CHAPTER X
Medical Research
Initial Efforts in Southeast Asia
In July 1962, a group from WRAIR was sent to Southeast Asia to evaluate theexisting resources for medical research and to develop plans for co-ordinationand expansion. They surveyed the laboratories then operating in East andSoutheast Asia: the Air Force's Fifth Epidemiological Flight at Yamata, Japan,with one air-transportable trailer-type bacteriology laboratory, the 406thMedical General Laboratory at Camp Zama, Japan, the NAMRU-2 (U.S. Naval MedicalResearch Unit No. 2) in Taipei, Taiwan, the U.S. Army Medical Research Unit inKuala Lumpur, Malaysia, and the U.S. Army Medical Component of the SEATO(Southeast Asia Treaty Organization) Medical Research Laboratory in Thailand,
At the completion of their survey, the study group recommended expansion ofthe existing medical research program to include studies of U.S. troops and oflocal national troops and civilian populations, allocation of additionalpersonnel and funds, and establishment in Saigon of a WRAIR medical researchunit, similar to those in Bangkok and Kuala Lumpur, because a theater laboratorywould not be able to deal with all the subjects to be covered in the expandedprogram.
In November 1963, as a result of the survey group's recommendations,Lieutenant Colonel (later Colonel) Paul E. Teschan, MC, was sent to Vietnam witha team of seven officers and 12 enlisted men. They quickly established liaisonwith United States and Vietnamese military medical staffs and installations,with the Public Health Division of USOM (U.S. Operations Mission), AID, and,through them, with the Minister of Health, members of the Pasteur Institute, themedical school faculties, medical missionaries, and representatives of privateU.S. charitable and medical foundations. They thus had access to allpopulations-Vietnamese and American, military and civilian-that was requiredto detect problems and settings in which productive investigation could be doneand to deploy and support qualified investigators.
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Studies of the Medical Research Team
Initially the team studied infectious disease, combat surgery, and militarypsychiatry, and evaluated new medical materiel. Their first effort was aserologic survey among U.S. military advisers in the Delta region for evidenceof viral hepatitis, leptospirosis, and dengue-related viruses.
Cholera
Cholera, absent from Vietnam for 10 years, spread from Cambodia into Saigon-ChoLon and some provinces. Several thousand cases appeared within about 2 months,and the clinics and hospitals were soon overwhelmed. The disease was found amongthe destitute and frequently in immunized persons, Cholera rarely appeared inmore than one member of a family and generally ran a self-limited course,perhaps somewhat shortened by antibiotics. No Americans were affected.
Dr. Richard Finkelstein, from WRAIR, and Dr. Howard Noyes, from the SEATOlaboratory in Bangkok, went to Saigon to work in the Pasteur Institute. CaptainRobert A. Phillips, MC, USN, and the staff of NAMRU-2 arrived from Taipei,instituted their mass treatment system of replacement of massive fluid andelectrolyte losses, quickly taught it to the Vietnamese, and soon virtuallyeliminated further deaths from cholera.
Plague
Plague caused concern as a potential threat to U.S. troops. Darkened streetswere alive with rats, and the rats were alive with fleas. In late 1962, during aplague epidemic in Saigon, Colonel (later Brigadier General) William D. Tigertt,MC, and Lieutenant Colonel Kevin G. Barry, MC, had established a small researchunit with personnel from the 7th Medical Laboratory, whose efforts were directed primarily toward plague surveillance and diagnosis. Later, the liaisonalready developed during the cholera epidemic led to the joint study of plagueby the Ministry of Health, the Pasteur Institute, and the WRAIR team. ColonelTeschan was appointed by the Minister of Health to the reactivated Commissionfor Pathologic Researches in Vietnam. Such common enterprise was later extendedto studies of hemorrhagic dengue which produced hemorrhagic fever in Vietnamesechildren and also affected U.S. troops.
During its second year, under the direction of Lieutenant Colonel StefanoVivona, MC, the team developed a close relationship with the Pasteur Institutein Saigon; through this collaborative effort, the only plague researchlaboratory in Southeast Asia was constructed and oper-
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ated. From this laboratory, the extent and severity of plague in Vietnam weredocumented; for example, whereas only eight cases were reported from a singleprovince in 1961, by 1966 human plague was shown to be present in every provincein I, II, and III Corps areas, and in one province in IV Corps area, with 4,500cases occurring in 1965 alone. Studies of rodent reservoirs and flea vectors ofplague revealed new endemic foci, and during a pilot program for rodent andvector control in the Minh Mang district of Cho Lon, rat fleas were found to beresistant to DDT. These data, in addition to laboratory studies of theinsecticides dieldrin and Diazinon, provided the Ministry of Health withinformation essential for reducing the vectors and controlling the disease.
The common house shrew was shown for the first time to be a reservoir ofplague; an asymptomatic carrier state of virulent plague bacilli in the throatsof healthy people was demonstrated for the first time in Vietnam; rat and fleasurvey programs and insecticide evaluation programs were expanded; and a programwas initiated for production and evaluation of a lyophilized, attenuated livingplague vaccine.
Malaria
During its third year, 1965-66, under the direction of Lieutenant Colonel(later Colonel) Robert J. T. Joy, MC, the medical research team expanded itsmission to include specific research studies by individual team members, supportof other research studies by outside investigators, and collection of medicalinformation or health data for WRAIR, which would serve as a guide for researchin the laboratories of the USAMRDC (U.S. Army Medical Research and DevelopmentCommand). Specific areas of interest included malaria, plague, gastrointestinaldisease, fevers of undetermined origin, combat psychiatry, environmental stress,and other causes of morbidity and mortality in U.S. soldiers.
The data collected warned the team of the possibility of a rise in the numberof cases of chloroquine-resistant falciparum malaria and they devoted much oftheir effort to this disease. Among their contributions were the discovery ofasymptomatic malaria, with its potential for importation to the continentalUnited States; documentation of failures of malaria discipline and personalprotective measures, which provided information needed for control; introductionof new therapeutic drugs (Fanasil and pyrimethamine) and other regimens for thetreatment of malaria; and provision of consultative advice to the variouscommand surgeons. A major contribution to the control of malaria in Vietnam wasthe introduction of DDS (diaminodiphenylsulfone). The efficacy of this drug as aprophylactic agent was confirmed in volunteers in the United States, and in1966, a field test in Vietnam proved its value in
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combat troops. Subsequently, it was routinely used by military personnel inVietnam for prophylaxis against falciparum malaria.
The team recommended that a central rehabilitation hospital for malariapatients be established and used simultaneously as a center for studying thedisease and the evaluation of new therapeutic agents. This hospital was approvedby The Surgeon General and became the 6th Convalescent Center at Cam Ranh Bay. Aformal link with the Navy preventive medicine unit in Da Nang provided for thecollection of specimens by the Navy unit, with laboratory support from the team,and for the exchange of information and research data. The 61st MedicalDetachment of the 20th Preventive Medicine Unit (entomology) was established andworked with the team in the laboratory.
In the fall of 1966, the team in essence drafted a USARV regulation onmalaria control guided by letters and comments from Colonel Tigertt; a medicalresearch team for malaria survey for USARV was established; and Captain AnthonyT. C. Bourke, MC, was appointed the USARV consultant in malaria.
Stress
Studies done by the medical research team of neuroendocrine stress caused bycombat, in helicopter crewmen and Special Forces "A" Detachmentmembers, contributed significantly to the understanding of the pathophysiologyof stress in the soldier. Studies of heat stress incurred by crews of the Mohawk(OV-1) aircraft led to changes in clothing and to ventilation of the cockpit,measures which materially improved crew comfort and efficiency. Collaborativestudies with the Department of Neuropsychiatry of the ARVN Cong Hoa Hospital ledto a better understanding of the stresses of combat affecting both American andVietnamese soldiers.
Fever of Undetermined Origin
A major collaborative study done by the team with the 93d Evacuation Hospitaland the SEATO laboratory in Bangkok resulted in determining the specificetiology of FUO in 60 percent of patients studied. Of the cases diagnosed, 50percent were due to dengue, with Chikungunya, scrub typhus, and malariaaccounting for most of the remainder. These laboratory results, carefullycorrelated with clinical findings, enabled clinicians to suspect these diseases,in the absence of classical findings, early in the course of hospitalization.
Renal Failure
In February 1966, Colonel Barry arrived at the 3d Field Hospital in Saigon toinstitute clinical research studies in patients with malaria,
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including studies of body water, extracellular fluid, blood volume, and renalfunction. Because the only facilities for performing hemodialysis were in Japanand the Philippines, delays in evacuation and treatment of patients with acuterenal failure often resulted in increased morbidity and mortality. ColonelBarry, recognizing the need for in-country treatment of this complication,established the first renal unit in Vietnam at the 3d Field Hospital.
Special Projects
The Field Epidemiologic Survey Team
The war in Vietnam pointed up deficiencies in the knowledge of certainimportant tropical diseases and, more significantly, the deficiencies in theability to predict noneffectiveness and in the application of preventivetechniques. It also provided the opportunity for a unique and valuableexperiment in medical support of military operations in a hostile environment.
The FEST (Field Epidemiologic Survey Team) was organized in May 1966 byLieutenant Colonel Llewellyn J. Legters, MC, preventive medicine officer of theUSA John F. Kennedy Center for Special Warfare at Fort Bragg, N.C., whorecognized that a research group operating in the remote areas where U.S.military forces were being committed could study the epidemiology of tropicaldiseases in the environment where most of them were transmitted.
The FEST, composed of Special Forces officers and enlisted techniciansstationed at Fort Bragg, was trained at Fort Bragg and at WRAIR in specificlaboratory and field epidemiological skills suitable for studying diseases ofspecial interest to the Army Medical Department and in providing medicalsupport, preventive, and curative, to ground troops in Vietnam. Training wasoriented primarily to specified scientific areas of interest such as theentomological aspects of tropical sprue, febrile illness, schistosomiasis,filariasis, dengue, and malaria.
After the training period, FEST was formally constituted as an element ofWRAIR, deployed to Vietnam on 26 September 1966, and became part of the medicalresearch team in Saigon for administration and logistics, but was attached toHeadquarters, 5th Special Forces Group.
The studies of this team which continued through 1968, diminishing as the warbecame conventionalized, generated valuable scientific information aboutmalaria, plague, schistosomiasis, filariasis, tropical sprue, and otherailments.
Dermatological Research
The character of warfare in Vietnam also created unique opportunities forresearch on cutaneous diseases of military importance. At the height of therainy season, the rates of disabling skin disease among
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infantrymen were extremely high, reaching 50 percent in some rifle companies.Surgeons at the infantry battalion level were often overwhelmed by the number ofsoldiers displaying skin lesions of uncertain etiology which were slow to healdespite vigorous topical and systemic antibiotic therapy. Combat commanders andphysicians alike became extremely receptive to scientific investigations of thecommon skin diseases that had defied the most heroic efforts at prevention andcontrol.
The U.S. Army Medical Research and Development Command sent a special fieldepidemiological research team from WRAIR to the Mekong Delta in 1968. The teamhad trained in simulated tropical combat environment at camps in the southernUnited States and in the Florida Everglades under the supervision of Dr. HarveyBlank of the University of Miami (Fla.) School of Medicine. Mr. David Taplin,also a member of the University of Miami faculty, conducted workshops in appliedmicrobiology and subsequently accompanied the team to Vietnam to help establisha base laboratory.
The reception accorded the team assured them of the support so necessary forproductive research under wartime conditions. The commanding general of the 9thInfantry Division, Major General (later Lieutenant General) Julian J. Ewell,pledged the full co-operation of his officers and men. The requirement for alaboratory in the Delta was more than met when the USARV surgeon, General Neel,made available a completely equipped MUST unit that provided an ideal settingfor microbiological studies, with negligible risks of contamination from mud,dust, and insect life. Colonel William A. Akers, MC, Chief, Dermatology ResearchUnit, Letterman Army Institute of Research, promised co-operation and providedpersonal liaison at theater and division levels in Vietnam. Most important ofall was the complete acceptance of the team by the officers and men of combatunits who displayed a cheerful willingness to be examined, despite theincursions on their limited free time.
Under the leadership of Captain (later Major) Alfred M. Allen, MC, the teamconducted intensive research among combat forces, support troops, andneighboring Vietnamese populations in the Delta. They examined American andVietnamese infantrymen at forward company and battalion areas in active firezones and accompanied infantry units on patrol to evaluate proposed methods ofskin disease prevention. Use of portable field laboratories and special culturemedia permitted isolation of pathogens that had eluded detection by standardmethods. In less than 6 months, Captain Allen's team had precisely identifiedthe populations most likely to develop common disabling skin disease, isolatedthe offending pathogens, measured the effects of exposure, and initiatedeffective new methods of prevention and treatment.
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The chief causes of cutaneous disability in American combat forces wereinflammatory ringworm, ecthymatous pyoderma, and tropical immersion foot.Disease rates correlated with the degree of exposure to such things as insectbites and prolonged contact with wet clothing. Prickly heat, acne vulgaris, andtinea versicolor, while common, as a general rule were not disabling, nor wascystic (tropical) acne, which can be very disabling, a significant cause ofmanpower loss.
Elastase-producing fungi were found to be the major cause of inflammatoryringworm in the American combat forces. The usual athlete's foot type wassurprisingly rare, being replaced by intensely inflamed, serum-oozing lesions onthe dorsa of the feet, the ankles, and groin, often forming multiple smallabscesses in hair follicles. The clinical features and the microbiologicalcharacteristics of the disease indicated that the infections were transmitted bya source in Vietnam rather than by irritation of old, latent infections, aspreviously believed. A search for sources of infection revealed that 25 percentof the wild rats tested were infected with organisms which were morphologicallyindistinguishable from those recovered from American soldiers.
In contrast to those found in infantrymen, the infections among supporttroops strongly resembled the type found among troops in training at southernUnited States military bases during the summer.
Penicillin treatment significantly reduced healing time of ecthymatouspyodermas in American soldiers despite a prevalence of penicillin-resistantstaphylococci. Erythromycin was also effective in a small number of cases.Tetracycline was avoided because of the high proportion of resistantstreptococci recovered from the pyodermas.
The clinical and pathological features of tropical immersion foot wereconsistent with low-grade cold injury. Soldiers who had contracted the conditionfollowing prolonged immersion displayed increased susceptibility to repeatinjury even after complete healing had occurred. Skin biopsies showed chronicinflammation and dilatation of vascular channels.
Skin infections in Vietnamese adults were strikingly different from thoseamong Americans, even in military populations with identical exposure. Trichophytonmentagrophytes infections and streptococcal pyoderma were rare; ringworm,although fairly common, was nearly always caused by an atypical variant of Trichophytonrubrum which produced a chronic, scaly, dry rash generally confined to thewaist. Vietnamese children, on the other hand, were similar to American combattroops in their frequent experience with streptococcal pyoderma and ringworm.
After Captain Allen's departure from Vietnam, dermatological research wascontinued by Captain Joseph Thompson, MC, Captain Joseph M. Ballo, MC, andLieutenant Colonel Robert. T. Cutting, MC. The results of two field trials todetermine the efficacy of griseofulvin in the
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prevention of ringworm infection showed that it was significantly protective,provided the recommended dosage schedule was strictly observed.
The field dermatology research program in Vietnam was rewarding in therelatively brief span of its existence. Early application of the measuresrecommended on the basis of the team's findings dramatically lowered disabilityrates wherever they were put into effect. Research priorities were realigned tobe more directly aimed at prevention of those diseases having the greatestimpact on combat manpower. Laboratories in the United States focused theirattention on the newly found clues to pathogenesis of the common disabling skininfections. Representative isolates of pathogenic strains of fungi and bacteriarecovered in Vietnam were collected for future study. The influence of theresearch findings even extended to the development of new items of tropicalmilitary footwear. As a direct result of the dedicated efforts of this team, andbecause of military-civilian co-operation, development of effective methods toprevent the devastating effects of skin diseases came, for the first time,within reach.
Photographic Coverage of Army Medical Activities
During the latter part of 1965 it became evident that photographic coverageof Army medical activities in Vietnam was unsatisfactory. Since the MedicalAudiovisual Department, WRAIR, was capable of providing highly professionalstill and motion picture support of the WRAIR's diverse research activities, itwas decided to field a photography team to be attached to the WRAIR researchteam but to be equally responsive to direction from the USARV surgeon.
Two weeks after the decision was made, four civilian volunteers, all fromWRAIR, began a comprehensive coverage of surgery, helicopter evacuation, combat"medics" in action, field hospital operations, and other medicalactivities wherever and whenever they saw them. They formed a highly mobile andaggressive team, not only responding to requests and direction from the medicalcommand, but also seeking out on their own initiative areas and activitiesrequiring photographic coverage.
The Surgeon General, realizing that the team approach was the most efficientmeans of acquiring accurate and timely pictorial records of the Army's medicaleffort in Vietnam, directed that additional personnel and funds be provided toestablish a permanent team of military medical photographers. This team,consisting of one officer, one noncommissioned officer, and three enlisted men,became operational in December 1967. Adhering to the pattern alreadyestablished, the new group continued to work closely with the USARV medical andsurgical consultants, following the action to the areas of greatest activity.Thus began the collection of thousands of color slides and hundreds of thousandsof feet of
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motion picture film which later became the basis for film libraries, not onlyin the United States (such as these at WRAIR and at the Medical Field ServiceSchool at Fort Sam Houston), but also in Europe, Hawaii, and Asia. At leastthree major film productions resulted from the footage obtained, one onhelicopter evacuation, another on MUST, and a third, the award-winning"Army Medicine in Vietnam."
Surgical Research
In its fourth year, the team concentrated on surgical research and on testingthe FEST concept. The research was done by a group which was attached to theteam in April 1966, initially at the 93d Evacuation Hospital, later at the 3dSurgical Hospital, and finally at the 24th Evacuation Hospital. The groupdemonstrated that studies of the type conducted in "shock units" inthe United States can be carried out with satisfactory results on combatcasualties in the field. Later studies conducted by the research groupcontributed to the knowledge of many other subjects.
Recognition of the seriousness of pulmonary insufficiency in shock,particularly in patients with nonthoracic injuries, led to extensive research inthe management of this complication. Plans were made for the development andtesting of new respiratory assistance devices.
Further progress was made in the development and use of plastic polymers astissue adhesives in controlling bleeding and repairing internal organs. Sprayguns containing the adhesive were provided the surgical research team for use intreating casualties in Vietnam.
New methods for fixation of fractures of the jaw were studied, as was a newtechnique using a silicone plastic placed directly into oral wounds to restoretemporary oral integrity until reconstructive surgery could be performed.
Other innovations under study by the research group were the use ofelectrical anesthesia, laser irradiation, synthetic blood vessels, plasmaexpanders and new additives in the preservation of whole blood. Sulfamylonointment for control of infection in burns, and various methods for suppressionof an immune response of the body to homografts and transplants.
