jVlfDJOU ASPECTSOf 6 AS WAfcfAfcE 
jVI E D J C A L DlVJSJOM 
U. S. OffJCf Of CJVJLJAM DEfEMSE 
TENTATIVE MANUSCRIPT 
UNPUBLISHED Section 1 
INTRODUCTION 
Since gas warfare was introduced by the Germans in 1915 without warning 
and contrary to existing rules of warfare, it has gained much attention in the 
public press. The results attributed to the- effects of war gases have been greatly 
exaggerated, and this weapon is wrongly , credited with more iniquities than have 
ever been associated with any other weapon. The misinformation concerning the typos 
and degrees of injuries produced by it has been grossly misleading. 
To what extent gas should be held responsible for a great train of symptoms 
of which so many ex-soldiers complain is an open question* It has been blamed for 
every conceivable sort of ailment. 
There is no doubt that a large number of ex-soldiers who are now incapacitated, 
and who claim that gas was responsible for their condition were exposed to gas at 
Some time during their service abroad. Many of them were also exposed to other 
conditions such as the respiratory tract infections which could produce similar 
effects. 
During the las.t war few observations were made on the immediate effects of 
war gases on individuals, because it was impossible to examine most exposed meh 
until several hours after they were gassed. During this interval many important 
changes took place which could not be studied carefully. 
Since the last war many investigations have been conducted which have re- 
vealed much valuable information. In this work the effects of the pulmonary irri- 
tants and vesicant gases upon the lung were studied largely on dogs. From this 
experimental evidence the following conclusions were draim: 
a. In the great majority of dogs gassed at sublethai concentrations changes 
can no longer be demonstrated two months to a year after recovery. 
b. In a minority, of instances permanent lung alterations are found, but the 
damage is not Widespread, is usually confined to small areas and consists of small 
patches of organization, thickening of the bronchial walls with loss of elasticity 
and occasional occlusion of the bronchioles by organized exudate. This scarring 
of lung areas is usually insufficient to affect the functional efficiency of the 
lungs. 
c. Since the lungs of dogs are more susceptible to damage than those of 
human beings it is he as enable to conclude that in the vast majority of surviving human 
patients who were not severely gassed, and who received adequate medical care in hos- 
pitals, most lesions probably healed within a short time, and that the small amount 
of fibrosis remaining: in the minority of cases rarely caused any serious disability. 
Although gas is very efficient as a weapon to produce temporary disabilities, 
the death rate is surprisingly low. The II, S, Army suffered 258,338 casualties of 
whom 34,249 died on the battlefield. Of those who died on the battlefield it is 
estimated that probably not more than 200 succumbed to fulminent injuries due to gas. 
The mortality from non-gas war wounds was 17,940 or 13% compared with 1421 who died 
of injuries due to gas, or a mortality of 0.5^. Section 2 
Physical Properties of Gases 
War gases are, for the most part, disseminated in the form of liquids or true 
gases. It is important, therefore, that the general principles relative to the 
conversion of liquids to gases', and the physical behaviour of gases be understood 
by the student of chemical warfare, ■ ■ 
Partial pressure; The total pressure of a gas is the sum of the partial 
pressures of its constituents. 
For instance, the pressure of the atoms here at sea level (760 mm. Hg.) 
is made up essentially of the partial pressures of ram* Hg.), 
(7S% = 593 mm, Hg.), and H20 (2% = 15 mm.) 
Vapor Pressure and Temperature: Substances can exist as solids, liquids, or 
gases, depending upon the temperature. The vapor pressure which a substance exerts 
always increases with the temperature. 
For instance, water changes from solid to liquid at 0°C. The vapor pressure 
of water is 4.6 mm, Hg at 0°C,, 17.5 mm., at 20° C,, and 760 mm, at 10CT C, The 
air is saturated with water vapor when the partial pressure of water vapor is equal 
to the vapor pressure of water at that temperature. The same principle may be 
applied to all substances, whether their partial pressures may be greater or less 
than that of water at a given temperature. 
Density of a gas (vapor): Equal volumes of gases under the same conditions 
of temperature and pressure contain the same number of molecules (Avogadro). There- 
fore, the density of a gas is proportional to its molecular weight. 
Methods of Dissemination; Chemical agents are usually disseminated as vapors 
or as small solid or liquid particles called smokes. When each molecule is free to 
move according to the gas laws we have a true gas, while the smoke particles, or 
aerosoles follow the laws governing colloids. Smokes are further subdivided into 
irritant smokes and screening smokes, depending upon their main use and physiological 
action. Chemical clouds are of two types - one in which a vapor is mixed with air 
(gas clouds), and the other, a suspension of extremely small liquid or solid 
particles in air (smoke clouds). 
Mechanics of Evaporation: A liquid changing into a gas removes heat from 
the air during vaporization, while smoke materials either burn or hydrolize in air, 
thus generating heat. The result is that immediately downwind from the source of 
smoke the air is heated. The magnitude of these temperature changes is usually 
small but depends upon the particular material used and the concentration generated. 
All war gases are heavier than air. The addition of a heavy vapor and the cooling 
effect of evaporation in a gas cloud cause the cloud to hug the ground and seek out 
depressions. The concentration of vapor in a gas cloud varies inversely as the square 
root of the height above the ground, Section 2 
Behavior of war eases up6n release: 
Lateral Spread; When either vapor or smoke is released into the air the cloud 
is blown from side to side by shifting air currents which cause a lateral spread 
as the cloud moves downwind. In steady winds,, this spread amounts to about 15 pur 
cent of the distance from .the source. Under very unfavorable conditions when the 
wind is rapidly ‘ changing direction, or in a fish-tailing wind, the spread is very 
great* Under average conditions a cloud of any size will gain 20 yards in width for 
each one hundred yards'traveled. 
Drag Effect: Wind currents carry gas clouds along the ground with a rolling 
motion, since the wind velocity near the ground is almost zero but rapidly 
increases, upward., This rolling motion causes the cloud to stretch out in length. 
The increase in the length of the cloud is called the "drag effect". For clouds 
released on the, ground the.drag'amounts to about 10 per cent of the distance 
traveled over grass, plowed lands, or over water, and to about 20 per cent . for 
gently rolling terrain covered with bushes, growing crops and small patches of 
scattered timber. In heavy timber the drag effect is much greater. 
Vertical Rise: The vertical rise of a gas or smoke cloud depends upon several 
factors, A gas cloud is cooled by evaporation and tends to hug the ground. 
Convection currents cause a more or less' rapid mixing of the gas with the overlaying 
air. Convection currents are most active over roads and when the ground is dry, the 
sun is shining brightly, and when the ground is much warmer than the air, ’During the 
day, and especially when the sun is shining, the ground surface frequently becomes 
from 10-50 degrees hotter than the surrounding air. The heated ground surface 
causes violent convection currents, known as the "running mirage". At.night and in 
the early morning the ground surface is frequently cooler than the surrounding air 
and under such conditions there are no convection currents. This is the reason for 
firing chemical agents at night, especially during the hours from midnight to sunrise 
and shortly thereafter. 
Persistency: The length of time an agent will remain on the ground at the 
point of release is called the' persistency of that agent. If the remaining concentra- 
tion, under conditions favorable for the use of that agent, is sufficiently great 
at the end of 10 minutes to require protection of any kind, that substance is 
said to be a persistent agent. When no protection is needed under the above 
conditions, the agent is said to be non-persistent. 
Thus it may be said that those gases with a high vapor density and those Which 
vaporize slowly will tend to be persistent. Gases with a low vapor density and a 
high vapor pressure will be acted upon quickly by convection currents and diffuse so 
rapidly as to be quickly dissipated below lethal concentrations. 
Absorption and adsorption: Host gases have a tendency to condense upon or to 
be "adsorbed" by solids. In some cases this adsorption is very considerable. 
Charcoal has a remarkable capacity for adsorbing a great variety of gases from the 
air and for this reason it is used in the cannisters of gas masks. This character- 
istic is undoubtedly due to the fact that charcoal is finely porous and thus presents 
a very large surface to the condensation of gases.. This process is usually spoken 
of as "absorption," But this is not strictly correct. The term adsorption is proper Section 2 
since the phenomenon is really one of condensation on the surface of the charcoal. 
Absorption is, in some cases at least, a loose form of chemical conbination, while 
adsorption is regarded as purely physical. 
Concentration: Another term which it is necessary to use in describing and 
explaining the effects of chemical agents is "concentration," This refers to the 
amount of the chemical which is present in a unit quantity of air. It is not some- 
thing which can or need be accurately measured, but, if the odor of gas is sharp and 
strong, the concentration is low. The more of a toxic material present in the 
atmosphere, the more quickly and severely will one exposed to it be affected. 
Hydrolysis is the reaction of any chemical substance with water whereby one 
or more new substances are created. This is a reaction of great importance in 
chemical warfare as many chemical agents are rendered harmless after a time by 
this reaction. If the hydrolysis product is itself a poison, as is the’ case with all 
agents containing arsenic, considerable effort is required to neutralize the agent 
effectively. 
Absolute requisites of a chemical agent: A substance to be useful as a chemical 
agent must have the following properties: 
a. It must be very toxic, or very irritant, or produce a large volume of 
smoke, or have incendiary properties, 
b. It must be stable in storage and reasonably stable on contact with moisture, 
* 
c. It must be capable of manufacture on a large scale, 
d. Raw materials must be available for its manufacture, 
e. It must be suitable for loading in munitions and should have little or no 
corrosion on ordinary steel.- 
f. The substance must be capable of vaporazation, or other means of 
dissemination, in sufficient concentration, or in sufficient amounts under field 
conditions to produce the effect desired. 
g. If the substance is a gas under ordinary conditions, it must be easily 
compressible bo a liquid and easily vaporized when the pressure is released. 
Additional desirable properties; In addition to the absolutely necessary 
properties, it is highly desirable that chemical agents possess the following 
properties; 
a. It should be capable of handling and transportation without special pre- 
cautions, 
b. It should be cheap to manufacture. 
c. It should be capable of quick production in existing commercial plants 
without extensive alteration in existing equipment. Section 2 
4 
d. When disseminated as a vapor the molecular weight should be several times 
as great as that of air (which is approximately 29). 
Classification of chemical agents by physiological actions into 
a. lung irritants 
b. vesicant or skin-blistering gasses 
c. lacrimators or tear gasses 
d. sternutators, or those gases that irritate the nose and throat and cause 
vomiting. 
e. systemic poisons. 
It should be realized that this grouping is based on the most prominent physiological 
action. Most war gases share, in some degree, the injurious properties of others. 
Almost all of them, if breathed long enough will cause injury to the lungs. SECTION III 
CWS Symbol 
01, 
CG 
PS 
Common Name 
Chlorine 
Phosgene 
Chlorpicrin 
Chemical Name 
Chlorine 
Carbonvlchloride 
Trichlornitromethane 
Chemical Formula 
Cl2 
C0C1? 
Cl^CNOp 
Tactical Classification 
Casualtv 
Casualty 
Harassing 
Boiling Point 
-33.6°C 
8.2°C 
112°C 
Vapor Pressure at 
68Dt>-206G 
. F. 
4993 mm Hg. 
1130 
1 8.28 
Vapor density 
2.k 
3,4 
3-6 
Volatility Oz./lOOO cu. ft. 
165.0 .... 
Summer - 
Fersistency 
Winter - 
5 min, open 
20 " woods 
5 Iran, open 
20 H woods 
10 " open 
30 n ’.roods 
1 hour open 
4 hours woods 
12 hours open 
Several weeks 
Odor 
Ensilage 
Licorice 
Odor detectable at 
Oz, /l000»cu. ft. 
0.01 
0.004 
0.007 
Min, Irritating Concentration 
Oz, /lOCO cu. ft. 
0,05 
0.44 
0.02 - 3 min. 
Lethal Concentration 
Oz./lOOO cu. ft. 
5.6 for 10 min. 
0.05 for 10 min. 
2.0 - 10 min. 
Method of neutralizing 
alkali 
steam hydrolyses 
NaoS0o solution 
2 
LUNG IRRITANTS 
PHYSICAL AM) CHEMICAL PROPERTIES S III 
2 
LUNG IRRITANT GASES 
There are three chemical warfare agents which act primarily as lung irritants, 
Chlorine (Cl), Phosgene (CG), and Chlorpicrin (PS). Chlorine and Phosgene are 
gases under usual atmospheric conditions. Chlorpicrin is a liquid with a relatively 
high boiling point and so tends to be somewhat persistent. 
With all three agents there is a latent period after exposure which may last 
as long as 2U hours before manifestations of injury appear. The latent period is 
likely to be short after exposure to chlorine. 
PHOSGENE 
Pathology; The principal lesions are pulmonary edema, rupture of pulmonary 
alveoli and a concentration of the blood, with increased viscosity and a-tendency 
to thromobosis. 
■Relatively high concentrations of phosgene may be breathed without immediate 
irritation' of the respiratory tree, hence the most distant bronchioles and alveoli 
may be affected. As a result of the irritation the permeability of the alveolar 
and capillary walls is increased causing a pulmonary.edema. The upper parts of the 
respiratory tree arc seldom affected by the gas. 
The severity of the pulmonary edema will be proportional to the amount of gas 
inhaled. Following exposures to very high concentrations death may result after 
only a few hours. The lungs may be water logged, may be somewhat smaller than 
normal but will show no evidences of emphysema. 
If death occurs later on the first day the lungs will be:normal in size or 
larger than normal, there will be considerable vascular congestion and in the bases 
there will be patches of emphysema alternating with areas of collapse. On section 
frothy serum drips from the tissue and petechial hemorrhages may be seen, widely 
scattered through the injured lung. A variable; amount of serous.or bloody fluid 
may be found in the pleural cavity. 
After the first day the lungs are not so waterlogged. There is less fluid 
lost from the cut surface pf the lung and patches of aeration are noted in the 
bases. As time goes on the edema .gradually clears. Deaths aftey the third day 
are probably due to broncho-pneumonia rather than to pulmonary edema. 
Associated with the pulmonary edema there is a concentration of the blood 
through loss of fluid. The hemoglobin may be as high as 150/£. There is also a 
tendency to pulmonary thrombosis because of the slowing of circulation through 
the congested lung and the concentration of the'blood. 
With the increased resistance in the pulmonary circulation there is a gradual 
dilatation of the right heart which is reflected in an engorgment of the veins 
of the head and neck. This failure of pulmonary circulation, combined with the inc- 
omplete oxygenation of blood due to inadequate alveolar surface brings about failure 
of the left heart. The characteristic picture at the time- of post mortem is to find 
the right ventricle so dilated that it presses the interventricular septum over into 
the space normally occupied by the left ventricle. S III 
3 
Disruptive emphysema is acused primarily by the violent coughing which 
ruptures the already damaged alveolar walls. 
Phosgene (C0Clo) in the presence of water is hydrolyzed to HC1 and COp* The 
effect it produces 6n tissues cannot be explained by this reaction alone, since the 
injury produced by phosgene is more serious than that produced by HC1. in comparable 
amount. 
The upper respiratory.tract is seldom injured by phosgene. 
Symptoms of Phosgene Poisoning: Inhalations of even moderate concentrations of 
phosgene cause immediate catching of the breath and a sense of substernal dis- 
comfort. This may pass off rather rapidly with no further warning of injury until 
the onset of acute symptoms from 12 to 24- hours later. 
The inhalation of very high concentrations, of the gas may produce a, prompt 
and fulminating type of injury. Pulmonary edema develops, followed by deep cyanosis 
and venous congestion, with death occurring in 2 or ,3 hours. 
The inhalation of lower concentrations, however, may cause' a variety of clinic- 
al pictures. 
following exposure to moderate concentration of phosgene the patient may be a 
symptomatic for a period which may last as long as 24- hours. Pulmonary edema now 
develops very rapidly. Respiration is rapid and shallow, the chest wall fixed in 
the position of full inspiration. There are violent fits of coughing in which 
a frothy, pink sputum is raised. •Cyanosis develops rapidly and may become very 
intense. The veins of, the neck,, chest, and head become distended. The pulse is of 
good quality and ranges about 100 per minute. The patient is said to be in the 
blue stage of cyanosis. 
The general appearance of the patient may change rather abruptly. The livid 
blue is replaced by an ashen grey color resembling shock. The pulse becomes very 
rapid and thready. The .skin becomes cold and clammy. This represents the grey 
stage of cyanosis. Occasionally cases of phosgene poisoning do not go through the 
blue stage but lapse abruptly into the grey cyanosis of asphyxia. 
While in either of, these stages the patient.is apprehensive and restless. The 
eyes are staring, the lids half closed. 
Mild injury is also seen in which cyanosis does not develop. The patient soon 
becomes drowsy and falls asleep. He may have a sense* of tightness in the chest 
which is aggravated by coughing. He may vomit after taking food or liquids. The 
pulse is usually slow (4-0 or 50 a minute) for a few days. Convalescence progresses 
uneventfully unless secondary infection occurs. 
Those patients with mere severe injury, as indicate-" by blue cyanosis, do well 
so long as the vital centers have an adequate supply of oxygen. If the pulse does 
not exceed 100 peT minute the prognosis is good. edema fluid starts to clear 
on the third or fourth day and convalescence is rapid from that point. At any 
point in the course of the disease, particularly if the patient is exposed to mental 
or physical strains, the oxygen supply to the vital centers may be insufficient. S III 
The pulse becomes rapid and thready, the skin clammy, the patient semicomatose• 
Patients suffering from grey cyanosis frequently recover, though the death 
rate is very high. Many recover only to succumb to a complication, broncho-pneumon- 
ia, -which is usually fulminant and highly fatal. 
, A less common clinical picture is occasionally encountered after exposure to 
moderate concentrations of phosgene. Circumstances may be such that for several 
hours the casualty may bo inactive, not suspecting his injury. During this time 
changes have occurred within the lungs which roduco the pulmonary reserve to a 
point where additional demands of oxygon cannot bo met. Should the casualty now 
engage in physical exertion the demand for oxygen would bo beyond that which the 
injured lung is able to supply. There is extreme anoxemia of the respiratory and 
circulatory centers, often causing immediate death. 
The pathology produced by chlorine or chlorpicrin is very similar to that 
produced by phosgene. Because they are more irritant at the time of exposure, the 
victim tends to get out of the area at once so that there is less liklihood of in- 
volving the entire lung as with phosgene, Chlorpicrin often causes nausea and 
vomiting. Chlorine frequently causes severe injury to the larynx, trachea and upper 
bronchi. 
The clinical course following injury by any of the members of this group- is 
very similar, 
TREATMENT OF LUNG IRRITANT CASES 
Cases of all degrees of severity may be met with, and it may be difficult at 
times to decide whether or not a man has really been gassed. The benefit of the 
ddubt should be given to the patient in all cases, and any man showing any feature 
of lung irritant poisoning should be rested for 24 hours and observed. It should 
bo borne in mind that a delayed action may be exhibited by some pulmonary irritants, 
but if no objective symptoms have arisen after the lapse of 48 hours the patient 
can be discharged, 
(a) Treatment in the Acute Stage: 
The essentials of treatment for acute poisoning by any pulmonary irritant gas 
are rest, warmth, venesection and oxygen. It is necessary to think of lungs 
choked by an edema fluid which may be absorbed in three or four days if the circu- 
lation can be maintained, 
(l). Rest: The importance of rest cannot be exaggerated. In the earlier 
stages undue muscular exertion may lead to an aggravation of the symptoms. In 
the later stages, when the oxygen supply of the body is interfered with by pulmonary 
edema, any physical exertion will probably result in disastrous consequences. 
All cases should be treated as stretcher oases, and their clothing loosened so 
as to ease breathing. If this is not practical, walking cases should be given 
every assistance, so that they may avoid physical effort as much as possible. 
Those who show definite symptoms should not bo allowed to leave their beds or 
stretchers for any purpose whatever. S. Ill 
(2) Warmth; This helps to combat shock, and also to diminish the oxygen 
consumption that is entailed by the muscular movements of shivering. Attention 
should therefore be directed to this point when thd patient's clothing is removed. 
(3) Venesection: As soon as venous congestion begins to appear, 15 to 20 
ounces (300 to 600 ccs) of blood should be withdrawn from a vein by a large boro 
needle. This treatment is beneficial for all cases except those of.the leaden 
grey hue with failing circulation and a rapid, thready pulse. For this latter 
group it is harmful. After venesection the headache often disappears, dyspnoea is 
somewhat diminished and sleep usually follows. If these results follow, nothing 
further may be needed, 
(4) Oxygen: Oxygen should always bo given to casualties with serious 
pulmonary edema, that is, to those with any cyanosis or grey pallor. The aim should 
be to tide the patients over the critical period of tho first two or three days, 
and for this purpose oxygen should be administered continuously by moans of any 
..•apparatus, such as a B.L.B. Mask or a nasal catheter, that will ensure a 
suitable mixture-with air. 
The oxygen need not be warmed, and a sufficient current of it should be 
used (from two to ten litres a minute) to ensure a change, in the patient's colour 
from livid blue or grey to a pink tint. If the light is insufficient to allow 
cyanosis to be judged, guidance may be obtained from the behavior of the pulse. 
This treatment must be maintained, day and night if necessary, with a progressive 
lessening of the oxygen supplied, until the patient no longer tends to lapse into 
cyanosis when the oxygen is withdrawn. 
If the supply permits, oxygen should also bo given to the milder cases of 
edema in order to prevent their lapsing into a state of asphyxia. 
The experience of tho last war showed that no patient in whom it was possible 
to restore a pink colour by tho proper use of oxygon died from simple pulmonary 
edema. In a hospital likely to x-eccive any considerable number of cases of lung 
irritant poisoning (not of broncho-pneumonia from mustard gas), it is important to 
provide some definite routine of oxygen administration, 
b. General Treatment: 
Serious cases are best treated in a well lit 'and well ventilated ward, protect- 
ed from chill, Tho diet should bo liquid and sparingly given in the acute stage, 
but bland drinks should bo allowed freely. 
Expectoration should be encouraged by postural drainage. The foot of tho bed 
or stretcher is raised three or four feet for a few minutes at a time, with tho 
idea of draining fluid from the chest 1 Vomiting is helpful in emptying the lungs, 
and ofben occurs spontaneously, but it is liable to produce exhaustion, and it 
should not be induced by powerful drugs such as apomorphino or ipecacuanha. 
Expectorants should not be given to severe cases during the first two or three 
days for fear of, increasing the tendency to cough and so aguraenting the damage in 
the lungso In mild cases, or when the acute symptoms have abated in the severe 
eases, ordinary expectorant mixtures containing ammonium salts may be given with 
advantage, S. Ill 
The most serious complications of pulmonary irritant injuries during the 
last war wore infectious processes such as bronchitis and pneumonia. No studies 
have boon made to date relative’ to the efficacy of the-- sulfanamides in the treat- 
ment of such infections# Inasmuch as the infectious process is usually caused by 
those bacteria which normally inhabit the upper respiratory t ract., it may be ex- 
pected .that the sulfonamides will be effective* It is doubtful, however, if they 
should be used prophylactively because of their effect :on the oxygen carrying power 
of blood. 
If pulmonary complications develop (such as infective bronchitis, broncho- 
pneumonia, etc.) the patient should, if possible, be treated in a separate ward; 
otherwise, he should be separated by at least six feet from his nearest neighbour. 
.... Ho drugs were found to be of any special value in the last war. Atropine did 
not!prove effective in checking edema or in relieving bronchial spasm.' The faster 
acting barbituatcs 'will generally be satisfactory for the control of restlessness. 
Morphine is dangerous.because it tends to produce anoxemia and should only bo used 
in small doses (l/6th gr.) to control extreme restlessness. The relief of asphyxia 
by oxygon is the best mean’s of relieving headache and the best cardiap stimulant 
is oxygon. •’■■■■ . ;: 
(c) Treatment in the Convalescent Stage: 
. , No case should be moved for purpose's-of convalescence until definite cyanosis 
or other severe symptoms have, disappeared. It is alsb vary important that a note of 
the special symptoms attending the acute illness should be forwarded:with each 
case in order that subsequent treatment may be properly applied. The milder 
casualties are likely to recover after a short rest; those who have passed through 
a stage of severe cyanosis.,, however, qr who have suffered from a complicating 
broncho-pneumonia, require a prolonged period of convalescence, ■_ ,1 
All except the nq.ro sovero cases should bo gotten up from bod as soon as 
possible; slight bronchitis or gastric disturbances, which usually arc only tempor- 
ary, do not contraindicate this, but cases of abnormally rapid or slow pulse should 
bo rested a little longer. . .. •" ■ 
A system of carefully graduated exorcises should be instituted with full 
opportunities for lying down and resting in the intervals. The response to exer- 
cise of each individual must be carefully studied. : Exhaustion must be guarded 
against'as symptoms of "disordered action, of the heart" (effort syndrome) nay 
develop, and add weeks or months to the period of convalescence. 
' ’ ■ ■ ■■ • 
Employment of Anesthesia for Chemical' Casualties? When anesthesia is necessary 
for wounded casualties who have, also boon exposed to lung irritant gases, local 
infiltration or nerve block is the motho.d-'pfeferred, but intravenous, spinal, or 
rectal routes may. be.-.employed. At tines’ those methods arc- neither available nor 
desirable, and in some cases within contain restrictions-it may bo practicable or 
necessary to use inhalation anesthesia. ■ 
During tho latent phase of pulmonary irritation, surgical interference must bo 
confined to life-saving measures such as those necessary in laryngoal-trachcal 
injuries, hemorrhage, etc., and if anesthesia is necessary its use should be as 
brief as possible. , v-* ■ •' h J S.III 
When inhalation anesthesia is definitely indicated, ether shoud bo avoided in favor 
of less irritant anesthetics. In situations where the use of spinal anesthesia is 
\being considered it should be remembered that it may predispose to the development 
of cardivascular collapse which so often occurs following exposure to pulmonary 
irritants. 
If pulmonary edema-has developed* the treatment'of this condition is more 
important than surgical treatment’ of any accompanying injuries, .and 
general anesthesia is absolutely contraindicated. If the patient survives the 
edema all surgical interference should be deferred for at least 48 hours, 
AFTER-EFFECTS OF POISONING BY LUNG IRRITANT GASES 
Apart from infective b rone ho-pneumonia, -vyhich usually appears towards the end 
of a week, the sequelae of poisoning by- the asphyxziant- gases are, contrary to pop- 
ular belief, much less grave than was anticipated in the last war. The great major- 
ity of cases were restored to good health. Some continued to show incapacity for 
strenuous or oven moderate exorcise. This was often associated with tachycardia and 
a rapid, shallow type of breathing. Recurring frontal headache, generally worse 
after exercise, and epigastric pain of a temporary nature wore frequent* While 
pain in the chest was variable, the presence of a mild bronchitis was found in an 
appreciable proportion of cases. 
In the last war, the two important, sequelae which tended to prolong invalidism 
were ’'disordered action of the heart” ( effort syndrome) and nocturnal ’’asthma,” 
’’Disordered action of the heart” (irritable heart, or effort syndrome), is 
a condition characterised by precordial pain, a sense cf exhaustion, dyspnea and 
persistent tachycardia after exercise but no evidence of organic heart disease, 
was the commonest and most persistent after-effect. A small proportion proved 
intractable, and there was evidence to show that invalidism was increased if men 
were pressed to physical effort too early and too fast during the beginning of 
convalo soer.ee. 
Nocturnal asthma, which differed from the ordinary asthma of civil life, took 
the form of spasmodic attacks, lasting from three to thirty minutes, with shallow 
and rapid, bub not difficult, respirations and with no abnormal physical signs in 
the chest during the attack. The pulse might be slow and full, or rapid and almost 
impalpable, and both the haemoglobin percentage and the red cells were increased. 
Both disabilities almost always yield in time to a slowly progressive routine 
of graduated exorcise, coupled with careful supervision and feeding, and firm re- 
assurance to dispel neurasthenic factors. 
Patients who have passed through a phase of infective broncho-pneumonia should 
always be considered as a group apart, 
INVALIDISM AFTER LUNG IRRITANT POISONING 
Until knowledge came through clinical experience, there was much apprehension 
in tho last war concerning permanent damage to the lungs following the inflammation 
caused by chemical irritants. It was thought that severe emphysema and fibrosis of 
the lungs, or perhaps pulmonary tuberculosis, might result among the survivors. 
Nothing so gloomy occurred. S.III 
It soon became evident that men who have suffered from the most severe cyanosis 
with acute pulmonary edema could recover rapidly and completely. Many went back 
to full military duty after a convalescent .period of from three to four months. 
Others, as described above, suffered from neurasthenic features of exhaustion or 
from temporary loss of wind and endurance. But a small proportion did develop per- 
manent disability, with progressive dyspnea, recurrent bronchitis and a radiographic 
picture of scattered fibrosis and emphysema in the lungs. Since it was proved that 
a man could recover completely from the effects of the chemical irritant, it is 
probable that these rare examples of chronic invalidism were due to slow fibrosis 
caused by the secondary complications of broncho-pheumcnia. 
As regards tuberculosis, a general survey of the situation in the last war was 
made, and it soon became evident that, in spite of what was being ¥>rrittcn in certain 
countries, there was, as would seem logical no ascertainable connection between 
gassing and tuberculosis. On the other hand, gas may aggravate pre-existing tuber- 
culosis. Section IV 
CWS Svmbol 
HS. • 
M-l. 
ED. v- 
Common Nnme 
Mustard gas 
Lewisite 
EthvldichXorarsine 
Chemical Name 
Bisbetachlor- 
ethvl sulfid 
Bi chlorvinyl- 
dichlcrarsine 
Ethyldichlor- 
• arsine ■■ - 
Chemical Formula , :• 
(CXCHpCHpJpS 
(CIChrCHAsClp) 
Ws?h-r: V: 'I::.!'..' 
Tactical Classification 
Casualty 
i; Casualty 
Casualty and Harassing 
■ ■■ ■— 
Boiling Point - ■- 
228'c. . 
I90°c. ‘. r 
- 1 -5 ’ ‘ , ; p ~ • 
,156PC. : : 
Vapor Pressure at 
68 F. - 20°C. 
0.065 nmi He. ■' 
C ; • ; ••••■* f 
0.395 mm He* 
5.0 mm Hg. ' ' ' 
Vapor Density 
‘5.4 
• 7.1 .. I ' • J 
6.5': ! h ' ; : : 
Volatility 
Oz./lOOO cu. ft. 
0.57 v 
•4,5 r : 
*47 rQ : ■ 1 1 
• ') . . 
» "r: • . 
Persistency 
5-10 days, open 6 
2t3 weeks, woods v. 
In winter, sev- 
eral v/eeks, open 
:and woods 
: In summer: 24 hours, 
, open •. •; » • 
1. week,’' woods* 
In winter, 1 .week 
1- hours.open, 
2- .Hours, woods; 
In winter:, 2-4 Hours open; 
12 hours woods 
i " *5 .1 r:\ 
Odor 
Garlic dr 
Horseradish 
Geranium' • r 
P ; ‘ ' * 
Biting * 
Odor detectable at 
Oz/lOCO cu. ft. 
0.0005 
;, .1 * ,v . 
0.0014 
} . > 
0.001- M : 
Min. Irritating Concentration 
Qz./ieoo cu. ft. 
0.0004 - 1 hour 
(eye injury cone.) 
0.0008 
0.00 A ' 1 
Lethal Concentration 
Qz.1000 cu. ft. 
0.15 - 10 min. 
0.12 - 10 min. 
0.5 - 10 min. (bv breathing) ‘ 
Method of neutralizing 
Bleach powder 
% Na2S 
Alcoholic NaCH 
spray 
NaOH solution 
VESICANTS 
PHYSICAL AND CHEMICAL PROPERTIES Section 4 
MUSTARD GAS 
Lesions Due to Liquid Mustard Gas; - * , 
Skin Burns • ■: ; ' 
Mustard gas has a high lipoid solubility which results in rapid pene- 
tration of the skin though some time may elapse before clinical manifesta- 
tions occur. The initial signs and symptoms of a typical liquid burn are 
an erythema accompanied by itching. Vesicles develop in 8 to 12 hours. 
They vary in size from very small to very large ones, depending upon the 
size of the contaminated area. 
The blister of mustard is painless, flat, and surrounded by a zone of 
erythema. The vesicles have a tendency to coalesce. They are prone to 
become infected, < 
In the central area of the lesion capillary engorgement is 
prominent and frequently goes on to deep cyanosis with necrosis of tissue. 
If the burn is severe, necrosis may result without vesication. The vesicles 
tend to be flaccid though some rupture spontaneously. 
The vesicle content is at first a clear, watery, serous fluid. The 
fluid becomes cloudy, as bacterial invasion occurs—the usual course unless 
it is drained. The vesicular fluid is non-toxic and non-irritating . 
(in contra-distinction to that removed from lesions caused by Lewisite,) 
If the vesicle is opened early, the base is found to be pink in color. 
This is shortly replaced by a gray sloughing membrane which begins to 
separate about the. sixth day. The separation of the'slough is accompanied 
by healing of the lesion which is, in most instances, well'advanced by the 
third week. Those lesions which involve the deeper layers, result in 
marked vascular destruction tending to cause a protracted healing period. 
The scar is fibrous,iof low vitality, and often has a copper-colored 
pigmentation which ’tends to clear with time. 
If clothing becomes contaminated with liquid mustard, the heat of the 
body will vaporize the liquid and a vapor burn may result. If clothing" 
is wet it is penetrated more rapidly by .the gas than if dry. Of course, 
the thickness of the clothing and the amount of contaminant will govern 
to some degree the rate of penetration, 
EYE BURNS DUE TO THE LIQUID: 
Contamination of the eyes by liquid gas is a very serious injury, 
frequently resulting in permanent disability. 
Following contamination there is generally a period of irritation. 
This frequently passes off quickly leaving the patient without s,-Tnptoras 
for a short time. Usually within 30 minutes of injury symptoms of acute 
conjunctivitis are experienced by the patient, and these rapidly become 
severe. Photophobia, lacrimation, and pain are prominent. Section 4 
There is an intense edema of the lids and of the bulbar and palpebral 
conjunctive. The cornea is cloudy and opacities are often seen. Intra- 
ocular tension is increased in most instances. The lacrimation is shortly 
replaced .by a muco-purulent discharge and secondary infection commonly occurs. 
The extensive destruction-of the conjunctiva favors the development 
of symblepharon as healing occurs. Permanent opacities of the cornea are 
liable to result, 
GASTROINTESTINAL TRACT 
Liquid mustard gas may be ingested in contaminated food causing damage 
to the mucous membrane of the gastro-intestinal tract. This results in 
vomiting of mucus and blood, and severe epigastric pain, 
LESIONS DUE TO MUSTARD VAPOR 
(a) EYES; 
Signs and symptoms of injury due to mustard vapor in the unprotected 
individual are generally first observed in the eyes. At the time of exposure 
there is no sense of irritation, and clinical manifestations may not appear for 
as long as 24 hours. Smarting and lachrymation, the first symptoms, are quickly 
followed by pain and photophobia. The lids and conjunctiva become edematous, 
A muco-purulent discharge indicates the presence of secondary infection, Chemosis 
may be of such a degree that the conjunctiva protrudes between the lids, inter- 
fering with drainage, * . , 
The cornea is often hazy in the early stages, the haziness fading above 
and below where the cornea has been shielded from the gas by the. lids. The 
corneal epitheleum loses its lustre. Exfoliation of the corneal epithelium 
may occur. Ulceration is seldom encountered unless the cornea is traumatized. 
As recovery takes place the edema gradually recedes in the cornea and 
its lustre is regained,. In the absence of corneal ulceration or conjunctival 
adhesions, serious complications are seldom encountered, Lachrymation and 
photophobia are liable to persist and neurasthenic conditions may occur in 
susceptible individuals. 
Eye injuries by mustard vapor in the war of 1914-1,8 fell into 3 main 
groups clinically: 
(a) mild cases, 75$ - fit for duty in 2 weeks 
(b) intermediate cases, 1555 - recovery in 4 to, 6 weeks 
(c) severe cases with corneal change - 10$ recovery in 2 to 4 months, 
with a small percentage having permanent visual impairment, 
(b) SKIN; 
The severity of the injury to skin after exposure to mustard vapor Section 4 
is influenced by a number of factors. All clothing will sooner or later 
be penetrated, but thick, closely-knit, clothing tends to retard penetration. 
Injuries are liable to be most severe where sebaceous glands are abundant, 
as in the axilla or groin. Wet or sweaty clothing absorbs the vapor in 
larger amounts than dry clothing. Thin or traumatized skin is more sus- 
ceptible to the effects of mustard. 
A generalized erythematous blush occurs, accentuated in the axilla, 
perineum, and often over the cubital and post popliteal spaces. The thick 
tough skin of the scalp and the palmar surfaces of the hands frequently 
escapes injury. 
The redness deepens and, generally by the second day after onset of 
symptoms, vesicles make their appearance. The vesicles tend to coalesce. 
The course and pathology of the blister caused by the vapor is the 
same as that already discussed under injury due to liquid mustard. Very 
mild cases may not progress to the blister stage. Flaky desquamation -/- 
usually occurs. In the absence of very deep or extensive burns or secondary 
infection, systemic reactions seldom occur, 
(d) DIGESTIVE TRACT 
If saliva or nasal secretions,contaminated by mustard are swallowed, 
a chemical gastritis results. Epigastric pain, nausea and vomiting are 
characteristic symptoms, The condition rarely lasts more than 48 hours. 
The rest of the gastro-intestinal tract is seldom involved, ‘Permanent 
injury is not caused, though functional nausea is occasionally seen, 
(d) RESPIRATORY TRACT 
Inhalation of mustard vapor results in the destruction or injury of 
the cells of the respiratory tract. There is no sensation of irritation 
at the time of exposure to the ordinary field concentration of the gas 
(unlike Lewisite). The patient breathes normally, so that the vapor gains 
access to all parts of the tract. 
Symptoms appear for from 4 to 6 hours or longer, after exposure. 
At this time there may be- some smarting of the nasal mucus membranes. 
The laryngeal mucosa becomes inflamed and edematous. Hoarseness or aphonia 
are prominent. In severe cases the vocal chords may slough. 
In severe cases the mucosa of the trachea and bronchi are affected 
much the same as the skin. An intense inflamation results with death of 
the superficial layers of cells. Secondary infection is. liable to occur 
in the area,of the sloughing membranes. As the septic sloughs accumulate, 
the infection may spread into the alveoli resulting in localized areas of 
broncho-pneumonia. 
HOSPITAL TREATMENT FOR CASUALTIES SUFFERING FROMBUSTARD GAS INJURIES: 
Before a mustard gas casualty is admitted to a hospital it is Section 4 
essential that he undergo decontamination so as not to expose other patients 
about him to the agent. It is preferable that decontamination stations be 
established near the site of the incident so that decontamination may be 
accomplished as soon after exposure as possible. However, as a certain 
percentage of patients will be brought to the hospital in a contaminated 
state, arrangements must be made for decontamination after arrival* 
Hospital care consists principally in symptomatic ministrations to 
the injured and steps to prevent secondary infection. These will be dis- 
cussed by systems. 
Eyes: 
Much can be done to make the patient comfortable by lavage with a 
saturated solution of boric acid or a 2$ sodium bicarbonate solution. 
The patient should be placed in a darkened, quiet, room. Ho dressings 
should be applied. The pupils should be widely dilated with 1% atropine 
solution. Dilatation should be maintained as long as there is uveal 
tract involvement. Boric acid ointment (5$) or a mildly antiseptic 
ointment, such as 1:5000 bichloride or mercury, are beneficial in pre- 
venting crusting and adhesions of the lids, but should not be used in 
the first 24 hours. Hot boric acid compresses every 2 to 4 hours vd.ll 
be found comforting and beneficial. For very severe eye pain due to 
corneal ulceration 1% pontocaine or 2% butyn ointments may be used but 
for the average case no anasthetic ointments are advocated, A 2g$ 
solution of sulamyd is effective in reducing infection of the eye and 
conjunctiva. Ten to fifteen drops of the solution should be instilled 
in each eye with a medicine dropper every few hours. Cocaine in all 
forms is contra-indicated because of its effect upon the corneal epithe- 
lium. Infected corneal ulcers should be cauterized with liquid phenol. 
Special attention should be directed toward the prevention of symblepharon. 
As convalesence becomes apparent by the lessening of conjunctival 
inflammation a mildly astringent solution such as 
Zinc Suplhate gr 1 
Sat. Sol. Boric Acid oz. 1 
may be applied to the palpebral conjunctiva. 
TREATMENT OF THE RESPIRATORY TRACT 
Rhinitis; 
A short time after the onset of eye symptoms smarting and burning of the nasal 
mucosa develop. In some cases severe headache develops, especially of the supra- 
orbital or maxillary variety. Warn deuches of a 5$ solution of sodium bicar- 
bonate several times a day are very soothing. The danger of infection is greatly 
reduced by the use of a 15$ solution of sulamyd. This should be sprayed in the 
nose and throat every few hours using a non-netallic atomizer. In a few instances 
injury may be so severe that ulceration of the nasal mucosa occurs. In such cases 
epistaxis is likely to be profuse and persistent. If symptoms are unrelieved bv 
the bicarbonate irrigation the following solution may be useful for local applica- 
tion: Section 4 
Zinc Sulphate gr. 1 
Sat. Sol. Boric Acid oz. 1 
Laryngitis: Medicated liquid par rail n may be used as a spray to 
relieve the harsh dry cough. Steam inhalation using tr. benzoin in boiling 
water is especially soothing. 
Bronchitis and Broncho-pneumonia: Most of the deaths from mustard 
gas in jury result from secondary infection of the damaged lung. It is 
necessary, therefore, to segregate those patients showing evidence of sepsis 
from those who are ’’clean.” • 
Gas casualties with pulmonary injury who develop septic complications 
such as bronchitis or broncho-pneumonia should receive the general treatment 
applicable to those diseases. 'The common invading organisms are those which 
normally inhabit the upper respiratory tract, and it may be anticipated that ■ 
the sulfonamides .wall be effective in thereapy. 1 •" . • 
Expectorants are of value if the mucous is* tenacious; - Oxygen therapy 
is indicated in the presence of cyanosis. Venesection is contraindicated in 
the treatment of broncho-pneumonia following mustard gas injury of the lung. 
Skin: Sepsis is the most' - serious complication of burns of the skin 
since it may result in general reaction and-always delays healing. It is - 
important,: therefore, that careful 'and thorough tfa'shing of the skin be 
accomplished as early as possible. It should be'recalled that trauma to 
injured skin must be avoided, as even slight7 trauma from an ill-fitting dress- 
ing may aggravate the gas injury* It should be repeated that bleach will ■ 
aggravate ■ a- burn i-f applied to an erythematous area.; Hair is a source of 
infection and it should be removed by shaving* - •* -- 
" As the type of treatment to' be applied will be ■ governed by the severity 
of the injury we, shall discuss each type of skin injury separately. 
Erythema; Skin injury of this degree may be likened to sunburn in its 
severity, discomfort and duration. Spontaneous,.improvement with desquamation 
and occasionally a temporary pigmentation nay be expected. For itching pow- 
dered isoamyl salicylate is very effective. 
Vesication: Skin devitalized^to this-extent is very prone to secondary 
infection and the greatest care should be exercised to prevent this compli- 
tion. Eary cleansing of the skin around the vesicles with the usual"” 
surgical antiseptics is of; value though these solutions are too caustic to_ 
be used on the burned areas. The blistered area should be cleaned gently with 
an ample amount of soap and water. . • . ■.-.‘..•r 
If the vesicles are-discrete they may be evacuated under sterile conditions 
with a syringe and needle,. The intact may be allowed to seal the 
raw surface and the wound covered with a dressing. An alternative is to remove 
the epithelium after the vesicle has been evacuated in which case cod liver 
oil dressings should be applied daily. Section 4 
7 
If larger vesicles develop they should be drained after which the epithelium 
should be removed. . _ , 
The skin lesions following vesicant injury have a tendency to increase 
in size for several days. The crusting techniques applicable, to most thermal 
injuries are therefore unsatisfactory because the crust does' not make contact 
with healthy skin at the expanding periphery of the lesion. 
It is wise to keep the entire lesion covered with.a sterile dressing. 
Mild antiseptics should be applied to the healthy skin,around the burn as 
infection is liable to arise at the margins of the, wound .if", the surrounding 
skin is not properly cared for. 
The general principles of wound care should govern the treatment of the 
burned area. Stimulating ointments such as scarlet red majr be of value in the 
later stages. Finch grafts may be used on .large, clean wounds with a healthy 
granulating base, ‘ x'VV' 
Septic wounds should be treated by the usual methods .including.hoi saline 
or magnesium sulphate compresses. Such patients' should be isolated from the 
11 clean" cases. ; * " " " - T’" . " V " V 
Patients with burns about1tHe perineum will receive a great deal of. 
comfort from sitz baths at body teidpehature. " / ’ ' 
Functional after-effects; These fall into two main categories—In the 
first, patients of unstable personalities may develop neuroses from an ex- 
posure to a minimal and even of mustard gas. , This anxiety, 
state is aggravated if the’patient is Wot^given proper consideration. 
The second class is a more important oney because'the organic lesions of 
mustard gas set up irritant reflexes such as coughing or photophobia which 
are perpetuated by'-introspection iohg after the organic lesion has cleared. 
Lack of understanding of .such a possibility on the part of r the medical officer 
may result in a prolongation of the disorder. 
Function aphonia and photophobia are the most common of these disorders. 
This is not surprising since the initial trauma affects two highly specialized 
organs of sense, the loss of which would be most disabling to the individual. 
Ill-advised, unnecessary or unduely prolonged-treatment''tends' to accentuate 
the condition. Maintaining the patient in a darkened room longer than nec- 
essary for an eye injury is liable' to provoke psychic complications. 
Aphonia on a functional basis is generally accompanied by a harsh, dry 
cough. Occasionally the cough is associated with the expectoration, of a 
watery sputum of*salivary origin. If the medical officer wall inspire con- 
fidence in the patient as to his early recovery and have him take breathing 
exercises many of the symptoms will clear, . •: r ...... 
Effort syndrome is a common complication of mustard :gas injury and 
reauires experience for proper management. Early approach by a competent 
psychiatrist is most beneficial. « , , . Section 4 
Of very definite value in reduction of psychic disorders is the early 
discharge of patients to convalescent centers. This should be carried out 
as soon as convalescence is well developed and the danger of septic compli- 
cations has passed. 
Doctors should realise that gas poisoning, whatever the chemical irr- 
tant concerned, does not in itself cause a permanent poisoning of the 
patient or chronic impairment of health. It is necessary to insist on this 
truth lest the patient be allowed to develop a morbid dread and drift into 
neurasthenia and general debility, 
LEWISITE 
Lewisite is a clear or light brown oily liquid-which gives, off 
a colorless vapor having an odor like geraniums. The gas quickly 
causes a biting sensation in the nose. The gas has a freezing point 
of 10° F. so that is remains a liquid at a much lower temperature 
than mustard. In the presence of water, lewisite is a rapidly 
hydrolyzed, the products being hydrochloric acid and an insoluble 
arsenic compound having vesicant properties. The gas is soluble in lipoids 
and lipoid solvents. It has about one seventh the persistency of mustard— 
therefore it vaporizes relatively rapidly. It penetrates tissue much more 
rapidly than mustard. The liquid is much more irritant than liquid 
mustard. 
Lewisite is both a lung irritant and vesicant chemical, more 
rapid than mustard in its action/ but not so insidious because of 
its pungent, penetrating odor and the immediate discomfort experienced 
on contact with or inhalation of the gas. 
Pathology: Injury due to levdsite produces pathological changes 
very similar to those already discussed under mustard. - The vesicles 
of lewisite contain the toxic hydrolytic products of the compound, 
i.e,, substances with vesicant properties and which are capable of producing 
degenerative changes in the heart, kidneys and liver by virtue of their 
arsenical content. 
Injury due to Liquid Lewisite 
Skin: Levdsite attacks and penetrates the bare skin. It produces 
an immediate sense of irritation which usually persists. 
Erythema develops in from 15 to 30 minutes and at this stage the 
lesions of mustard and levdsite have an identical appearance. Vesica- 
tion is usually fully developed within 12 hours. 
The lewisite blister is sharply defined and extends over most of 
the area of erythema (in contradistinction to the vesicle of mustard 
which is surrounded by an angry, erythematous zone). The fluid is 
cloudy or opalescent and on examination it is found to have a high 
leukocyte count and to contain arsenic. Section IV 
9 
Serious injury from absorption of arsenic from levrisite lesions 
may be expected if large areas are involved and the blister fluid is 
not promptly drained. 
■ On clothed skin lewisite is definitely, less effective than mustard. 
If the clothing is wet or damp the liquid vd.ll be'"quickly 'hydrolyzed 
unless massive contamination has occured. .’It is also known that even 
with dry clothing small drops of liquid lewisite are not as effective 
as drops of mustard of similar size, .. ': 
.. ‘ ■ ! t ’ t * * ‘ * ; ; 
Unless contamination is massive or clothing very thin and dry it 
is unlikely that injury due to the liquid will result to the clothed 
skin. Injury is much more likely to result from the vaporization of 
the liquid on the-clothing. ’ - • 
Eye Burns due to Liquid Lewisite:. Injury, of the eye due to liquid 
lewisite, however small the dose, creates a grave emergency. The patient 
has immediate pain quickly followed by lachrymation, photophobia and red- 
ness,- all of which make their appearance within 10 minutes to half an 
hour after injury. These symptoms progress very rapidly. Within 24 
hours chemosis, redness and ulceration of conjunctiva and cornea may be 
alarming. The cornea may-become hazy. 
The prognosis is seriqus since most such injuries result in some 
degree of permanent disability. ' • . - ■ 
Injury due to Lewisite Vapor 
Byes: Even in low concentrations lewisite may be detected by its 
characteristic odor. If a respirator is donned at once complete protec- 
tion of the eyes is afforded. There is immediate irritation of the eyes 
on contact with lewisite vapor. This stimulates lachrymation, the flow of 
tears hydrolyzing the gas. 
Action on the Respiratory Tract: The irritation of the vapor forces 
the exposed person to apply his respirator which will effectively protect 
him from injury to the respiratory tract. If the respirator is not used 
the pathology and symptoms resulting are similar to those for mustard gas 
injury except that they are much more acute. 
Lewisite Vapor on the Skin: In similar concentrations lewisite vapor 
is not as caustic as that of mustard. However, because of its low freezing 
point it will be more damaging than mustard vapor in cold weather. 
Wet clothing will .hydrolyze the vapor as it does the liquid. Dry 
clothing absorbs the vapor making it dangerous to wear. 
Prophylaxis and prevention are discussed in First Aid in the Preven- 
tion and Treatment of Chemical Casualties. 
Treatment Should be directed toward the symptomatic relief of the 
patient as outlined under mustard gas injuries. A preliminary bath should Section IV 
be given to protect against infection and to remove any remaining chemical. 
If vesication occurs the blister should be drained, the epithelium 
removed and the wound irrigated with normal saline to remove any traces of 
arsenic which may be present. The area should then be irrigated with 2-3% 
hydrogen peroxide. As pointed out before the blister fluid contains a 
vesicant agent,, and it will therefore' be necessary to protect the skin around 
the vesicle from contact v/ith the liquid. This may be achieved by the 
application of a bland ointment, such as boric acid or petrolatum. 
If burns are deep and are not too extensive, perhaps the most satisfactory 
method of management is the complete excision of the burned area including an 
ample margin around the area of apparent involvement. This wound may 
be closed by sutures, and if proper surgical technique is employed, heal- 
ing by primary intention may be anticipated. 
Some studies have been made as to the advisability of injecting 
oxidizing agents directly into the tissues of the involved area in an 
effort to destroy the vesicant agents in situ. The data available on 
this technique are not conclusive, but there is room for doubt as to 
the advisability of such procedures since injection of most of materials 
advocated may cause devitalization of tissues. 
I 
Systemic effects of arsenic absorption should be guarded against 
by a high fluid intake (and output) and large amounts of carbohydrate, 
which should be given intravenously is necessary. Vitamins, especially 
the B complex, should be given for their anti-neuritic properties* 
Treatment of burns of the eye is the same as that outlined under 
mustard. Section V 
GAS INJTJKXES TO THE EYE 
Following the early use of mustard gas by the German army in 1917, 120 eye casual- 
ties were reported. Many were exposed to gas without knowing it at first and in 
a few hours they developed photophobia and blepharospasm. Cases who sustained 
injury could bo divided into three classes: 
1* Mildly affected cases with little or no corneal infection—about 75%>, 
2# Moderately affected eyes with slightly roughened cornea, but not stain- 
ing with fluorescein - about 15%, 
3# Severe cases with the cornea definetely staining and corresponding 
conjunctival involvement - about 10^, 
The first class was fit for duty in one to four weeks, the second in four to six 
weeks, and the third sent homo and required various periods for convalescence. 
There were a small number of liquid burns of the eyes and eye lids# 
Pathological Changes: 
Class (l) - Dilated vessels in the exposed area duo to* direct irritation# 
The injection soon subsided. 
Class (2) - No speciment actually examined. 
Class (3) - Eyes removod in cases of death showed a denudation of the 
corneal epithelium with the flattening of the remaining cells# The 
white appearance of the conjunctiva in the early stage was duo to 
coagulation and arrest of circulation in the conjunctival vessels. In 
the late stages the appearance was reversed, the exposed area being 
injected and the vessels sometimes remaining permanently enlarged while 
the rest of the conjunctiva assigned its normal appearance. 
Clinical Picture; All classes suffered from photophobia and blepharo-spasm. 
Class (l) - Moderate to acute injection of exposed conjunctiva, the rest of 
the eye being relatively unaffected. Cornea unaffected. 
Class (2) - The bulbar conjunctiva covered by the lids was usually white but 
the conjunctiva in the interpalpebral fissure was congested# The cornea was 
often hazy, but did not stairi. 
Class (3) - The bulbar conjunctiva was white- and the destruction was more 
pronounced than in class (2). The cornea showed an "orange-skin” roughness 
and in many cases stained for a variable period. 
Clinical signs of the acute stage; 
The patient is fairly comfortable for two or three days. Photophobia lacrymation 
and itching become pronounced. Photoneurosis may occur in a number of individuals 
of a burned group because of symptoms observable in others. Lid edges are moistened 
aid red, a wrhite secretation occurs at the inner canthus, probably due to desquama- 
ted epithelium, especially after the use of strong antiseptics.# Severe ciliary Section V 
injection is absent, but there is great congestion of the larger conjunctival 
vessels* There were usually several areas of corneal ulceration at about five 
or seven o*clock* ; - •■ y. 
1* If these areas consisted of superficial stippling and pain was fairly 
severe, recovery was the rule. This apparently was a sign that the corneal 
nerves wero viable and doop corneal odoma was not present. .’ 
2. If a-white, band-like area extended across the cornea and there was little 
pain and redness, corneal sloughs and permanent disability were frequent. If 
the patient had been previously injured by mustard, ulceration of old areas 
usually recurred. The slit-lamp showed' sloping sides and swollen epithelium 
around the periphery of the•ulcers. Dark lines, probably swollen nerve fibers 
wero soen in all layers of the cornea. They appeared like cylindrical ~ 
vacuoles, Somo of them were branched. Folds in Dcscomets wore numerous. 
- There were usually signs of iritis with posterior synechia and dilated iris 
vessels.- '• ;i. 
Clinical signs in the chronic state: ; 
One of the most important signs in this stage was known as "Marbling." 
The conjunctiva sloughed and there was an absence of small vessels leaving 
large areas of the sclera bare. Here and there-a large distended vessel 
was soen, becoming more tortuous as it neared the limbus, ending in a small 
cork-screw. The cornea was insensitive. Superficial corneal damage was 
usually in the lower third; doop corneal damage was shown by infiltration 
upward. - ■ * 
Tho effect of previous treatment on delayed keratitis: 
The cases which had had. a tarsorrhaphy did best. Those treated by lubricants 
alone aid not do so well. The ones treated by antiseptics and cocain did the 
wo.r st, ■ . ■. . 
Contact glasses; 
The therapeutic use of glasses did not help, sometime.s it causejd the con- 
junctiva to swell so there was difficulty in removing the glass. They were 
important for improving visual function later. \: •' 
Treatment: Persons who have serious damage to the eyes follovdng exposure to 
vesicant vapor and all who have had any liquid contamination 6"f the eye should be 
admitted to a hospital. Upon admission the conjunctival sacs should be carefully 
irrigated with 2% sodium bicarbonate solution. Ointments should be avoided in the 
early treatment of vesicant injury to the eye because the gases are lipoid soluable 
and so are held in intimate contact with the eye. 
The visual acuity should be noted shortly after the admission of the patient. 
This is of great psychic value as it demonstrates to the patient'that he can see. 
It is also a valuable part of the clinical record. Secondary ipfeotion of the 
cornea usually makes its appearance early and is ushered in by a discharge of muco- 
purulent material. Instillations of 2% sulamyd arc’ very effective in reducing 
infection, 5 to 10 drops should be placed in each sac .every 3 or 4. hours* In the 
World War solutions of boric acid, normal saline and sodium, bicarbonate Wore use d 
for eye irrigations. No dressings should be applied during the acute phase. Section V 
The pupils should be widely dilated with 1% atropine solution as long as there 
is evidence of involvement of the uveal tract. Ointments should be avoided for 
the first 24 hours after which bland ointments such as 5% boric acid or very 
mildly antiseptic ointments such as lj6000 bichloride of mercury preparations may 
be used. Hot boric acid compresses every 2 to 4 hours will be very comforting. 
For very severe eye pain l/2% pontocaine or 2% butyn solutions should be used to 
reduce blepharospasm and thus aid in the administration of Ideal therapy.1 Anasth- 
etic ointments should not be used.' Cocaine in absolutely centraindicatedi 
The management of the acute stage of vosipant injury to the eye is frequently 
complicated by the intense edema of the conjunctiva. This not only servos to make 
local therapy difficult but by pressure bn the globe interferes with the blood 
supply at the limbus. Early canthotomy will servo to lesson tho difficulty of 
local therapy and, by relieving the tension produced by spasm of tho obicularis, 
reduce the pressure on the globe. ' . 
Canthotomy is a simple procedure which seldom should require anasthe-sia or 
special training. A pair of blunt pointed scissors is slipped between thel'globe 
and the outer canthus and a cut is made laterally. 
Delayed Reactions: Following injuries to the eye in which a largo portion 
of tho palpebral conjunctiva is destroyed, degenerative reactions of the corneal 
epithelium arc liable to'Occur. This phenomenon, usually starting a-week or two 
after tho initial injury, is probably duo to a mechanical or toxic factor. A 
violent keratitis occurs frequently resulting in a permanent loss of-visual func- 
tion in tho affected eye. It is impossible to anticipate from tho examination of 
the original injury whether these degenerative'changes will occur in any given 
case. It is felt by some that in oases'with extensive damage to the palpebral 
conjunctiva early surgery consisting of the'extensive removal of the damaged tissue 
is indicated. Such procedures should only be executed by a competent ophthalmic 
surgeon. 
Results of gas burns of the eye: A large proportion recovered with no effects 
In from two to three weeks. In a small percentage delayed corneal degeneration 
caused permanent impairment of vision in various degrees. The severe late results 
led to exfoliation of the corneal epithelium with Bowmans membrane being exposed 
in a few cases. 
“Where permanent disability resulted it was usually due to delayed effects 
such as low grade keratitis, secondary iridocyclitis, and ulceration of the cornea. 
Abscesses of the cornea occasionally formed which perforated into the anterior 
chamber making enucleation necessary. Section VI 
[QSPITAL INVESTIGATION AND TREATMENT OF CASES OF GAS-POISONING. 
INTRODUCTORY 
The main clinical features of gas poisoning by pulonoary irri- 
tants (Phosgene group) and vesicants ("mustard” group), and the gen- 
eral principles of treatment were established by the experiences of 
the last war. Additional knowledge has accrued since then from animal 
experiments And accidents to humans. It will be accepted, however, 
that many problems have remained unsolved or incompletely solved and 
if gas is used by enemy in new forms or greater concentrations, ■» . 
new problems must inevitably arise. In such an event, it would become 
an urgent necessity to gather reliable information as quickly as poss- , 
ible in order to provide general instruction (throughout the, country 
and in other theatres of war) concerning the recognition of special 
clinical phenomena and the proper treatment. The intimate investi- 
gation of small numbers rather than scattered and incomplete and un- 
controlled observations on large numbers would be best calculated to 
provide the information required. 
It is proposed therefore that in each area one younger clinician 
should be nominated who could, at short-notice, be put in undisturbed 
charge of cases, wherever they might occur in the area, so as to insure 
adequate physiological and pathological investigation. 
* 
I. Notes on the Indentification of Gas Casualties. 
This part is intended to serve two purposes: (a) to give the 
authorities accurate data on which to determine whether gas has in 
fact been used by the enemy. Speed and exactness of observation 
are the essential requirements. The investigating officer is not 
expected to fill in every detail of the form, and indeed, it is 
better to leave the form incomplete than to make vague observations; 
(b) to give the authorities as complete a picture as possible of the 
whole incident, to enable them to determine what kind of gas has 
been used and the circumstances in which it was employed. Time is 
of less importance, and the principle stated above holds good: 
that the intimate investigation of small numbers is likely to pro- 
vide the most useful information. 
II. Notes on the Reception and Management of Gas Casualties in 
Hospital. 
These notes are intended for the guidance of the Medical 
Superintendent and tho physician whose duty it would be to take 
.charge of the reception, sorting, and care of gas cases. A "team" 
for the treatment of gas cases should be organized in every hospital 
capable o;f receiving such casualties. 
III. Notes on the Observations required in Cases of Gassing. 
These notes are intended for the guidance of the clinician ap- Section VI 
2 
pointed to take charge of gas cases in each area. They form the 
basis of a more or less uniform investigation and research which 
should be conducted throughout the country. The form should not be 
regarded as a rigid framework of research-, but rather as a guide to 
the minimum series of-observations, which can be elaborated in one 
direction or another, according to the special interests of the in- 
vestigator. Any new phenomenon observed, however, or any promising 
line of advance in investigation or treatment, should be at once 
reported to the’Chemical Warfare Service of the United States Army 
- INDENTIFICATION OF GAS CASUALTIES 
Accurate answers are essential; it is better to leave the form 
incomplete, and add footnotes, than-to give vague comments. 
■ ''• . ... PART 1. GENERAL INFORMATION 
Name: ’ Approx. Age; 
~ *1 * V* . ; r - .. 
Address; Sex; 
CIRCUMSTANCES OF EXPOSURE 
1. Patient alive/dead when found. ■ 
2. Exact place of exposure; ■ . 
Town or District; 
Position; e.g., open air’j;inside a building, crater, 
. . or elsewhere; (specify); 
(Write in the appropriate word; do not underline) 
3. Was an eneny attack in progress at the time? e.g., air raid, 
bombardment, etc. ’ 
What other evidence was there of enemy damage? 
A. Time ..of Exposure A.M. P.M. 
5. What was casualty doing at time of exposure? 
6. Weather; A. Warm • : cold 
B. Sun rain mist fog 
wind direction of wind Section VI 
7A Was respirator put on 
a. before gas was suspected? 
b. after gas was suspected? 
how long after gas was suspected? 
7B Was protective clothing worn 
a. before gas was suspected 
b. after gas was suspected 
8. If not, was the ordinary clothing contaminated 
a. with vapor 
b. with liquid 
Was any of the clothing discarded? 
8a. Was the smell of gas apparent? 
What kind of smell? 
9. Was there contact with the gas as a 
a. vapor 
b. spray 
10. First Aid treatment. 
How soon given? 
lyes? • 
Skin? 
Other? 
11. Was any subsequent treatment given? 
If so, where? 
What was done? 
Signature 
Office or rank 
Post or station 
Footnotes Section VI 
IDENTIFICATION OF GAS CASUALTIES 
PART 2. NOTES FOR CLINICAL DIAGNOSIS. 
A. HISTORY. 
1. First sensation after exposure; ...... r 
I 
2. Did the first sensations pass off soon and, if so, when? 
3. First symptoh of illness: 
U* Time-lag between exposure and first symptom: 
5. Patient’s activities after exposure: ........ 
(a) Did he walk for assistance? 
(b) If so, approximate distance and time: 
(c) Could he walk easily, or was he breathless? 
(d) Was he transported by stretcher? 
B. PRESENT CONDITION ’' ru'~' 
1. Present complaint; 
2. Is the patient obviously ill? 
3. More ill than he feels, or the reverse? . 
A. Systematic examination: 
(a) Skin; 
•Cyanosis Pallor 
• Pigmentation Jaundice 
Erythema Blisters 
Burns Necrosis 
(In each case state or sketch the area affected.) Section VI 
(b) Eyes: 
Pain Lacrimation 
Blepharospasm Conjunctivitis 
Vision impaired lost: 
(c) Respiratory Tract; 
Pharyngitis Bronchitis 
Laryngitis Bronchopneumonia 
Nasal discharge Pulmonary edema 
Hoarseness Dyspnoea 
sneezing, cough 
Frequency and type of breathing: 
Sputum; character 
quantity 
blood-stained, etc. 
(d) Digestive system; 
Vomiting Diarrhea 
Abdominal pain 
(e) Urinary system; 
Lumber pain Quantity of urine 
" y v 5 j . '. ’ 
Character of urine 
(f) Circulatory system; 
Pulse Temperature 
Venous congestion Evidence of shock 
(g) Nervous system; 
Headache Mental Confusion Section VI 
Giddiness Convulsions 
Depression Coma 
Specimens for chemical analysis. 
Blister fluid ' . , Blood (about 5cc) 
Urine (about 6 oz.) v,': > " t 
Vomitus (do not pass stomach tube or give emetic.) . 
Note; It must be understood that these specimens are desirable and 
may be of importance; but any difficulty in obtaining them 
should not be allowed to delay the transmission of clinical 
findings or the treatment of the patient. Section VI 
HOSPITALS AND GAS 
Notes on the Reception and Management of Gas Casualties 
I. 
Should the enemy use gas, the medical services would inevitably be 
taxed heavily and the hospitals would be confronted with a variety of new 
problems, both clinical and administrative. Some of these must remain unfore- 
seen. For others past experience and other sources of information provide a 
solution. As with bombing, so with gassing, modifications of plan and method 
in respect of the collection, transport, hospital treatment and evacuation cf 
casualties would evolve from experience derived in new situations. In the 
meantime it must be considered urgently necessary to establish a state of pre- 
paredness in every suitable hospital in the countiy for such contingencies as 
can at present be visualized. Such preparedness demands thought and action 
and training, but need not involve any undue elaboration or expenditure. Much 
information and instruction has already, been Issued on decontamination and tho 
treatment, of the individual case. Outside the hospitals training and prepara- 
tion should be now well advanced. The present notes relate to organization 
within the hospitals. 
II. 
Medical Officers in Charge of Gas Casualties 
In every hospital capable of receiving casualties there should be at 
least one physician whose duty it would be to take charge of the reception, 
sorting, and care of gas casualties. From the available manuals and other 
literature, and attendance at lectures and courses he should make himself 
acquainted with the essentials of diagnosis and treatment. He should hold 
himself responsible for the instruction of house officers, nurses, and orderlies 
and, in the teaching hospitals, of students, in the methods of treatment ad- 
vocated for casualties due to both the vesicant and pulmonary irritant gases. 
Where staff is short, the cooperation of dental surgeons for assistance with 
oxygen therapy could also be sought. In conjunction with the Medical Superin- 
tendent or Medical Officer in Charge, he should inspect the arrangement and 
equipment of the hospital decontamination center. He should personally super- 
vise the training of a decontamination unit (male and female). He should 
acquaint himself with the storage, source, and reserve supply of oxygen cylin- 
ders. He should procure or improvise sets cf apparatus for the distribution of 
oxygen from one cylinder to several patients. He should ensure that all those 
likely to be concerned understand the use of the nasal catheter, the 3.L.B. 
mask, and the fine adjustment valves and flowmeters, and that there is a suf- 
ficient supply of all these and of rubber connection tubing and glass connections. 
Wherever conditions permit, intimate records of symptoms, signs and 
progress and more particularly of new phenomena and thereapeutic improvements 
should be kept. Section VI 
8 
III. 
Organization 
As with wounds so with gas casualties, "reception and management" may- 
be held to cover decisions in relation, to (a) the grouping or separation of 
cases into categories for special treatment; (b) the initial reception and 
sorting of cases; and (c) the disposal of cases, including suitability and 
optimum time for transportation elsewhere of special types of cases. Such 
decisions clearly require different consideration and arrangements in the case 
of vesicant and pulmonary irritants. 
IV. 
The Reception and Management of Casualties Due to Vesicant Gases 
Although every hospital should have its decontamination center and a 
trained decontamination unit, it should not be called upon to deal with mildly 
or moderately contaminated cases given good cooperation on part of the public, 
the Protection Services and first aid posts and cleansing centers. It should, 
however, expect to handle (a) severely contaminated cases (liquid) or persons 
who have recently been exposed in, or in the neighborhood of, the hospital. 
Of such cases, once decontaminated and in receipt of initial treatment for 
skin and eyes it should be possible to evacuate the majority as stretcher or 
sitting cases forthwith or at an early date, except for those whose associated 
wounds are of such severity as to preclude movement. 
During the hours or days following a local gas attack it is probable 
that other cases than those in the above categories would begin to arrive for 
treatment of developed lesions. Minor skin and eye cases could be treated as 
out-patients or, if desirable on other grounds, evacuated. Admission might 
be necessary for severe or extensive skin lesions. Again, however, the 
evacuation of most of these, excepting the more severe broncho-pulmonary cases, 
should generally be justifiable. Cases in the above categories would be in a 
past that in which further decontamination by washing would be necessary, 
or, ir. fact, of any value. In the case of persons recently gassed and suffer- 
ing from wounds and wound-shock, decontamination should not go beyond careful 
uncrossing with free use of scissors, attention to exposed parts and initial 
t-eshment of the eyes and cutting of obviously contaminated hair if there is 
reason to assume liquid contamination. Once undressed and so treated patients 
would no longer present serious dangers to those working in the operating 
theatres or to other patients or personnel in a ward. .Elaborate protective 
measures for personnel would not be likely to prove necessary after the first 
or undressing chamber. Section VI 
FART III 
OBSERVATIONS REQUIRED IN CASES OF GASSING 
,A.-, OBSERVATIONS REQUIRED-IN ALL -CASES OF GASSING. . ; • • 
f ■ ■ . ■ j „ 
1. A. Cpmpjlet-e clinical record should be kept of all that happens 
.to. a patient .from .the time when he comes under observation until 
he is: dujt of"danger or death occurs. Observations should be 
recorded at the time they are made and the time accurately noted. 
2. So far as possible accurate information should be obtained as 
to the time and place of exposure to gas, the protection em- 
ployed from gas-mask or otherwise and the promptness with which 
it was emp^o^ed,. and the interval elapsing between exposure and. - . 
admi s s i orTTdhOS’pi tal. 
.. 3 • s • Tnp: ppobable pr. proven nature of the gas should be . noted and 
Vp&rtVpuiarp.ascertained as to its mode of.dissemination (shell, 
’ ‘* V/ b6md, ‘ spray) • • • ?■ ■ - . ■: • 
5 M ». * . 
A. The age, sex, physique, and typo, of the patient should be noted - .. • 
* "and Hhe date'and time, of admission, . . .. 
*tr .■ / ; . ... . , ‘ 
. > - . t , >0 . ■ 
- 5?The,' general physical ,and mental,state of the patient on. admission. 
* -Hv -e - • 
6. The temperature, pulse-rate, respiration rate and B. P. should be 
recorded at,four-hourly„intervals unless occasion arises to make 
* ,;/m6fe‘frequent observations or .the patient has so far improved...as-.. - 
' l’( to make frequent readings no longer necessary. . . - - 
7. The occurrence of thirst, nausea, vomiting should bp recorded. 
. ...... ,., . . . -M-iv. , ; v . . - 
’8;v The fluid intake and urinary output should, be’carefully recorded 
and observations made on fluid loss by. sweatingf etc* 
9* The warmth or otherwise of the extremities should be noted. 
10. The urine should be examined daily (spec, grav., albumin, sugar, 
red cells, casts) in the early stages. 
11. The nature of the treatments employed and tho time of intro- 
duction of any of treatment should be entered. 
12. In the event of death the manner of death should be described 
and a detailed pathological report obtained whenever possible. 
B. SPECIAL OBSERVATIONS REQUIRED IN CASES OF GASSING WITH PULMONARY IRRITANTS. 
1. The colour of the patient on admission (blue or grey cyanosis, Section VI 
pallor, etc,) Changes in color and relationship to treatment, 
2, The presence or absence of overfilling of the neck veins. 
3, The type as well as the rate of respirations (shallow, grunting, gasping, 
expiratory or inspiratory difficulty, etc.) 
\ • ' 
4, The amount and character of the expectoration over six-hourly periods. In 
the case of copious serous transudate from the lungs specimens should be 
kept for analysis and microscopic examination, 
5, With as little disturbance to the patient as possible daily observations on 
the auscultatory lung signs and on the size and sounds of the heart, 
6, The methods of oxygen administration, when employed (nasal catheter, B, L, 
B, mask, etc.) and the rate of administration (litres per minute). At 
which stage does oxygen (a) become necessary, (b) do most good? 
7, Other therapeutic measures employed (venesection, posture, drugs, in- 
travenous fluids), 
8, The subjective and objective effects of those methods of treatment, when- 
ever possible avoiding the simultaneous introduction of two or more of 
them. The effects on pulse rate and quality, systolic and diastolic B.P,, 
the state of the veins in the neck, and color and respiration rate of 
oxygen, venesection and posture change especially to be noted, 
C, SPECIAL OBSERVATIONS REQUIRED IN CASES Qfr GASSING YJ'XTH VESICANTS. 
1, The extent, degree and special appearances of the skin lesions on admission 
and subsequent changes in these. If possible color photographs or 
paintings, when comparing local treatments. The.subjective phenomena and 
effects of treatment, 
2, The time elapsing before and after initial decontamination and the methods 
of decontamination employed, , 
3, The local treatments subsequently employed with dates and times of 
initiation'(tannic solutions, sulphonamide, etc.) 
4, The character, degree and special appearances of the eye lesions (con- 
junctivitis, blepharitis, chcmosis, corneal opacity or ulceration). The 
initial treatment employed at time of decontamination and the time of 
this. Subsequent treatments and times and effects on subjective and 
objective manifestations of different treatments compared, 
i ' ! • ' . 
5, The degree and extent of respiratory tract lesions (laryngitis, tracheitis, 
bronchitis and bronchopneumonia). Symptoms and signs and effects of 
chemotherapy in prevention of secondary infection, 
6, In the case of vesicant gases other than "mustard” general and visceral 
effects, and detailed observations on the blood for evidence of haemolysis etc* Section VII 
DECONTAMINATION OF CLOTHING, EQUIPMENT AND MATERIALS* 
’A very essential measure of prophylaxis against injury from mustard 
gas is the systematic decontamination of alL. clothing, equipment, materials 
and other objects contaminated by the gas* Our knowledge of the stability 
of this vesicant, its penetrative power and its persistent character forces 
us to realize that all such clothing and materials will -be dangerous to wear 
or to handle until they have been subjected to some process, active or passive, 
which.will ensure either the destruction or the removal of the mustard gas they 
may contain* - '•••••■* "• ■■ •r .. 
Although the Medical Officer is responsible only for the personal 
decontamination of individual contaminated casualties (i*e*.persons who are 
both contaminated and sick dr injured) who-'come under his care, it. is impor- 
tant' that he be familiar with the general principles on which decontamination 
is based, as the degree of efficacy of a particular process in given circum- 
stances may have a direct bearing on the incidence of mustard gas casulties. 
Satisfactory decontamination is essentially a skilled process, 
hence the personnel employed in carrying it but must be trained for the.pur- 
pose *, .Moreover, they must possess a knowledge of chemical'warfare substances 
and their characteristics if they are to make' effective use of any anti-gas 
measure they may adopt* These measures will vary, in the case of mustard gas, 
according to the'material to bo decontaminated, the nature and extent of the 
contamination, and the environment, the process adopted in a particular case 
being often dependent on .local .conditions and the facilities available*,. 
DECONTAMINATION OF STRETCHER'S.; . • r • , 
•• _ •( . V,'.- ■ •; v, 
If the ordinary pattern of stretcher is splashed with, liquid mustard 
gas it is difficult to obtain complete decontamination,' since the canvas is 
fixed to the. woodwork by a largo number of nails, which renders the removal and 
replacement of the canvas impracticable under field conditions* It is there- 
fore important to adopt all possible mea-sures to prevent contamination occurring* 
Stretchers, when not actually being used, should, therefore, be kept 
under cover (e*g. indoors' or under any improvised roof, tarpaulin, etc*) to 
prevent them being splashed with liquid blister gas* As an additional pre- 
caution the canvas should be covered with a stretcher The stretcher 
panvas may be protected with an improvised of a resistant material such 
Tas heavy building paper* Such improvised covers should be destroyed after use* 
If, in spite of precautions, contamination does occur, the complete 
stretcher should be scrubbed with bleach paste and later washed thoroughly 
with water, after which it should be left to weather as long as possible. 
The handles may not be safe for contact with the bare hands for several days, 
but this difficulty can be overcome by wearing anti-gas gloves* Any danger 
from residual contamination on the canvas can be counteracted by the use of the 
covers described above, • Section VIII 
PREPARATION FOR TREATMENT OF GAS CASES IN A TYPICAL LONDON HOSPITAL 
GAS AT GUY'S ' ’* ' 
SORTING AND RECEPTION OF GAS CASUALTIES 
Sorting 
Cases will be admitted through the War Memorial Gateway, They 
will be unloaded in the passage leading to the Eye Hard, where they 
will be inspected by the Sorting Team, consisting of the Sorting 
Officer (myself or my the surgical interne, if’His,duties 
permit, two stretcher bearers, all wearing protective clothing. The 
function of the Sorting Team will be allocate the patients.as 
follows: ' ' 
1, To the Decontamination Unit, Patients who have been exposed to 
blister gas vapour or liquid and whose injuries are not. so grave 
as to contra-indicate the Vigorous process of cleansing. The.... 
Sorting Officer will append, labels to'these patients as follows; 
■Cl). "Eyes", These patients will be admitted straight to 
' ' the' Decontamination Unit Reception Room, and receive , ' V,. ., 
immediate attention from the Eye H,S, 
■ (2)' Priority”, These patients will-be rushed 
through to the Cleansing Room and subsequently to 
the Reception Room or if possible straight to.the 
Eye Ward, 
(3) "Cleansing Routine”, These patient«-v4.-il--undergo the 
normal- routine of the Reception Room, Cleansing Room 
and Resuscitation Room and will be admitted in due 
course to the Eye Ward, . ; 
2* To the Eye Ward, Patients whose surgical injuries or shock take 
precedence over their exposure to blister gas; They will be passed 
in through the window of the Eye Ward kitchen, relieved of their 
outer garments and boots and if necessary have-their hair rapidly 
shaved before being admitted to the Ward, 
3. To the York Ward, Patients who have been exposed to lung irritants. 
They will be taken in the- Guy1s ambulance to the Borough High 
Street entrance of the York Ward, 
4. To the Out-patient Hall, Patients suffering from the effects of 
tear gas or nasal irritants, or patients■in whom there is no clear 
evidence either of blister gas or lung irritant contamination. Section VIII 
Reception 
1. Decontamination Unit 
(1) Removal of Outer Garments, As far as possible this should 
be done outside by 2 undressers in protective clothing. This 
procedure should be applied only to patients labelled "cleansing 
routine". If the night is dark, if the weather is cold, or if 
the blitz is violent, outside undressing should be dispensed with 
(2) Reception Room 
(i) "Eyes", Cases labelled "eyes" should be taken straight 
to the Eye H.S, who will irrigate the eyes while 2 undressers 
remove such garments as possible, 
(ii) "Cleansing priority". Undressers will remove only 
the outer garments and shoes and send the case through to the 
Cleansing Room immediately, 
(iii) "Cleansing Routine", These cases will be undressed 
as far as possible before being admitted to the Cleansing Room. 
The Reception Room personnel (all wearing full'protective 
- clothing) will consist of 2 outside undressers, the Eye H.S., 
and 4 inside undressers to deal with "Cleansing Priority" and 
"Cleansing Routine" cases, 
(3) Cleansing Room. Here washing will be undertaken under the 
supervision of a House Officer by 2 student cleansers and 2 
nurse cleansers, assisted by a student eye washer (all in modi- 
fied protective clothing.) 
(4) Resuscitation Room. Warmth, hot drinks, reassurance and 
first aid is the function of this part of the unit. The first 
three mil be provided by Sister Broome and her nurses. The 
condition and first aid treatment of the patient will be attended 
to by the surgeon on call, if available, or his deputy. 
2, The Eye Ward. 
(1) From the Kitchen. Cases whose surgical condition demands 
priority will be passed through'the window from the Park and 
dealt with by the H.S, on duty, 2 undressers and a nurse (all 
in full protective clothing). The outer garments and shoes will 
be removed and the hair cut short if necessary. Splashes of 
liquid may need removal and application of anti-gas ointment to 
the affected skin. The eyes may require irrigation, and if 
further washing out is desirable a label marked "irrigate eyes" 
¥/ill be affixed to the patient before he is passed through to 
the v;ard. Patients received from the kitchen should be placed 
in beds immediately adjoining the door and screened off. Section VIII 
(2); From the Decontamination Unit, These cases will be treated 
on their surgical merit. They will be admitted by the door 
adjoining the central staircase. The inquiries due to their 
exposure to blister gas will be treated as burns, other than 
the eye and lung complications, and their wounds will be treated 
by ordinary surgical methods, 
3. The York Ward. 
Cases received here will have been exposed to long irritants 
(phosgene). The more serious cases needing immediate oxygen 
thereapy will be admitted to the female ward, the less severe 
cases aid cases for observation will be admitted to the male 
and childrens’ ward. (These wards will, have been previously 
evacuated),, 
4* Out-patient Hall. 
Cases which have been brought in through the War Memorial Gate- 
way as suspected gas casualties, but'which are considered by 
the Sorting Officer to have been exposed neither to blister 
gas nor to long irritants, will be admitted through the Park 
entrance to-the Out-patient Hall and dealt ,with as necessary. 
Labelling of Gas Contaminated Case... 
Labels of four different colors' have been prepared: 
Yellow (for Mustard) - Cases which are to pass through the Gas 
Decontamination Unit, . ■ 
... . 
Red (for Blood) - Surgical Priority cases for patients whpfse 
or general condition demand immediate resuscitation 
and contra-indicate their passing through the process 
• of gas decontamination, • 
Blue (for Cyanosis) - Lung Irritant cases. 
White - Cases v/hich have probably not been contaminated and which are 
to be sent to the Out-patient Hall for observation 
The first two types of label are divided by two perforated lines 
into three parts. On each of these three parts is printed the classi- 
fication of the case, as follows: 
Yellow. ”Gas Decontamination Unit, Cleansing Routine,” ’ 
Patients whose injuries do not preclude their being sub- 
“mitted to the routine of gas decontamination, 
,"Gas Decontamination Unit, Cleansing Priority,” Patients 
who are to be submitted to cleansing, but whose injuries 
or condition demand that resuscitation should not be unduly 
delayed. These cases will be treated with priority by 
Outside Undressers and in the Reception and Cleansing Rooms, Section VIII 
"Gas Decontamination Unit, Irrigate Eyes,” 
Patients whose recent contamination of "the""eyes either with 
liquid or with vapour demands imnediate irrigation. Irri- 
gation is commenced by the Eye H.S, in the Reception Room 
and is continued in the Cleansing Room by the Eye Washer. 
Red, "Surgical Priority," Patients whose outer clothing and 
shoes jonly are to be removed before immediate admission to 
the ward* 
"Surgical Priority," Irrigate both! while the outer clothing is being 
removed and after they reach the ward. 
These labels, each of the three parts of which are marked with 
a serial number, are used in the following way: 
Yellow, (Gas Decontamination Unit) 
1* The whole label is .affixed in the sorting station to the 
patient’s coat, 
2* When the outer 'clothing is removed one portion of the label 
is torn off and accompanies the discarded bundle of cloth- 
ing into the decontamination bin. The rest of the label is 
clipped bn to part of the remaining clothing, 
, 3# When the rest of the plothing is removed the second 
portion- of the-•label--is' torn off and accompanies the bundle 
of underclothing into the decontamination bin in the re- 
ception room, "This bundle is placed in a numbered canvas 
bag, and a disc bearing the corresponding number is hung 
round the patient’s neck, .. 
4# The remaining portion of the label accompanies the patient 
to the cleansing room and finally to the resuscitation room, 
5. In the resuscitation room a record is kept in a book, 
showing the patient’s the number bn the label and the 
number on the disc. This will facilitate the patient 
regaining his clothing after it has been decontaminated. 
Red, (Surgical Priority) 
1, The whole label is affixed in the sorting station to the 
patient’s coat, 
2, When the outer clothing- .is removed one portion of the 
label is torn off and accompanies the discarded bundles 
of clothing into the decontamination bin. The rest of 
the label is clipped onto part of the remaining clothing, 
3, When the rest of the clothing is removed the second portion 
of the label is torn off and*accompanies the. bundles of undei 
clothing into the decontamination bin in the ward, 
4# The remaining portion of the label is kept with the rest of 
the patient’s records. The serial number pn label will en- 
able the ward sister to identify the patients clothing after 
it has been decontaminated. 
July 1941 
P.H.F. Bishop 
Deputy Superintendent Section IX 
The following is a series of articles on gas warfare 
considered appropriate for newspaper publication* Section IX 
WAR GASES 
No, 1 
In this series of articles on attempt 'will be made to tell you about war 
gases, what they are, how they act, how injury may be prevented and something 
about the organization which has been, or is being, set up in your community to 
protect and care for you if ga$ is used, f. . ..... f > .. 
i 
This is especially necessary as the general public is misinformed as to the 
dangers incident to the use of war gases, and, since we are all part of the "front 
lines", it is necessary that the true facts be known. 
Our military experts tell us that it is unlikely that gas will be used on the 
Civilian population* Despite the increasing range and capacity of aircraft the 
idea of a gas attack on such a scale as to cause injury to a substantial portion 
pf the population of a large city is regarded as fantastic, Sven in limited 
areas gas, to be highly effective, must be used in great quantities. 
Gas might be used in an attack upon a city either alone or in conjunction 
with other weapons. The better the people are trained and equipped to deal with 
gas the less likely it is that gas would be used against them. 
Quick-acting types of gases may be used against a town or city to produce 
immediate casualties, throw the population into a state of panie and disrupt their 
Protective Services, Slow-acting types, which may remain effective for several 
days in a liquid form, may be used to "contaminate" important factories, railroads, 
highways, etc, to prevent their use. Such gases could be sprayed or sprinkled from 
airplanes in the form of a fine rain or they may be contained in bombs dropped from 
planes, 
WAR GASES 
No, 2 
Some of the war gases are liquids at ordinary temperatures. As evaporation 
take place the vapors given off may cause injury to those in the neighborhood. 
Some of the gases may "contaminate" an area for several days or even weeks, depend- 
ing upon the weather. They will evaporate more rapidly if the weather is hot. 
Such gases are known as "persistent" gases. 
Other war gases are released as vapors or evaporate almost at once. They 
are quickly acted upon by currents and eddies of air which rapidly break up the 
gas cloud. Such gases are said to be "non-persistent," 
Each group is composed of several members but all war gases have one character- 
istic in common: So that they will remain close to the ground they are all heavier 
than air. In addition all the known war gases act either on the skin or the lungs 
or both. 
We have all heard reports about new all-powerful gases against which there 
would be no protection, or against which our present gas masks would be ineffective* Section IX 
Such reports are without basis in fact. There are many gases commonly used in 
industry which are more injurious than any of the known war gases but, for one 
reason or another, none are suitable for use in the open. Furthermore, our 
gas mask is a very versatile piece of equipment and it is doubtful if a gas will 
be developed against which it will prove ineffective. 
The soldier in the field cannot leave his post or seek shelter if gas is 
used against him. To do so would permit the enemy to advance through his lines. 
The civilian, on the other hand, can, if gas is used, take shelter in such a 
way as to eliminate most -of the danger. Even after contact with gas the 
exposed person can do a few simple things for himself which will in most instances 
prevent serious injury if carried out promptly. These procedures will be dis- 
cussed in a later article in this series. 
’ 1 ‘ _ ' WAR GASES 
No. S l; r •. • - • •• ,J ' 
The "persistent” gases (those which will remain in (’’contaminate”) an 
area for a long time) will burn the skin* or.injure the lungs or eyes. The two 
principal members of the. group, are mustard and lewisite• They will remain in 
an area for several days or weeks depending on the weather. The presence of gas 
can usually be detected by its odpr, The sense of smell is the best gas.detector 
known. ' " . rV!;v, ..... * • •- .■';.••• 
Mustard gas; .The_vapors given-pff: by mustard gas smell like garlic or 
horseradish. The gas can be smelled in very low-concentrations, even in 
concentrations below that capable of producing injury. Of course if one stays 
in even a very low concentration for a long enough period of time injury may 
result. 
Mustard gas will penetrate any porous material in time. It will be held 
•away from the body by heavy clothing for a short period. The clothing, once it 
has been penetrated by the gas, is a source of danger because it will hold the 
gas in intimate contact with the skin. 
Even if no steps are taken to neutralize the gas following exposure to 
mustard vapor it is usually r4 to 6 hours or longer before any.discomfort is 
experienced. The person may then have a sensation of smarting or burning much 
the same as if he had been sunburned,.: His eyes will smart, burn, and water as 
if they had tobacco smoke in them. He may have a mildly sore throat, a nasal 
discharge and cough, much the same as the symptoms of a common cold. If 
exposure has been more severe blisters will appear in the ’’sunburn”, the eyes 
will burn and water more and,.the. ’’Common cold” will be quite troublesome. If 
severe -injury is sustained all the symptoms will be exaggerated but this should 
rarely occur if prompt steps are taken upon exposure to mustard gas vapor. 
The person may come in contact with liquid mustard either by brushing against 
an object'covered with it or some of the droplets may fall on him during a raid. Section IX 
Should this occur the injury will be more Severe at the point of "contamination" 
but should'not be as extensive as with a vapor burn. Of course if the individual 
stays in the area he will have a vapor bum as well. Even with liquid mustard 
there will seldom be any symptoms for one or two hours. A blister usually appears 
rather promptly after symptoms develop from a liquid injury. 
Unless the amount of liquid is very great the burn will be’about like that 
caused by an equal amount of'very hot grease. It-will take somewhat longer in 
healing than the grease burn,but should cause no greater alarm. 
If liquid mustard should got in the eye it will cause serious damage unless 
it is washed out immediately. Any person who has gotten liquid mustard in his eye 
after rendering first aid to himself must be seen by a doctor. Obviously injuries 
by falling droplets of liquid mustard should be few and far between if the in- 
dividual will remain under cover during a gas attack. 
Lewisite is very similar to mustard gas in its action. It smells like 
geraniums but causes a biting sensation in the nose even in very low concentrat- 
ions. Symptoms resulting from, lewisite injury develop more rapidly than those 
following exposure to mustard and are of about the same degree of severity. 
Lewisite contains arsenic, however, and this will cause poisoning if it is 
absorbed in any amount. 'Any person having a blister following exposure to 
lewisite must be seen and cared for by a doctor. Tho organization of the 
Emergency Medical Services for the care of gas victims will be described later. 
Any person who gets liquid lewisite in his eye must immediately wash his 
eye and then bo seen by a doctor. 
WAR GASES 
No. 4 
Tho lung irritants: 
Most of tho lung irritant gases that wo know about are "non-persistent” - 
that is, they are quickly diluted by air to such on extent that they arc in- 
capable of causing injury. Chlorine, which has a pungent odor; phosgene, 
which smells like fresh cut hay; and chlorpicrin, which has a sweetish odor 
like fly paper, compose this group. 
Of the non-persistent gases the one most likely to be used is phosgene. 
If there" is a moderate amount of phosgene in the area, there is often a "catch- 
ing of the breath" and a sense of tightness in the chest on breathing the gas. 
Other than this momentary discomfort, the victim may have no symptoms for as 
long as twenty-four hours. If injury has been mild, there may be some in- 
crease in the breathing rate. The injured person becomes drowsy and falls 
asleep. When he wakes, he feels quite refreshed. He will probably have some 
tightness in his chest and have a cough. Section IX 
4 
With more serious injury, the victim will breathe hard in an effort to 
get more air, A bluish color may creep into his face, first appearing about 
the lips and gradually spreading. 
With the injury caused by the lung irritants, there is .an impairment in 
the ability of the lung to absorb oxygen. 
It is therefore necessary that nothing be done to increase the victim’s 
need for oxygen, A person exposed to a lung irritant must be kept at absolute 
rest - he must not be permitted to get out of bed for twenty-four to forty- 
eight hours, even if no symptoms develop. 
If any symptoms develop, even those indicating only slight injury, the 
injured person must be cared for by a doctor. 
With proper rest and care, such as is available in our modem hospitals, 
death should seldom occur following exposure to tho lung irritant gases. 
Complete recovery will occur in tho vast majority of cases. Research shows 
that those who recover from the injuries caused by these gases are no more 
susceptible to pneumonia and tuberculosis than others. 
Tear gas and sneeze, and vomiting gas are non-persistent agents which may 
be classed as "Harmless Nuisance Gases," We shall discuss them as a group. 
Symptoms come on very promptly after exposure to one of them. Tear gas 
causes smarting and watering of the eyes, thus interfering with vision. By 
getting out of the area, facing the wind and holding the eyes open, the symp- 
toms will quickly disappear. Do not rub or bandage the eyes. 
Sneeze and vomiting gases cause considerable distress which is always of 
a temporary nature. Following exposure the nose should be washed out with a 
solution containing a teaspoonful of baking soda to a glass of luke-warm 
water. This will neutralize much of tho agent and make the victim more com- 
fortable, Severely gassed persons may require a short period of bod rest. 
WAR GASES 
No. 5 
In this article we shall discuss how, by following a few simple 
rules, injury by war gases may be prevented or modified. If mustard 
or lewisite are used, the most serious injuries will result from the 
liquid agont. Therefore, during a raid, remain inside, or go inside if you 
are outdoors, to prevent the liquid reaching you. 
You will recall that we said that the war gases are heavier than air so 
that they will cling to the ground. You can got away from the vapor, then, by 
going to the upper floors of a building and by avoiding basements and other 
low places* Even after the raid it is bettor that you remain within a building Section IX 
on the upper floors than that you try to get out of the gas area. You 
will not know in what direction you should go. It would be better for you 
to get a little "sun bum" than to run through an area where there was a lot 
of liquid mustard. Your air-raid warden will guide you to safety when it is 
safe- for you to move. 
SELF AID, IN A GAS. ATTACK 
1. Self aid is the best aid for the prevention'1 of'Injuries due to war 
gases* * War gases are usually not dange.-rous it\ you take steps immediately to 
remove then from the skin and eyes,* j$ff active. mekns to accomplish this are 
in every kitchen and bathroom*, 
4 ’ * ' * ' * • ‘ r •• . * . 
2*. If you are- inside a building, remain there and go upstairs, for 
war gases cling to 'the -ground*' . Do net leone your house unless it is 
absolutely necessary* If you. are outside and not able to get indoors 
immediately, walk - don't run - to get out of the gas area* Avoid puddles 
of liquid agent, basements, valleys and other low places* 
3* If you have been exposed to a,war gas** , 
’; a,» ’ Breath through cloths wot. with.-baking soda solution* 
b* If you can’got inside. a, building do so,, but first remove 
your outer clothing and leave it outside* 
c* Wash your hands and then your face with laundry soap and water* 
d* Wash your eyes at once with a large amount of a solution of 
■ baking soda* one teaspocnful of baking soda in a glass; of 
■rr ■ “ ■ -water.. .■ »■ " 
e* Take a bath using plenty of laundry soap, ; 
f* Wash your eyes again with baking 'soda-solution* 
4* If splashes of liquid gas have gotten on you- 
a. Using snail pieces of cloth, cleaning tissues or toilet 
paper blot up as much of the liquid as you can} being 
careful not to spread it, 
b* Daub the contaminated area with clothes wet with Clorox 
Purex, Sani-Chlor, etc. 
o* Steps b, -and d in-3 above. • -- • “• 
'' :' . • 4- • > h v *' • ’ ■ : CV .* ’' ’ • 
5* Never get excited* Lie down and cover yourself with a blanket 
Medical aid is on the way. There is no immediate serious danger from 
exposure to any known war gas. Section IX 
WAR.GASES 
No. 6 
The Anti-Gas Organization in your City-s 
The anti-gas organization in your city is divided into two parts. 
In association with the casualty stations and hospitals of the 
Emergency Medical Services, facilities are being developed to remove 
"persistent” gases from injured people. This is necessary so that 
they will not carry the gas into the hospital. The average person can 
"decontaminate" himself as wo described in a previous article. These 
special facilities should bo reserved for those who have other injuries 
as well. The personnel needed to nan these stations are now being 
trained. 
As we described, the "persistent" gases nay remain in an area for 
days or weeks making it dangerous. To cope with this situation, decon- 
tamination squads have been organized in the Department of Public Works# 
These squads are equipped with street flushing machines, brooms and 
special spraying apparatus. They have been or will be furnished with 
special chemicals which can be used to destroy "contaminating" gases. 
They are being trained in techniques required for their work. 
A senior gas officer should be appointed from one of the established 
municipal agencies, preferably the Health Department. This man will be 
responsible for giving technical advise as regards the work of decontam- 
ination squads. He will also be responsible for the identification of 
the gas which has been used and will mark out the gassed area. He will 
also give technical advice about the care- of food and water which may 
have been exposed to gas. He will supervise the handling of clothing 
which has been contaminated by persistent gas., He will, of course, 
select and train others to help him with his work. 
Courses have been conducted through the auspices of the War 
Department Civilian Protection Schools and the Office of Civilian 
Defense for the training necessary in the various branches of the gas- 
protection services. While all members of the services have not 
attended, a sufficient number have now been instructed to act as teachers 
of others in most of our exposed cities*