of a lack of field-grade Regular Army medical officers in Vietnam, two of the four were "siphoned off" and assigned as division surgeons or hospital commanders, thereby necessitating a request for even more dermatologists to be sent to Vietnam.6

3Jacobs, Stanley E.: Dermatology in Vietnam. [Unpublished account of Captain Jacobs' professional experiences in Vietnam, 1966-67.]

4Report, Lt. Col. Raymond W. Blohm, MC, Medical Consultant, USARV, September 1966, subject: Medical Consultant's Monthly Report.

5Letter, Col. Marshall E. McCabe, MC, Chief, Medical Consultant, Office of the Surgeon General, Department of the Army, to Director, Professional Services, 21 Dec. 1966, subject: USARV Consultant Report, September 1966.

6Blohm, Raymond W. [Unpublished account of Lieutenant Colonel Blohm's professional experiences as USARV Medical Consultant, 1966-67.]


By the end of 1967, four full-time dermatologists had been assigned to the U.S. Army in Vietnam. They were located to provide area coverage, as follows: 17th Field Hospital, Saigon; 24th Evacuation Hospital, Long Binh; 85th Evacuation Hospital, Qui Nhon; and the 9th Infantry Division, Bear Cat. This provided coverage for all but the I Corps area. Lt, Col. (later Col.) William C. Fisher, MC, commander of the 8th Field Hospital in Nha Trang, was designated USARV dermatology consultant. In this capacity he provided guidance and consultation services during visits to the field.

This pattern of deployment of dermatologists in Vietnam remained until 1969, when the USARV Medical Consultant, Lt. Col. (later Col.) Andre J. Ognibene, MC, recommended that six dermatologists be assigned to the Army in Vietnam.7

By the end of the year, in addition to those in Long Binh (III Corps) and Qui Nhon (II Corps), dermatologists were assigned to the 95th Evacuation Hospital in Da Nang (I Corps), the 71st Evacuation Hospital in Pleiku, which supported the U.S. 4th Infantry Division in western II Corps, and the 3d Field Hospital in Saigon.

An excerpt from Colonel Ognibene's End-of-Tour Report is relevant to dermatologic interests and is especially worthy of note because it came from a knowledgeable source with no vested interest in dermatology.8

Dermatology support remained critical throughout the year despite direct requests for individuals in 3112 MOS [dermatologists]. At present, three C 3112s [dermatologists who had completed residency training] are in-country * * *. It is mandatory to have at least two additional individuals. * * * Despite shortages, a remarkable upgrading of dermatology care was noted during the year. Although short staffed, the dermatologists traveled to divisional units to provide teaching programs and were responsible for reducing combat manpower loss due to skin disease. There apparently remains a failure to recognize the importance of skin disease in the tropics in relation to combat loss since assignment of the required dermatology support structure with its teaching capacity would go far in solving the problem and has not yet been accomplished.

Because dermatologists remained in continued short supply to the Army as a whole, only three were assigned to Vietnam in 1970 and 1971, and of these, only two were fully trained. Thereafter, the need for dermatologists diminished because of the rapid decrease in troop strength during 1971 and 1972.


From the earliest stages of the U.S. troop buildup in 1965-66, it was apparent that the value to the Army of clinical specialists would be vastly increased if they could play an active role in consultation and training as

7Report, Office of the Surgeon, Headquarters, USARV, subject: AMEDD Activities Report, Calendar Year 1969.
8Report, Lt. Col. Andre J. Ognibene, MC, USARV Medical Consultant, to Surgeon, USARV, 28 Oct. 1969, subject: End of Tour Report.


well as in direct patient care. It was intended that these services be provided to give geographical area coverage. With respect to dermatology, it was envisioned that one dermatologist would provide such coverage for an entire corps area. Since field medical units and dispensaries (troop clinics) organic to divisions and separate brigades were generally those in greatest need of such services, it was necessary for the clinical specialist to travel to these divisions and brigades to provide consultation and to administer training.

Before 1969, provision of consultation and training in clinical specialties was carried out on an ad hoc basis.9 Because of such factors as transportation difficulties and large caseloads in base area hospitals and clinics, travel to outlying units tended to be infrequent and at irregular intervals. As a consequence, relatively few of the physicians and corpsmen who were providing primary care to patients in major troop units had direct access to advice from specialists. In addition, provision for upgrading the level of training in certain specialty areas which were of critical importance on a day-to-day basis was not always sufficient.

In March 1969, an attempt was launched to remedy this situation. The proposed solution was known as the MEDCON (Operation Medical Consultant) concept.10 Under this concept, which was developed by the USARV Medical Consultant and the Plans and Operations Division of the 44th Medical Brigade, medical subspecialists as well as chiefs of medicine in various hospitals were required to make liaison visits to aid stations and unit surgeons on a systematic, recurring basis. For chiefs of medicine or their representatives, visits to unit surgeons would occur once during each quarter; however, it was recognized and commented upon at the time that for certain subspecialties, such as dermatology, these liaison visits would necessarily have to be more frequent.

The MEDCON concept was implemented in May 1969 by direction of the USARV Surgeon, Brig. Gen. (later Lt. Gen.) Hal B. Jennings, Jr., MC.11 The concept was supported by the 44th Medical Brigade, whose chief function was to arrange the consultant visits and provide transportation. From the outset, dermatologists were extensively involved in this program of teaching and consulting.

Although it worked well in some areas, in general the MEDCON concept was not particularly successful.12 It was difficult to carry out adequately because of a serious lack of transportation. For reasons of physical security, nearly all travel to divisional units had to be by helicopter, and helicopters were in critically short supply for all but combat-related missions. After the MEDCON concept had been explored for about half a year,

9Ognibene, Andre J. [Unpublished account of Lieutenant Colonel Ognibene's professional experiences as USARV Medical Consultant, 1968-69.]

10See footnote 8, p. 19.

11See annex to footnote 8, p. 19.

12See footnote 7, p. 19.


frequent scheduled area medical conferences were believed to be a better alternative. These conferences were "to spread medical knowledge and to engender friendly relations between hospital personnel and the units they support."

Despite the difficulties involved in making the MEDCON concept fully workable, the trial period did establish that the stationing of a fully trained, competent dermatologist in support of two or three divisions, with a base at a supporting hospital, was probably the most satisfactory solution to the problem of providing optimum dermatological services in the Vietnam theater. This, of course, was dependent upon the provision of adequate transportation facilities.


Consultants representing the AFEB (Armed Forces Epidemiological Board) played a major role in investigating the important skin diseases with which U.S. forces were concerned. They also recommended measures for control of these diseases. The consultants arrived in October 1967 as a three-man team, headed by Dr. Harvey Blank, Professor and Chairman, Department of Dermatology, University of Miami, Florida, and Director, Commission on Cutaneous Diseases, AFEB. The other team members were Dr. Nardo Zaias, a dermatologist, and Mr. David Taplin, a cutaneous microbiologist; both of these men were Assistant Professors of Dermatology at the University of Miami and both were Associate Members of the Commission on Cutaneous Diseases.

The idea of bringing a distinguished civilian dermatologic consultant team to Vietnam had been entertained by the Army since late 1965.13 U.S. Army personnel did not experience major problems with skin disease as early in the war as did marines in I Corps, but it was apparent that common skin afflictions, such as fungal infections of the groin, would eventually become a major cause of morbidity and lost man-hours in ground combat units.

In an AFEB memorandum dated 10 December 1965,14 the Board stated that "the precise causes and extent of cutaneous disability and resulting non-effectiveness of military personnel in the South Viet Nam Theater and similar areas should be determined." At about that time, official contact was made with Dr. Blank concerning a consultant trip, and it was agreed

13Letter, Col. William D. Tigertt, MC, Director, WRAIR (Walter Reed Army Institute of Research), to Maj. Robert J. T. Joy, MC, Chief, US. Army Medical Research Team (WRAIR) Vietnam, 19 Nov. 1965, subject: Civilian Consultants in Dermatology for US. Military Forces in Vietnam.

14Memorandum, Capt. Sidney A. Britten, MC, USN, Executive Secretary, Armed Forces Epidemiological Board, to the Surgeons General, Departments of the Army, Navy, and Air Force, 26 May 1967, subject: Commission on Cutaneous Diseases Proffer of an Expert Team.


that he and others would make a visit whenever the military authorities in Vietnam felt that it would be necessary.15

A year and a half passed before the need for the dermatologic consultant team became urgent. In mid-1967, the USARV Surgeon, Brig. Gen. (later Maj. Gen.) Glenn J. Collins, MC, noted the steady encroachment of skin diseases on combat manpower and extended an invitation for a consultant visit.16

The team surveyed soldiers and marines in the field, visited clinics and hospitals, and gathered data indicating the rate at which skin diseases were occurring and the extent to which they were eroding into combat manpower. Of greatest importance was the fact that they brought a field microbiological capability with them and were able to culture the skin lesions they saw.

Their clinical findings confirmed Captain Anderson's impressions of nearly 2 years before.17 Bacterial and fungal infections, miliaria and acne, candidiasis and intertrigo, and, finally, gonorrhea were common among ground troops and were often the leading cause of time lost from combat duty in the wet, lowland areas of Vietnam.

The fungal pathogen of primary importance was the granular, or zoophilic, variety of Trichophyton mentagrophytes.18 This organism was the cause of the majority of fungal skin infections. It also was the pathogen principally responsible for the production of severe, inflammatory lesions. These lesions could be temporarily disabling and were apt to recur after brief exposures to a watery environment. Epidermophyton floccosum, Trichophyton rubrum, and Candida albicans also were prominent as causes of fungal skin infections, but they were not nearly so important as T. mentagrophytes.

Cultures of bacterial skin infections, including ulcers on the extremities, yielded coagulase-positive staphylococci (Staphylococcus aureus) and, in a smaller number of cases, group A beta-hemolytic streptococci (Streptococcus pyogenes).19 Sixty percent of the staphylococci were penicillin resistant by disc sensitivity testing. On the basis of culture data, the consultant team's impression was that staphylococci were the principal offenders in the common bacterial skin infections; in this they were in agreement with the opinion of most of the physicians who had served in Vietnam until that time. However, their report did mention that the role of beta-hemolytic streptococci might have been considerably underestimated. This inference,

15Letter, Col. William D. Tigertt, MC, Director, WRAIR, to Harvey Blank, M.D., Director, Commission on Cutaneous Diseases, AFEB, 6 July 1967, subject: Possible Dermatologic Research in Vietnam.

16Letter, Col. Robert E. Nitz, MC, Chief, Preventive Medicine Division, Headquarters, USARV, to Harvey Blank, M.D., Director, Commission on Cutaneous Diseases, AFEB, 10 Sept. 1967, subject: Visit of an Expert Dermatologic Team.
17Report, Dermatologic Team of the Commission on Cutaneous Diseases, AFEB, to the President, AFEB, 15 Jan. 1968, subject: Report on Trip to Vietnam.

18Blank, Harvey, Taplin, David, and Zaias, Nardo: Cutaneous Trichophyton mentagrophytes Infections in Vietnam. Arch. Dermat. 99: 135-144, February 1969.

19See footnote 17.


which was based on only seven culture-positive cases, was later to be proven correct.20

The following measures for prevention and treatment of skin and venereal diseases were recommended to the Theater Surgeon on 23 October 1967 for immediate implementation:21

a. Have griseofulyin tablets freely available in all dispensaries, pharmacies, aid stations, etc. These should be 500 mg tablets of microcrystalline or fine particle type.

b. Insist upon wearing of shower clogs or thongs and abbreviated clothing such as shorts rather than fatigues when in camp or aboard ship.

c. Recommend exposure of as much of the body as possible to the sun for 30 minutes every day when feasible. As little as practical should be worn during sun treatments, i.e. jockey shorts or jock strap depending on degree of isolation of the area available.

Both medical and administrative measures were recommended for implementation as soon as possible. The administrative measures were:22

a. Issue outer shorts for wear instead of fatigue trousers during non-combat activities and insist upon their use whenever possible.

b. Issue low quarter tennis shoes to combat troops to wear at night as a change from boots.

c. Change the present issue sock to one which is lighter weight, contains no wool and dries quickly.

d. Investigate laundry facilities to determine if clothing is being properly sanitized and improve inadequate installations, to come closer to "standard laundry procedures for cotton fabrics."

e. Increase the number of trained laboratory personnel, especially microbiologists, in the medical laboratories in Viet Nam and improve their supply situation.

f. Undertake further research into the design of improved tropical footwear and socks. * * *

In addition, the consultant team pointed out that "although the preceding recommendations are meant to help reduce disability as promptly as possible, they are only stopgap measures for widespread serious problems which require a great deal of additional detailed study." A series of detailed recommendations was made concerning clinical, epidemiological, and microbiological investigation intended to provide better methods of prevention and treatment.

To provide a means of conducting such mission-oriented investigations, the team also made several broad planning recommendations. Included were recommendations that:23 (1) dermatologic research positions be established in Southeast Asia and include not only dermatologists but also mycologists, bacteriologists and other laboratory experts; (2) the research effort be part of the Walter Reed Army Institute of Research in

20Allen, Alfred M., Taplin, David, and Twigg, Lewis: Cutaneous Streptococcal Infections in Vietnam. Arch. Dermat. 104: 271-280, September 1971.
21See footnote 17, p. 22.
22See footnote 17, p. 22.
23See footnote 17, p. 22.


Vietnam; (3) planning and action adapt modern medical knowledge to the prevention of disability, much of which was needless; and (4) consideration be given to establishment of a tropical field testing station in the United States, located near a medical school and research center.


Operation SAFESTEP was the name given to a program designed to provide better methods for preventing disabling skin diseases among infantrymen operating in wet terrain.24 It was conceived and conducted within the U.S. 9th Infantry Division when the division was engaged in riverine operations in the Mekong Delta. It was given high priority because skin diseases were the leading cause of disability within the division and at times were the chief limiting factor in the duration of combat operations. Much of the program was oriented toward research and development, and consequently, appropriate consultation was sought.

The principal dermatologic consultant to Operation SAFESTEP during the 2 years of its existence (1968-69) was Col. William A. Akers, MC, Chief of the Dermatology Research Program, U.S. Army Medical Research Unit, Presidio (later Letterman Army Institute of Research) of San Francisco, Calif. As a consultant, Colonel Akers was responsible for providing technical assistance, designating and implementing cooperative studies, and furnishing specialized technical services, such as histopathology. In the course of his activities as a consultant to Operation SAFE STEP, Colonel Akers maintained an extensive correspondence with the division surgeons who were directly in charge of the program and also made three consultant visits to Vietnam. These visits provided an on-the-ground appreciation of the disease problems involved and afforded an opportunity to establish technical liaison with high echelons of the command.

The first consultant visit, in June 1968, served to establish liaison with the command and staff structure of the 9th Division. The second visit was made in October 1968; its purpose was to:25

1. Assist a field dermatologic survey team from the Walter Reed Army Institute of Research in establishing a microbiological laboratory at the division's base at Dong Tam in the Mekong Delta.

2. Observe and assist in testing new footgear designed to reduce the incidence and severity of skin disease involving the feet.

3. Examine, diagnose, and obtain laboratory specimens from soldiers with skin disease for the purpose of establishing research priorities.

24Blackwell, Travis L., Duca, Peter R., Hickey, Timothy F., and Ellerin, Philip S.: Operation Safestep: An Approach to the Problem of Dermatological Diseases in a Riverine Environment. USARV Med. Bull. (USARV Pam 40-11) September-October 1968, pp. 20-22.

25Letter, Col. William A. Akers, MC, Chief, Dermatology Research Program, U.S. Army Medical Research Unit, Presidio of San Francisco, to Lt. Col. Archibald W. McFadden, MC, Division Surgeon, U.S. 9th Infantry Division, 10 Nov. 1968, subject: Interim Report of Dermatological Consultation to Operation Safestep, 9th Infantry Division.


4.  Determine the feasibility of utilizing divisional medical personnel in evaluating drugs and other therapeutic modalities in the treatment of skin disease.

The trip report contained a description of immersion foot as it existed in the delta. The description was significant because it pointed out the clinical differences between immersion injuries of the feet among U.S. Army infantrymen in the Mekong Delta and those involving U.S. marines in the northern coastal provinces, as described 3 years earlier by Captain Anderson. The report read as follows:26

Of interest were the numerous cases of "immersion foot" seen during this visit but not during my previous visit in May-June 1968. It is characterized by erythema, tiny vesicles, pain to pressure, and a brawny, non-pitting edema of the area covered by the boot and sock. The soles of the feet are generally spared. It does not resemble the photographs and descriptions I have seen of "immersion foot" suffered by the U.S. marines in I Corps. Often there is tender, femoral lymphadenopathy present. Some patients will have an oral temperature of 100° F-102° F. On simple bed rest and elevation of the feet, the fever, tenderness, and edema subside in 48 to 72 hours. The involved skin of the tops of the feet and legs then desquamates. There is rarely any desquamation of the skin of the soles of the feet. The patient is usually returned to duty in 3 to 5 days. Occasionally, abrasions become secondarily infected with bacteria, or fungus infections will develop, but this is an exception. The command has recognized the problem and established a 48 hour limitation to water immersion to be followed by a 24 hour dryout period in a dry place. This condition is distinctive from that usually described as "immersion foot" in the medical literature and from past military experience.

During his trip, Colonel Akers visited a Vietnamese marine battalion and examined 22 marines who had sustained immersion injuries after 60 hours of exposure to inundated terrain. Their clinical condition was not described; however, it was noted that of 10 men from whose feet cultures for fungi were taken, none yielded a pathogen.27

Six VC (Vietcong) prisoners of war and 26 civilian dependents (VC sympathizers or laborers) also were examined for skin diseases. Eleven (34 percent) of the 32 VC detainees showed evidence of immersion injury of the feet and lower legs. Clinical findings consisted of erythema and desquamation of the skin covering the legs and dorsa of the feet, and "white sogginess" of the soles of the feet. Details of their capture were not obtained, nor was the length of their exposure to wet terrain determined.28

From these findings, Colonel Akers concluded that, contrary to preva­lent opinion, Vietnamese could suffer from immersion injuries of the feet, particularly when dressed in boots and socks. He stated that further study should be carried out of the effects of exposure to water and mud on Vietnamese.

Colonel Akers29 described Operation SAFESTEP as an invaluable

26See footnote 25, p. 24.

27See footnote 25, p. 24.

28See footnote 25, p. 24.

29See footnote 25, p. 24.


tool for critical evaluation of clothing, footgear, and techniques of prevention. He cited two examples as evidence of the success of the program. One study showed that tennis shoes, when worn alone, permitted sand and grit to enter and cause skin abrasions, thereby negating their advantages with respect to rapid drying of the skin of the feet. Another study showed that drying the skin 11 hours out of each 24 during a 96-hour period prevented significant foot problems compared to permitting feet to be continuously wet or damp from paddy water.

A final consultant's visit was made to the 9th Infantry Division in May 1969, shortly before the division was returned to the United States and temporarily deactivated. Colonel Akers' trip report30 contained entries on miliaria, fungal infections, pyoderma, haloprogin, and a skin protective lotion. Of particular significance were the following excerpts:

1. Miliaria: Severe cases of miliaria were treated with 1,000-mg doses of ascorbic acid (vitamin C) daily for 14-day periods. The value of this treatment was not known since it was administered in an uncontrolled manner. A topical preparation containing menthol or camphor, salicylic acid, glycerin, and isopropyl alcohol also was used for the treatment of prickly heat at the battalion aid station level. In addition to these treatment agents, it was recommended that individuals wear the least amount of clothing possible when working or sleeping and that cold showers be taken twice a day. The use of soap in areas other than the face, hands, feet, and groin was discouraged since it was felt that excess use of soap could lead to miliaria.

2. Pyoderma: The use of topical cleansing medications and systemic antibiotics shortened the healing time of ecthyma from 14 to 16 days to 8 days.

3. Haloprogin. Haloprogin, a new, topical antifungal agent, was found to produce too much burning and stinging when used in the tincture form, and consequently, the study of the agent in an alcohol vehicle was discontinued after study of 11 patients. Results using haloprogin in a cream base indicated that it was an effective topical antifungal agent, but too few cases were treated to determine whether it was superior to tolnaftate (Tinactin).

4. Skin Protective Lotion: A skin protective lotion, the main ingredient of which had been in extensive use for 9 years to protect the hands of machinists against aqueous machine tool coolants, was tested in five Operation SAFESTEP volunteers. The men wore the standard jungle boot and issue cotton-wool socks continuously for 5 days. During this time, they walked 6 kilometers a day in a flooded paddy over a 9-hour period, and during the remainder of the time, they kept their boots and socks wet by immersing them in a trough of paddy water every 3 hours. The protective

30Letter, Col. William A. Akers, MC, Chief, Dermatology Research Division, Letterman Army Institute of Research, to Col. Robert H. Quinn, MC, Chief, Preventive Medicine Division, Headquarters, USARV, 26 May 1969, subject: Interim Dermatological Consultation Visit Report to the 9th Infantry Division.


lotion was applied once a day to the left foot, while the right foot served as an untreated control. At the end of the 5-day period, no subject had paddy foot (defined as tiny vesicles on an erythematous base, petechiae, crusts, and erosions) on the foot to which the lotion had been applied, while in contrast, two of the five subjects had mild immersion injury and two had moderate injury on the untreated foot.

Colonel Akers closed his final trip report with an admonition that no single, simple solution to the problems of skin diseases in Vietnam was in sight. However, he stressed that a number of advances had been made since his previous visit a year earlier. Among these advances were:

1. The identification by the Walter Reed Army Institute of Research dermatology team of group A beta-hemolytic Streptococcus as the main infecting agent in pyoderma.

2. The reduction of healing time of ecthyma from 16 to 8 days by intensive topical and systemic therapy.

3. The reduction of fungal skin disease from 35 percent per month to 3 to 8 percent by use of prophylactic griseofulvin.

4. The development of better socks, boots, and bivouac shoes by the U.S. Army Natick Laboratories.

5. The establishment of testing facilities at Dong Tam, the divisional base, under Operation SAFESTEP, thereby providing a valuable, timesaving asset in the fight against skin disease.