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Chapter III

Table of Contents

CHAPTER III

Statistics

Army statistics concerning skin diseases are more complete for the Vietnam war than for any previous conflict in American history. Medical statistical data were routinely collected and reported to higher echelons by all medical treatment facilities in the country. The quality and completeness of the reported information varied according to its source: that from hospitals was more complete than that from troop clinics, while that from facilities with a trained dermatologist assigned was diagnostically more accurate than that from facilities staffed by medical officers with little or no formal training in dermatology.

Statistics originated from three major sources-hospitals, clinics, and field medical units, commonly known as battalion aid stations. Data from hospitals were comparable in accuracy to those from military hospitals in the United States and included specific discharge diagnoses as well as an accurate patient census. Clinic data showed only the number of patient visits per month for 10 broad-cause categories of disease. Data from field units tended to be fragmentary and episodic and seldom indicated more than the organ system of involvement.

The net effect of this reporting system was that many cases of cutaneous disease were unreported, as was the noneffectiveness attendant to them. Despite these limitations, it was clear that skin disease was a leading cause of morbidity and time lost from duty.

HOSPITAL STATISTICS

Of all patients seeking medical treatment for skin diseases, only a small fraction (<1 percent) were hospitalized for these conditions. Consequently, hospital statistics represented only the tip of the cutaneous disease iceberg in Vietnam. Cases were selected for hospitalization on the basis of severity, refractoriness to outpatient treatment, and interest to the treating physician. This was in direct contrast to the situation with such diseases as malaria and hepatitis, for which hospitalization was routinely practiced. Thus, comparisons of rates of disease which were based on hospital statistics were apt to be misleading.

During the 8-year span of significant U.S. troop involvement in the Vietnam war (1965-72) there were 45,815 hospital admissions for skin


30

diseases among U.S. Army personnel. The annual incidence of hospitalized cases of skin disease varied between 33.1 and 18.9 per 1,000 per year (chart 1). This accounted for 4.0 to 7.5 percent of the annual incidence of all medical and surgical conditions, and for 6.0 to 9.3 percent of the annual incidence of all diseases combined. Overall, afflictions of the skin accounted for 7.4 percent of all admissions for disease over the 8-year period.

The annual incidence of hospitalized cases of skin disease in Vietnam was three to five times that among the active-duty Army population in the continental United States from 1965 to 1972. Rates of cutaneous disease in Korea, the only other Asian country with a large U.S. troop population, were more like those of the United States than those of Vietnam (chart 2).

Diseases of the skin were the third leading cause of admission for disease during the 8-year period of record, ranking behind diarrheal diseases and respiratory infections and slightly ahead of malaria
(chart 3). The relative importance of skin diseases as a cause of hospital admissions did not remain static year by year, but increased to exceed that of malaria as the war progressed (chart 4).

Monthly admission rates for skin disease varied as much as threefold during the course of a year, but there were no clear-cut seasonal patterns or trends (chart 5). Rates of hospitalization were generally higher toward the beginning and the end of the conflict than during the middle.

During the years for which data are available, 1967 and 1968, the average hospital stay for patients with dermatologic disorders was 8 days. By comparison, the average hospital stay for patients with respiratory infections was 7 days; that for patients with diarrheal diseases was 3 days; and that for patients with malaria was 21 days.1

The principal causes of admission to the dermatology services of U.S. Army hospitals in Vietnam were pyoderma, eczema, cystic acne, and tinea (table 1). Together, these conditions accounted for approximately three-fourths of all dermatologic admissions.

A similar but slightly different picture emerges when all dispositions for skin disease are considered, whether or not these were from the dermatology service of a hospital. Figures for the period 1965-70 show that hospitalization for infections comprised 45 percent of all dispositions with a dermatologic condition as the primary diagnosis (table 2). Of hospitalizations for skin infections, 8 percent were for dermatophytosis, 8 percent for boils and carbuncles, 67 percent for cellulitis and abscesses, and 17 percent for other localized infections.

The disposition of hospitalized patients with skin diseases was not well documented but can be inferred from figures furnished by Capt. Stanley E.

1Memorandum, Maj. Hans J. W. Mueller, MSC, Sanitary Engineer, Office of the Command Surgeon, MACV (U.S. Military Assistance Command, Vietnam), for Brig. Gen. Spurgeon Neel, MC, MACV Command Surgeon, 24 Mar. 1969, subject: Statistical Analysis of the Dermatologic Conditions of U.S. Troops in RVN.


31

CHART 1.-Hospital and quarters admissions for skin diseases, for all diseases combined, and for all medical and surgical conditions: U.S. Army personnel in Vietnam, 1965-72

CHART 2.-Annual incidence of skin disease (hospitalized cases) among U.S. Army personnel in Vietnam, Korea, and the continental United States: 1965-72


32

CHART 3.-Hospital admissions for skin diseases in comparison to admissions for other diseases: U.S. Army personnel in Vietnam, 1965-72

CHART 4.-Annual incidence of skin, respiratory, malarial, and diarrheal diseases (hospitalized cases): U.S. Army personnel in Vietnam, 1965-72


33

CHART 5.-Incidence of skin disease (hospitalized cases): U.S. Army personnel in Vietnam, 1965-72

TABLE 1.-Admissions for skin diseases during a 1-year period, 17th Field Hospital, Saigon, 1966-67

Disease

Number of cases

Percent

Pyoderma

114

32

Infected eczematous dermatitis

51

15

Eczema

49

14

Cystic acne

26

7

Cellulitis

17

5

Urticaria

17

5

Tinea

13

4

Tinea pedis, secondarily infected

12

3

Disease unspecified

53

15

    

Total

352

100


34

TABLE 2.-Disposition by primary diagnosis of selected dermatologic conditions of active-duty Army personnel, Vietnam origin, 1965-70

Diagnosis (ICDA Code1)

Number of  disposition

Disposition rate2

Dermatophytosis (110)

963

0.63

Boil and carbuncle (680)

1,047

0.69

Cellulitis and abscess (681, 682)

8,561

5.61

Other local infection (684, 686)

2,265

1.48

Dermatitis and eczema (690-692)

1,403

0.92

Diseases of dermal appendages (703-706)

1,824

1.20

Other dermatologic conditions3

12,731

8.34

    

Total

28,794

18.87

1ICDA = International Classification of Diseases, Adapted (8th revision).

2Per 1,000 average annual strength.

3Includes ICDA codes 053, 054, 0790, 0791, 085, 091, 098, 099, 117, 132, 133, 1342, 140, 172, 173, 216, 380, 683, 685, 693-698, 700-702, 707-709, 7571, 7572, 9914, and 992.

Source: Patient Administration and Biostatistics Office, Office of the Surgeon General, Department of the Army.

Jacobs, MC, of the 17th Field Hospital, Saigon.2 During the period from July 1966 through June 1967, the disposition of 382 hospitalized patients was as follows: 55 percent to duty, 19 percent to quarters, 23 percent evacuated out-of-country, and 3 percent transferred to another hospital in Vietnam.

MEDICAL EVACUATIONS

Between 20 and 25 percent of patients hospitalized by dermatologists were evacuated from Vietnam to hospitals in Japan or in the United States because they required long term treatment or, more commonly, because the treating physician judged that the disease would recur and become chronic with further exposure to the Tropics.3 Causes of evacuation varied widely across the diagnostic spectrum, but a few causes were clearly more significant than others (table 3). Patients evacuated because of cystic ("tropical") acne, eczematous dermatitis, dyshidrosis, and fungal infections comprised more than half the total.

During the 6-year period from 1965 through 1970, a total of 4,166 patients were evacuated from Vietnam because of dermatologic disorders. This amounted to 9.7 percent of evacuations for disease and 3.7 percent of evacuations for all medical and surgical causes.4 These proportions compare favorably with figures derived from the experience of American forces in

2Jacobs, Stanley E.: Dermatology in Vietnam. [Unpublished account of Captain Jacobs' professional experiences in Vietnam, 1966-67.]
3Report, Patient Administration and Biostatistics Office, Office of the Surgeon General, 31 Mar. 1975, subject: Dermatologic Conditions in Vietnam, 1965-1970.

4See footnote 3.


35 

TABLE 3.-Distribution of dermatologic causes of medical evacuation from Vietnam, 1965-70

Diagnosis (ICDA Code1)

Number

Percent

Dermatophytosis (110)

127

3.0

Boil and carbuncle (680)

43

1.0

Cellulitis and abscess (681, 682)

609

14.6

Other local infection (684, 686)

235

5.6

Dermatitis and eczema (690-692)

354

8.5

Diseases of dermal appendages (703-706)

403

9.7

Other dermatologic conditions2

2,395

57.6

    

Total

4,166

100.0

1ICDA = International Classification of Diseases, Adpated (8th revision).

2Includes ICDA codes 053, 054, 0790, 0791, 085, 091, 098, 099, 117, 132, 133, 1342, 140, 172, 173, 216, 380, 683, 685, 693-698, 700-702, 707-709, 7571, 7572, 9914, and 992.

Source: Patient Administration and Biostatistics Office, Office of the Surgeon General, Department of the Army.

the Southwest Pacific during World War II, when 15 percent of all evacuations were for dermatologic diseases.5

OUTPATIENT STATISTICS

Skin diseases were the single greatest cause of outpatient visits to U.S. Army medical facilities in Vietnam during the entire war.6 During the period 1965-72, there were 1,412,500 visits recorded for dermatologic disorders;7 these constituted 12.2 percent of the total number of visits for all causes, a figure approximately twice that for any other broad-cause category of disease (chart 6).

The rate of outpatient visits for skin diseases did not remain constant during the war, but showed substantial seasonal and annual fluctuations (charts 7 and 8). In general, the seasonal fluctuations coincided with the rainy and dry seasons (see Morbidity Statistics and Environmental Data, p. 46, for a more detailed analysis). The annual rate of visits seemed to bear a direct relationship to troop strength, increasing as the number of troops increased, and decreasing as the number of troops decreased. The rate of hospitalization showed a reverse relationship (chart 7), suggesting a greater tendency to treat dermatologic patients as outpatients when troop strengths were high and the fighting more intense, and, conversely, that skin diseases were more likely to be treated on an inpatient basis at other times.

5Pillsbury, Donald M., and Livingood, Clarence S.: Experiences in Military Dermatology. Arch. Dermat. & Syph. 55: 441-462, April 1947.

6Sulzberger Marion B., and Akers, William A.: Impact of Skin Diseases on Military Operations. Arch. Dermat. 100: 702, December 1969.

7Report, Medical Statistics Agency, Office of the Surgeon General, 20 Dec. 1972, subject: Outpatient Visits by Broad Cause Group, Army Active Duty, Vietnam.


36

CHART 6.-Outpatient visits for skin diseases in comparison to visits for other causes: U.S. Army personnel in Vietnam, 1965-72

Only 10 to 15 percent of patients with skin disease were seen at a clinic to which a trained dermatologist was assigned; the rest were seen at clinics, dispensaries, and battalion aid stations staffed by general medical officers and enlisted corpsmen. Trained dermatologists primarily ran a referral practice, seeing patients with severe, recalcitrant, or unusual diseases. The other physicians rendered primary medical care and therefore saw skin diseases in their most common forms. Consequently, medical statistics compiled by dermatologists were not comparable to those compiled by other physicians.

Several Army dermatologists gathered statistical data during their 1-year tour of duty in Vietnam. Captain Jacobs, at the 17th Field Hospital, Saigon, found that pyoderma, miliaria, tinea, warts, and eczema were the five most common causes of outpatient visits in 1967 (table 4).8 Maj. (later Lt. Col.) Henry E. Jones, MC, at the 95th Evacuation Hospital, Da Nang, found warts, acne, dermatophytosis, pseudofolliculitis, and penile ulcers to be most common in 1970-71 (table 5).9 Major Jones' figures were

8See footnote 2, p. 34.
9Jones, Henry E.: Vietnam Dermatology. [Unpublished account of Major Jones' professional experiences in Vietnam, 1970-71.]


37

CHART 7.-Hospitalization and outpatient visits for skin diseases in relation to troop strength: U.S. Army personnel in Vietnam, 1965-72

CHART 8.-Rate of outpatient visits for skin diseases: U.S. Army personnel in Vietnam, 1965-72


38

TABLE 4.-Most common diagnoses in new patients seen at the dermatology clinic, 17th Field Hospital, Saigon, July 1967

Diagnosis

Number of cases


Percent
 

Pyoderma

47

10.0

Miliaria

43

9.2

Tinea

43

9.2

Verrucae

37

7.9

Eczematous dermatitis

26

5.6

Candidiasis

22

4.7

Infected eczematous dermatitis

20

4.3

Acne

18

3.8

Tinea versicolor

15

3.2

Urticaria

13

2.8

Contact dermatitis

11

2.3

Plantar warts

11

2.3

Alopecia areata

10

2.1

Pseudofolliculitis barbae

9

1.9

Psoriasis

7

1.5

Others

137

29.2


Total

469

100.0

Source: Capt. Stanley E. Jacobs, MC.

remarkably similar to those from the dermatology clinic at William Beaumont General Hospital, El Paso, Tex., which served dependents and retirees as well as active-duty patients and was located in a hot, dry climate (table 6).

Among Vietnamese patients seen at the 95th Evacuation Hospital's dermatology clinic, leprosy, contact dermatitis, atopic dermatitis, psoriasis, and drug eruptions were the most common diagnoses (table 7).

Physicians at battalion aid stations and other treatment facilities did not keep similar statistics concerning their patients with skin diseases. However, a few did maintain pertinent records, indicating such items as the number of patient visits for dermatologic disorders as compared to other causes, the number of men placed on light duty or quarters because of their condition, and a rough diagnostic breakdown. Figures obtained from the U.S. 9th Infantry Division in the Mekong Delta provide representative data for troops in an area where rates of disabling skin disease were particularly high because of weather, terrain, and combat conditions. Capt. James A. Lowy, MC, who served as the surgeon for an infantry battalion in the 9th Division, noted that skin diseases accounted for two-thirds of all visits for disease over a 4-month period in 1968 (table 8).

The principal dermatologic causes of patient visits in infantry battalions were pyoderma, dermatophytosis, and immersion foot. Few if any


39

TABLE 5.-Proportionate distribution of skin diseases seen in U.S. Army dermatology clinic, 95th Evacuation Hospital, Da Nang, Vietnam, 15 May 1970 to 31 July 1971 [14.5 months]

Disease

Number of cases

Percent of total

Warts, all types

729

15.83

Acne, all types

466

10.12

Dermatophytosis, all types

371

8.06

Pseudofolliculitis barbae

289

6.28

Penile ulcer [? chancroid]

221

4.80

Miliaria

199

4.32

Pyoderma, all types

178

3.87

Contact dermatitis

167

3.63

Urticaria

126

2.74

Tinea versicolor

123

2.67

Psoriasis

106

2.30

Atopic dermatitis

95

2.06

Dyshidrosis

95

2.06

Alopecia areata

82

1.78

Monilia

71

1.54

Lichen planus

70

1.52

Herpes progenitalis

68

1.48

Seborrheic dermatitis

56

1.22

Miscellaneous dermatoses and dermatitides

51

1.11

Insect bites

48

1.04

Molluscum contagiosum

41

0.89

Sebaceous cyst

40

0.87

Pityriasis rosea

39

0.85

Hand and foot eczema

37

0.80

Lichen simplex chronicus

35

0.76

Syphilis infection, late and early

33

0.72

Erythema multiforme

32

0.69

Nevi

32

0.69

Balanitis

31

0.67

Basal cell epithelioma

25

0.54

Keloids

24

0.52

Corns and callouses

24

0.52

Drug eruptions

21

0.45

Vitiligo

20

0.43

Photoallergy

15

0.33

Nummular eczema

14

0.30

Pruritus

14

0.30

No diagnosis

56

1.22

Others

461

10.02

    

Total

4,605

100.0

Source: Maj. Henry E. Jones, MC

patient visits were recorded for these conditions in other battalions whose missions did not include ground combat operations (table 9).

Temporary disability caused by skin infections, immersion foot, and other dermatoses rose to staggering proportions in hot, wet areas such as


40

TABLE 6.-Proportionate distribution of skin diseases seen in U.S. Army dermatology clinic, William Beaumont General Hospital, El Paso, Tex., 1 Jan. 1970 to 30 June 1971 [18 months] 


Disease
 

Number of cases

Percent of total

Warts, all types

1,896

19.31

Acne, all types

1,082

11.02

Actinic keratosis

505

5.14

Nevi

442

4.50

Dermatophytosis, all types

371

3.78

Contact dermatitis

360

3.67

Atopic dermatitis

288

2.93

Basal cell epithelioma

274

2.79

Psoriasis

258

2.63

Dry skin, xerosis

234

2.38

Dyshidrosis

222

2.26

Lichen simplex chronicus

214

2.18

Seborrheic dermatitis

202

2.06

Seborrheic keratosis

174

1.77

Urticaria

162

1.65

Miscellaneous dermatoses and dermatitides

162

1.65

Pityriasis rosea

154

1.57

Cyst

139

1.42

Skin tags

115

1.17

Pseudofolliculitis barbae

114

1.16

Alopecia areata

108

1.10

Pyoderma, all types

93

0.95

Tinea versicolor

75

0.76

Photosensitive dermatosis

69

0.70

Lichen planus

66

0.67

Dermatofibroma

59

0.60

Herpes progenitalis

58

0.59

Nummular eczema

51

0.52

Drug eruptions

51

0.52

Molluscum contagiosum

46

0.47

Onychomycosis

45

0.46

Balanitis

41

0.42

Pruritus

40

0.41

Granuloma annulare

39

0.40

Acne rosacea

37

0.38

Corns and callouses

32

0.33

Erythema multiforme

32

0.33

Vitiligo

24

0.24

Intertrigo

21

0.21

Pediculosis pubis

12

0.12

Others

1,452

14.78

    

Total

9,819

100.0

Source: Maj. Henry E. Jones, MC.


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TABLE 7.-Proportionate distribution of skin diseases in Vietnamese patients seen at the 95th Evacuation Hospital, Da Nang, I Corps, July-October 1970

Disease

Number of cases

Percent of total

Leprosy

14

13

Contact dermatitis

9

8

Atopic dermatitis

8

7

Psoriasis

7

6

Drug eruptions

7

6

Candidiasis

4

4

Lichen simplex chronicus

3

3

Alopecia areata

3

3

Others

52

50

    

Total

107

100

Source: Maj. Henry E. Jones, MC.

TABLE 8.-Number of patient visits for skin diseases and for other diseases in an infantry battalion, U.S. 9th Infantry Division, Mekong Delta, 1968

Diseases

Total

Percent

Sept.

Oct.

Nov.

Dec.

Dermatologic

1,315

66.9

392

401

376

146

Gastrointestinal

424

21.6

94

120

112

98

Respiratory

213

10.8

29

122

46

16

Psychiatric

12

00.6

6

0

1

5

Malaria

2

00.1

0

1

1

0

    

Total

1,966

100.0

521

644

536

265

Source: Allen Alfred M., Taplin, David, Lowy, James A., and Twigg, Lewis: Skin Infections in Vietnam Mil. Med. 137: 295-301, August 1972.

TABLE 9.-Number of patient visits to battalion aid stations during a 4-week period in November 1968, U.S. 9th Infantry Division, Mekong Delta

Condition

Infantry maneuver battalions

Support battalions1

A

B

C

D

E

F

Dermatophytosis

66

38

103

4

1

0

Pyoderma

251

42

285

2

0

0

Immersion foot

117

14

82

0

0

0

    

Total

434

94

470

6

1

0

1Support battalions consist of a field artillery battalion, a combat engineer battalion, and an aviation battalion.

Source: Office of the Surgeon, U.S. 9th Infantry Division.


42

the Mekong Delta.10 At greatest risk were infantrymen who were required to make daily marches in flooded paddies and swamps while on patrol. A typical sick call list for a Mobile Riverine (infantry) Force in the delta revealed that one-third of the men in the unit reported sick at the end of a 4-day combat operation and that the majority were reporting because of dermatologic problems (table 10). Nearly all were placed on light duty or quarters for periods averaging 4 days.11

TABLE 10.-Sick call statistics of a 350-man Mobile Riverine Force unit following a 4-day combat operation, Mekong Delta, 3 Oct. 1968

Parameter

Number

Percent

Reported sick

116

33

Dermatologic problems, feet

82

23

Dermatologic problems, body

5

1

Light duty or quarters

96

27

Estimated man-days lost

360

---

Source: Sick call records, 3d/47th Infantry, U.S. 9th Infantry Division.

U.S. 9th Infantry Division records for a 1-year period (1968-69) showed that 47 percent of the total man-days lost because of all medical and surgical conditions (including battle wounds, nonbattle injuries, and diseases) in infantry battalions was due to skin disease (table 11). When restricted to a comparison between skin afflictions and other diseases, the contrast was even more striking. Skin disease accounted for nearly 80 percent of the man-days lost from infantry battalions, even during the dry season (table 12).

STATISTICS FROM SURVEYS

Surveys were carried out by several investigators to determine the prevalence of skin diseases among military populations in Vietnam. A team of consultants representing the Commission on Cutaneous Diseases, Armed Forces Epidemiological Board (Harvey Blank, M.D., Nardo Zaias, M.D., and David Taplin), visited Vietnam in October and November of 1967 and found that 65 percent of 142 men in a ground combat unit in the Mekong Delta had significant tinea, and that 49 percent of 450 men in another unit had skin diseases involving the foot.12

10Allen, Alfred M., Taplin, David, Lowy, James A., and Twigg, Lewis: Skin Infections in Vietnam. Mil. Med. 137: 295-301, August 1972.

11Taplin, David, and Allen, Alfred M.: Severity of Dermatological Problems in Maneuver Battalions Operating in the Mekong Delta. In Annual Report of the Commission on Cutaneous Diseases, AFEB, 1967-68, pp. 12-13.

12Blank. Harvey, Taplin. David, and Zaias, Nardo: Cutaneous Trichophyton mentagrophytes Infections in Vietnam. Arch. Dermat. 99: 135-144, February 1969.


43

TABLE 11.-Combat man-days lost due to skin diseases as related to those lost to all medical and surgical conditions, infantry maneuver battalions, U.S. 9th Infantry Division, Mekong Delta, 1968-69

Month

Man-days lost

Skin diseases as percent of total

Total, all medical and surgical conditions

Skin diseases

1968

July

3,147

1,843

59

August

3,585

1,953

54

September

4,904

2,641

54

October

5,472

3,846

70

November

3,952

2,119

54

December

4,185

1,584

38

1969

January

6,237

3,063

49

February

6,784

3,125

46

March

5,510

2,227

40

April

4,812

1,811

38

May

4,845

1,482

31

June

3,605

1,167

32

    

Total

57,038

26,861

47

Source: U.S. Army Vietnam Command Health Reports.

TABLE 12.-Number of man-days lost from three U.S. infantry battalions due to skin diseases and to other medical causes during a 1-week period in March 1969, U.S. 9th Infantry Division, Mekong Delta

Medical cause

Battalions

Total

A

B

C

Number

Percent

Skin diseases

58

34

124

216

78

Other causes

5

21

35

61

22

    

Total

63

55

159

277

100

Source: Allen, Alfred M., Taplin, David, Lowy, James A., and Twigg, Lewis: Skin Infections in Vietnam. Mil. Med. 137: 295-301, August 1972.

A Walter Reed Army Institute of Research team (figs. 3 and 4) headed by Capt. (later Lt. Col.) Alfred M. Allen, MC, obtained similar findings in the Mekong Delta a year later.13 Over a 4-month period that extended into the dry season (November 1968 to February 1969), 486 U.S. infantrymen and 223 U.S. support troops were surveyed for skin infections. Of the infantrymen surveyed, 19 percent had pyoderma and 53 percent had derma­

13(1) See footnote 10, p. 42. (2) AlIen, Alfred M., Taplin, David, and Twigg, Lewis: Cutaneous Streptococcal Infections in Vietnam. Arch. Dermat. 104: 271-280, September 1971. (3) Allen, Alfred M., and Taplin David: Epidemic Trichophyton mentagrophytes Infections in Servicemen: Source of Infection, Role of Environment, Host Factors, and Susceptibility J.A.M.A. 226: 864-867, 19 Nov. 1973.


44

FIGURE 3.-WRAIR (Walter Reed Army Institute of Research) Field Dermatology Research Team in Vietnam. The team was an element of the Special Forces component of the WRAIR unit in Vietnam. Weapons were carried for self-defense in combat areas. Left to right: David Taplin, assistant professor of dermatology, University of Miami School of Medicine (civilian consultant); Capt. Alfred M. Allen, MC, team chief; Sfc. Robert E. Weaver, laboratory technician; and S. Sgt. Ray A. Drewry, technician.

tophytosis. Corresponding figures for support troops were 13 percent for pyoderma and 39 percent for dermatophytosis.

Vietnamese soldiers and civilians also were surveyed. Of 93 South Vietnamese Army infantrymen examined, 8 percent had pyoderma and 46 percent had dermatophytosis. Of 81 Vietnamese adult civilians suspected of being Vietcong irregulars or sympathizers, 7 percent had pyoderma and 10 percent had tinea.

A mechanized infantry company in the northern area of South Vietnam was surveyed by the I Corps dermatologist, Major Jones, in July 1970 (the dry season). Forty-six percent of the 93 men examined had clinical evidence of significant skin disease, chiefly dermatophytosis, pyoderma, and acne (table 13).

THEATER STATISTICS

Medical statistics at theater level and above gave an incomplete picture of the effect that skin disease had on the fighting strength of the U.S. Army in Vietnam. Divisional and theater-level rates of noneffectiveness


45

FIGURE 4.-Captain Allen examining infantrymen at a fire support base in the Mekong Delta. Surveys for skin disease were conducted just as the men returned from patrols and included a thorough examination of the entire skin surface.

were based only on hospitalized cases; they did not take into account the vastly greater number of men with skin lesions too severe to permit further combat but not severe enough to warrant hospitalization. Another difficulty was that the divisional and theater morbidity rates were diluted by including in the denominator large numbers of support troops who were at little risk of developing severe and disabling infections.

The 9th Infantry Division's Command Health Report for September 1968 provided an example of how extremely misleading the official statistics could be.14 The report stated that the divisional admission rate to hospital

14See footnote 10, p. 42.


46

TABLE 13.-Skin disease survey of mechanized infantry company, I Corps, July 1970

Diagnosis

Number affected

Percent

Fungal infection

19

20

Pyoderma

8

9

Acne

8

9

Heat rash

5

5

Intertrigo

3

3

No disease

50

54

    

Total

93

100

Source: Maj. Henry E. Jones, MC.

or quarters for skin disease for September was 6.7 per 1,000 per year, a negligible figure in view of the fact that the rate of placement on light duty (that is, noncombat) status exceeded this figure at least 100-fold in virtually every infantry platoon in the division. This fact was never officially brought to light, however, since statistics concerning the number of infantrymen on light duty status never appeared in the Command Health Reports. The net result of this statistical reporting was that commanders and medical staffs at higher echelons often failed to appreciate the impact of skin diseases on the number of men available for full combat duty.15

MORBIDITY STATISTICS AND ENVIRONMENTAL DATA

Monthly variations in rates of skin disease among U.S. Army personnel in Vietnam seemed to show a seasonal effect (charts 5 and 8), especially when troop strengths exceeded one-quarter of a million men (1967-70). Lower rates prevailed during the dry months (November through April in the southern two-thirds of South Vietnam; February through June in the northern third) and higher rates during the rainy months (May through October in the southern area; July through January in the northern area). The seasonal variations were more striking for outpatient visit rates than for hospital admission rates.

When compared with three basic weather elements-temperature, relative humidity, and rainfall-the seasonal variations in rates of outpatient visits for skin diseases were found to coincide almost exactly with variations in mean monthly index values16 for rainfall and relative humidity (chart 9), but were 4 months out of phase with variations in mean

15See footnote 10, p. 42.
16Index values were derived by averaging mean monthly rainfall, temperature, and relative humidity data from five locations in South Vietnam: Da Nang (I Corps), Nha Trang (II Corps, coastal), Pleiku (II Corps, mountains), Saigon (III Corps), and Soc Trang (IV Corps). Weather data were obtained from monthly weather summaries of the Vietnam Directorate of Meteorology (Reports, Vietnam Directorate of Meteorology (Dai-Luoc Thoi-Tiet), 1967-70, subject: Monthly Weather Summaries).


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CHART 9.-Outpatient visits for skin diseases in relation to mean monthly rainfall and relative humidity indexes: U.S. Army personnel in Vietnam, 1967-70

CHART 10.-Outpatient visits for skin diseases in relation to mean monthly temperature index: U.S. Army personnel in Vietnam, 1967-70


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CHART 11.-Hospitalization for skin diseases in relation to mean monthly rainfall index: U.S. Army personnel in Vietnam, 1967-70

monthly temperatures (chart 10). Comparisons of weather data with rates of hospital admission for skin diseases failed to reveal a similar effect (chart 11). Thus, the kinds of skin diseases usually seen on an outpatient basis appeared to be directly and markedly affected by seasonal changes in rainfall and relative humidity, but not by changes in temperature. No such pattern was seen for hospitalized cases of skin disease, however.

FIELD MEDICAL STATISTICS

Field medical statistics and clinic visit statistics were similar in that both dealt with outpatients, but they differed in that they represented two separate echelons of medical care. The field medical system, in the form of unit corpsmen and the medical staff at the battalion aid station, was the primary-level health care delivery system for virtually all soldiers assigned to conventional units, which included the combat and combat support battalions. Cases that could not be treated and returned to duty at this level were referred to clinics, if in outpatient status, or to hospitals if nonambulatory. Consequently, a different spectrum of patients and diseases was seen in the field medical system compared with that in the clinic system, a distinction of vital importance in consideration of statistics concerning skin disease.


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CHART 12.-Combat man-days lost from maneuver battalions: U.S. 9th Infantry Division, 1968-69

Many cases of skin disease were unrecorded in the field medical system. Reasons for this varied from the apparent triviality of many dermatologic complaints to the lack of a workable system for collecting statistics at field level. Within divisions, figures indicating the number of visits to aid stations, organized by organ system of involvement, were forwarded from battalion to division level. This provided an indication of the number of cases occurring and the number of days that men were placed on light duty (noncombat) status because of disease or injury. The number of men on light duty was an accurate measure of the rate of noneffectiveness within an infantry battalion, although it did not correspond to officially reported rates of noneffectiveness, which was a measure based solely on numbers of hospitalized cases.

In the U.S. 9th Infantry Division, a strong attempt was made to gather meaningful data on loss of strength in combat units caused by medical conditions which did not require hospitalization. Table 11 shows figures indicating the number and source of man-days lost from combat


50

duty in 9th Division maneuver battalions. The total strength of these battalions was approximately 8,000 men. Dermatologic conditions accounted for 70 percent of the total man-days lost at the end of the rainy season (October) and 31 percent of the total man-days lost at the end of the dry season (May).

The number of man-days lost from other causes remained relatively constant throughout the year (chart 12), while those lost from skin diseases fluctuated according to season and to length of combat operations.

Two important aspects should be considered when reviewing these figures. First, the number of men within the maneuver battalions who were actually at significant risk of developing disabling skin diseases was a great deal lower than 8,000. One-fifth of the total strength (1,600) constituted the headquarters company elements, who thus were virtually not at risk. At least that many more were also at low risk because they were not directly involved in ground combat operations and thus were not exposed to the hostile terrain conditions that were important in initiating disease. Second, the reported number of man-days lost did not reflect the true figure, which was undoubtedly a great deal higher. Exactly how high this figure actually was cannot be known because commanders and their medical staffs were under great pressure to report the lowest possible figures and thereby maintain an image of control over the situation.

The specific causes of cutaneous disability, together with the body part affected, were recorded within the 10 maneuver battalions of the 9th Division (table 14).

TABLE 14.-Disability due to skin diseases in the 10 maneuver battalions of the U.S. 9th Infantry Division, Mekong Delta, February 1969

Maneuver battalion

Disability involving skin of body

Disability involving skin of feet

Total

Pyoderma

Fungal

Immersion foot

Other

6th/31st1

180

554

110

24

384

36

2d/39th

23

12

3

3

3

3

3d/39th

1

72

0

22

41

9

4th/39th

29

114

32

16

19

47

2d/47th (Mech)

8

57

10

3

1

43

3d/47th2

3

240

232

2

2

4

4th/47th2

30

604

237

59

291

17

2d/60th

36

151

102

14

0

35

3d/60th2

65

867

17

30

772

48

5th/60th

6

40

0

39

0

1

1Deployed in an inundated area.
2Assigned to Mobile Riverine Forces.

Source: Memorandum, Maj. Hans H. W. Mueller, MSC, Sanitary Engineer, Office of the Command Surgeon, U.S. Military Assistance Command, Vietnam (MACV) for Brig. Gen. Spurgeon Neel, MC, MACV, Surgeon, 24 Mar. 1969, subject: Statistical Analysis of the Dermatologic Conditions of U.S. Troops in RVN.


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Field medical statistics accumulated by the 9th Division also reflected the differences between combat and support battalions in rates of skin disease (table 9). Despite comparable numbers of men at risk, nearly all patient visits for dermatological conditions occurred in the maneuver battalions, not in the supporting units.