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Appendix

Contents

APPENDIX

817

THE PHYSIOLOGICAL EFFECT OF WARFARE GASES ON THE HUMAN BEING INCLUDING SYMPTOMATOLOGY, PATHOLOGY, AND GENERAL TREATMENT a
[Compiled by medical adviser of the chief of Gas Service, A. E. F.] FEBRUARY 8, 1918.

The employment by the enemy of poisonous gases as a means of offensive warfare makes it imperative that all medical officers should have some knowledge of the actions of the important gases used and of the rational lines of treatment which may be adopted in cases of gas poisoning. To that end the following notes are offered. It must be thoroughly understood that the enemy is constantly introducing new gases or combinations of gases, and that new conditions may arise which will make it necessary to modify many of the statements herein published.

With few exceptions the general symptoms of all asphyxiating gases are similar; so much so that these symptoms will be enumerated as a whole.

Mustard gas, however, presents so many different phases of the subject that it will be treated separately. There are also a few differences between the physiological effects of chlorine and phosgene.

Phosgene upon meeting moist surfaces is broken up, and hydrochloric acid liberated. It excites less spasm in the upper respiratory tract, thereby making it possible to penetrate to the innermost recesses of the lungs, where it causes an irritant edema, which may be, and often is, delayed an hour or more in its action. There is also much greater tendency to circulatory failure and the features suggestive of general collapse are more in evidence. Mustard gas produces serious burns due to direct contact with the gas. The most dangerous burns encountered are those of the respiratory path; these differ from the burns of phosgene in that they are in the tipper respiratory passages. Most patients suffering from mustard-gas poisoning are subject to secondary infection. There is never present the enormous effuson of serum occurring in phosgene.

There is no fundamental difference between the effect of gas shells and that of cloud gas, though there may be slight differences owing to attendant circumstances. Due to higher concentrations, the deaths from phosgene and chlorine clouds are about four times as much as from the same gases from artillery shell. All gases are capable of producing multiple symptoms. On the one hand, there is the immediate irritant, corrosive, and poisonous action of the gases; on the other, the remote effects due to the disturbance of gaseous exchange and secondary infections which are favored by the damage to the respiratory organs and to the specific toxic action due to the disorganiza- tion of the tissue elements in consequence of the corrosion.

The degree of the symptoms produced depends upon (1) the concentration of the gases, (2) duration of its action, (3) the effectiveness of the protective contrivances (respirators, masks, etc.) and the method of their employment.

The natural resistance of the soldier and his general health must also be carefully considered in connection with these cases. No hasty conclusions must be drawn from first observations of the patient for the reason that the action of the concentrated gas for a short period may cause the most intense corrosion though but small amounts of the poison may have been absorbed in the blood; again large amounts of the poison may have been absorbed in the blood with but little evidence of corrosiveness. Again mild cases of poisoning can be readily transformed into the gravest symptoms as a result of bodily activity, foul, dirty air, or as a consequence of the onset of secondary infection.

In treating cases suffering from gas poisoning the following must be carefully considered: Actions of the gas or vapors on-
1. The skin.
2. The eyes.
3. The mucous membrane of the air passages and tissues of the lungs.
4. The blood and the circulatory organs.
5. The nervous system.
6. The digestive organs.
7. The urinary organs.

a Copy on file, Historical Division, S. G. O.


818

As a rule, the first place in which the violent action of the gas is evident is in the air passages and in the alveoli of the lungs. The irritation is immediately followed by an inflammatory reaction characterized by congestion, by swelling of the mucous membrane, and by increased secretions in the air tubes, edema, and inflammatory formations.

With nearly all gases there can be expected attacks of coughing and burning pain in the chest, a feeling of pressure and breathlessness, which may come on at once or which may often be delayed for several hours according to the kind and concentration of the gas. In slight cases the symptoms may be limited to these and disappear during the course of 24 hours. In the more severe cases the distress becomes intolerable. The patients wail, groan, struggle for air, and toss themselves restlessly about. Their color varies from bluish red to the deepest cyanosis; breathing rapid and shallow, and becomes in the later stages irregular and faltering. The initial dry coughing soon begins to furnish a copius sputum, thin, fluid in character, albuminous, frothy, and often blood stained. There may be marked emphysema of the lungs, crackling râles, and diminished breath sounds. The body temperature rises from 102° to 105°, which generally occurs on the second and third days, accompanied by signs of bronchopneumonia of a greater or less severity. The breathlessness and cyanosis become more intense, and signs of resonating and crepitant râles can be found scattered throughout the lungs.

As a rule, however, the bronchopneumonia which appears during the first day or two and which seems to be due directly to the action of the gas and not to bacterial infection does not prove fatal save in a few cases. The symptoms usually disappear with a fall in temperature after a few days; usually, in fact, after two or three days. Those due to the action of harmful warfare gases on the lungs are considerably influenced by disturbances of the circulation, which are apparently caused by the diminished supply of oxygen to the blood.

DIGESTIVE APPARATUS

Gassed cases complain very frequently from the beginning onward of loss of appetite pain in the stomach, malaise, and nausea. Frequently the pain in the region of the stomach may last several days following recovery from gas poisoning. Diarrhea, with occasionally blood in the stools, is less frequent.

CIRCULATION

The ordinary phenomena in asphyxia of mechanical origin is that the blood pressure rises and that the heart soon loses its full driving power because its muscle can not maintain this increased effort when it is working with a scanty supply of oxygen. Consequently the pulse rate quickens, the right heart dilates, and the blood tends to pool up behind it in the veins. If this failure proceeds a pace, a patient who at the beginning showed congestive cyanosis of the face, with a full pulse, will gradually assume a gray pallor, while the pulse accelerates and falls off in power. These changes are augmented by the edema of the lungs, which directly obstructs the pulmonary circulation and causes an earlier failure of the right heart.

If the patient during this critical period tries to perform his work, he will use up still more rapidly the little oxygen that he is receiving, extra work will be loaded onto a heart which is already overstrained, and the circulation will be likely to fail still more speedily on account of the difficulty of maintaining compensation in the upright position.

URINARY ORGANS

In general no symptoms are shown in the urinary organs. Occasional cases of difficulty of urination or of retention of urine are found, but these may be attributed to nervous influence. The quantity of urine is not materially altered, while the color generally remains normal.

PROGNOSIS

A prognosis can only be made with the greatest caution in the first few hours. The majority of cases may be grouped straight away into classes: Mild, moderately severe, and severe. As a rule the quite trivial cases and the quite hopeless cases may be quickly recog- nized. It must not, however, be forgotten that cases which appear slight may suddenly develop very severe symptoms, and cases that exhibit the most profound asphyxial symptoms or the deepest unconsciousness may, after the lapse of only a few hours, give the impression of being out of danger. In these later cases, as a rule, the improvement is but transitory.


819

DIAGNOSIS OF MUSTARD GAS CASES

It is not necessary to spend much time on the diagnosis of these erythemas, bullae, or even upper pharyngo-laryngeal disturbances, which are sufficiently typical to be recognized without any definite etiological information. When the burns are limited to the face or the arms, one may think of the uncharacteristic burns due to a jet of liquid fire or some explosive. But in this latter case the lesions are very much deeper and the pain much more accentuated.

There should be no difficulty in recognizing the erythema; but perhaps the erythema of the eyelids, bullous or not, might be taken for an intense erysipelas; or the erythema of the back and extremities for a scarletina or prevariola rash, but the fever is absent. On the other hand, if limited to the face there is no glandular involvement; if limited to the extremities, even though most marked on the flexuous surfaces, there is no red mottling and it is smooth to the touch, with scattered white spots or minute droplets, like bullae , visible only in a tangent light.

A study of the eosinophilia of the blood may be of real importance. If it occurs in erysipelas or in scarletina, it is late and not marked. On the contrary, it occurs early in toxic erythema (Loeper).

One of the important points of this poisoning is its resemblance to certain artificial dermatites, due to the criminal appliance of different caustics. The alkalies make soft. the acids hard, eschars, which are single or few in number, darker in color or very much deeper than the lesions produced by these gases. The lesions produced by croton oil are somewhat analogous; also those produced by the essence of mustard, the nature of which perhaps is not very different. Apart from the limitation of the process in the cases of malingering and its extent in the intoxications, which we are considering, there is no sure means of diagnosis, the more in so much as eosinophilia exists in both cases.

The first isolated cases of burns which were seen in French hospitals, chiefly the ones who had a well-limited and almost rectangular phlyctene, might have been, and perhaps were, considered as cases of voluntary mutilation, and the blister may have been taken for a cantharides blister.

Finally, the pigmentation, so characteristic, described above, gives a most important means of diagnosis, for we do not know of any so intense, so extensive, so constant, so deep in color in the dermatites.

POST-MORTEM FINDINGS FROM CHLORINE AND PHOSGENE

In a case of death at 24 hours after gas poisoning, the trachea and bronchi are purple red and congested, while a thin exudate wells up into them from the lungs. The latter organs are heavy and edematous, while areated islets of emphysematous over distension alternate with depressed purple patches of collapse. On section, serous fluid drips abundantly from the lung tissue. Air that has escaped from ruptured vesicles is seen in chains of bubbles on the surface of the lungs, along the interlobar fissure, and even penetrating the tissue of the mediastinum. In some of the earliest cases the most intense disruptive emphysema may be observed, destroying the air sacs and interfering with the circulation of their walls.

Petechial hemorrhages appear on the surface of the lungs, on the heart, and also on the inner surface of the stomach. All the veins are greatly distended and the abdominal viscera are engorged with dark blood that clots very early after death. The heart itself may fail to show right-sided dilatation, for this does not of necessity appear post-mortem in cases of asphyxial death.

If the man succumbs at a later date, inflammatory complications appear in the lungs. There is superficial pleurisy, scattered bronchopneumonia, and a purulent secretion in the bronchi. The serous exudate will then be found to have disappeared and no fluid drops from the cut surfaces of the lungs.

POST-MORTEM FINDINGS FROM MUSTARD-GAS POISONING

Skin lesions.- Usually very superficial and do not involve the deeper layers.
Mouth and throat.- The mucous membrane shows various stages of an acute inflammatory process, from a simple reddening to swelling, excoriation, ulceration, and sloughing of the membrane. The larynx is usually severely affected and the cords may be ulcerated. Large sloughs are common.


820

Thorax.- Pleural effusions of moderate degree have been reported, but are not the rule.
Lungs.- Cases dying within the first six days frequently show marked pulmonary edema, with superficial hemorrhages and emphysema. Areas of septic destruction of the lung tissue may be found.
Pericardium.- Occasionally contain a small amount of clear serous fluid.
Heart.- Tough and firm ante-mortem clots sometimes found, especially in right auricle and extending to large vessels and right auricle. Myocardium, as a rule, appears normal.
Abdomen.- Stomach may show zones of acute congestion and sometimes submucous hemorrhages. Intestines similar changes as stomach.
Liver.- Signs of fatty infiltration; organ enlarged.
Spleen.- Nothing.
Kidneys.- Capsule strips easily; may be fatty.
Brain.- May show signs of congestion.
Blood.- Increase in its coagulability reported.

TREATMENT

General considerations.- In discussing the general treatment of gas poisoning in warfare, several things must be considered: The nature of gases used; the manifold symptoms and varying severity of different cases; and the place where treatment is to be administered, whether in the trench, dugout, field ambulance, evacuation, base, or general hospitals. It must also be remembered that, on the one hand, there is the immediate irritant, corrosive, and poisonous actions of gases, and that, on the other, there are things consequent with disturbance of gaseous exchange as well as on secondary infections which are favored by the damage to the tissues of the respiratory organs. The specific toxic action of disorganized tissue must also be considered.

As a rule, however, whenever much definite discomfort or grave symptoms are evident, the principles of treatment are as follows:
1. To diminish the respiratory activity of all gassed cases so far as possible.
2. To improve the supply of oxygen.
3. To combat the pulmonary edema and inflammatory changes in the lungs.
4. To keep the circulation going.
5. To promote the excretions of poison from the body.
6. To prevent the onset of secondary infections.
7. To alleviate the pain and discomfort.
8. To keep the patient warm.

Rest.
- (1) Respiratory activity of the organisms depends mainly on the degree of muscular activity. The greatest care must therefore be taken to prevent any muscular exertion in all cases. Such cases must not be allowed to walk, either alone or with assistance, but should be carried on stretchers whenever possible. All equipment that hinders the play of the respiratory muscles, such as belts, braces, etc., will be removed.
(2) There is obviously no treatment that can be directed against the effects of the chemical on the respiratory membrane. The only effective treatment thus far recognized is-
First. To diminish the amount of blood serum available for this effusion, Which is done by bleeding, and by restricting the intake of water. Bleeding is done at the very earliest opportunity, and 2 pints of blood removed as rapidly as possible.
Second. To give oxygen in high concentration. This is most economically and com- fortably done by a catheter in the nose, which delivers oxygen in the nose pharynx. The subcutaneous injection of 0 is useless.
Third. To place the patient with head lower than feet to aid in draining the serum that accumulated in the trachea and large bronchi.
Fourth. To produce artificial respiration if necessary.

Special stimulants and drugs.- Ammonia is very useful as an inhalation, but in using this drug care must be exercised not to apply its fumes too near the face. It should be discontinued as soon as labored respiration is noticeable.
Atropine has been used extensively by the British and French, with a view to checking the secretion of fluid.
Digitalin, 1/100 grain, hypodermically, has been used to some extent, but not very successfully.
Morphia, ½ grain, is most useful as a sedative.
Strychnine, 1/40grain, has been used in later stages of collapse.


821

TREATMENT FOR MUSTARD-GAS POISONING

In view of the special characteristics of mustard-gas poisoning, the following additional notes are given relative to the treatment of these cases.

Before discussing this subject, however, it might be well to review briefly some of the symptoms and special characteristics of this important gas.

The principal effects of poisoning from mustard gas may be summed up as follows:
First. Irritation and vesication of the skin and mucuos membranes, conjunctival, laryngeal, pharyngeal, etc., which are caused for the most part by the actions of the acid vapor.
Second. Bronchopulmonary complications, which seem to result from secondary complications.
Third. The importance that soiled clothing plays in relation to this poison.

In considering the treatment for this poison, each of the above must be carefully considered and studied.

From our knowledge of the clinging properties of this gas to clothing, it can be seen that prior to administering treatment of any kind the infected clothing must first be removed and gotten rid of. Next the body must be cleaned. This is best done as follows: Sponge the entire body, including scalp, with warm water, soap, and brush, bicarbonate of soda 20 per 1,000, or lime water 1 per 1,000. After drying, the patient should be issued clean clothing. The infected clothing should be soaked in bicarbonate of soda solution for a half hour, rinsed in clean water, and hung out to dry.

All persons coming in contact with mustard-gas cases should have their hands protected with gloves, and as an extra precaution, must bathe all exposed surfaces with bicarbonate of soda solution at the conclusion of their duties.

When possible a special building or tent should be used for the first treatment of these cases, thus avoiding infecting others.
Treatment of the eyes.- Wash the conjunctiva with a solution of bicarbonate of soda 1 per cent strength, then treat them with a little sterile oil. In washing the eyes use a syringe or douche cup, opening the eyelids wide, inverting them if possible, and paying particular attention to the condition of the corners. This treatment should be administered several times daily. In milder cases the most troublesome complication is usually the photophobia resulting from burns of the eyes, and the only treatment in these cases is protection against the light.
Treatment of mucous membranes.- The nasal and pharyngeal mucous membranes should be thoroughly cleansed with bicarbonate solution. In severe cases, with persistent cough due to ulcers of the trachea, the condition is best treated by steam inhalations and cough mixtures.
Gastrointestinal complications.- Regulation of the diet is of the utmost importance--a milk diet or, if necessary, plain water diet. The internal administration of 20 grains of bicarbonate of soda is often beneficial.
Respiratory symptoms.- Eucalyptus inhalations and fumigations should be used early, relieving the patients; acting as antiseptics, they appear to prevent secondary infections which affect the respiratory system.
Gas respirator.- To prevent air-borne infections, the wearing of a respiratory mask made from aluminum, perforated, and made to fit over the mouth and nose and retained in place by means of small strings in which is placed absorbent cotton saturated with the following solution:

RMenthol ................................................................................................40 grains.
Chloroform.
Creosote...................................................................................................aa.. 2drams.
Tr. iodi.........................................................................................................1 dram.
Sp. vini rect. qs. ad ...................................................................................2 ounces.
M. Fifteen drops on wool of mask every hour.
Cutaneous symptoms.- Blisters should be pricked with antiseptic precautions. The following dusting powder will be beneficial:
R Talcum powder .......................................................................................400 grams.
Carbonate of lime.
Carbonate of magnesia.
Oxide of zinc ..........................................................................................aa.... 200 grams.


822

Dust freely over parts and cover with a nonabsorbent wool. Compresses soaked in limewater may also be used. The main object in view is the neutralization of the gas, and the sooner this is accomplished the better will be the patient's chance of early recovery.

NOTE.- At present efforts are being made to neutralize the effects of the gas by giving intravenous injections of hexamine (urotropin), which looks very favorable.

H. L. GILCHRIST,
Lieutenant Colonel, Medical Corps, U. S. Army.

THE 28TH DIVISION

HEADQUARTERS FIELD HOSPITAL COMPANY No. 110,
OFFICE DIVISION MEDICAL GAS OFFICER,
28TH DIVISION, A. E. F.,
September 1, 1918.

REPORT OF GAS CASUALTIES FROM AUGUST 5 TO AUGUST 31, 1918

1. In submitting this report of gas casualties admitted to this hospital from its opening on August 5 to August 31, 1918, 1 desire to invite your attention to the attached scheme, which will, I believe, readily give all information concerning cases admitted from the 28th Division, as well as all other divisions represented in the casualties.
2. By referring to the scheme, it can readily be determined, for instance, how many casualties were admitted from Company D, 109th Infantry, by reason of: b
(1) Allied gasses (phosgene, chlorine, chloropicrin, and the chlorarsine compounds); (2) mustard gas; (3) evacuations; (4) returned to duty; (5) totals, both per company and regimental.
3. It will be noted that casualties were admitted from a number of divisions other than the 28th and are included in the report; also that the following order of entry is carried out: (1) Infantry; (2) Artillery; (3) machine gun battalions; (4) Engineers; (5) military police; (6) field signal battalions; (7) Medical Department; (8) American Red Cross; (9) antiaircraft machine gun battalions; (10) French.
4. So far as is known, no new gasses were used by the enemy during the recent operations, and we can only attribute the large number of casualties covering this report of 26 days as being due to the fact that many of the men were experiencing their first prolonged exposure to gasses, and not understanding the effects of this type of weapon nor being able to differentiate between a short inhalation of a slight concentration and the slight inhalation of a more concentrated gas; consequently many men, when they first felt the slightest constriction of the chest with some disturbance in breathing and eye involvement, considered themselves gassed and became somewhat panic-stricken. Hence their first instinct was to resort to the hospital for relief; when, instead, a few hours' removal from the gassed areas would have been sufficient to have returned many of them to duty.
5. This in a measure will explain the large number of cases admitted to the hospital and returned to duty after a 24 to 38 hour duration. It must be remembered, however, and consistently considered, that many of these men were in a state of fatigue or on the borderland of exhaustion during the early period of days embodied in this report, and this factor would in a considerable measure have an influence directly encouraging a possible psychic condition.
6. Interrogation of many patients revealed the following causes of casualties: (1) Asleep in dugouts during and following gas bombardments; (2) "gas-clear" alarm sounded and respirators removed too soon; (3) defective and improperly fitting respirators; (4) lying on gassed ground; (5) lying on gassed blankets and in gassed clothing; (6) failure to change clothing after knowledge of having received splash of mustard gas; (7) explosion of gas shells close by and not sufficient warning to adjust respirators; (8) wearing respirators without facepieces on, only mouthpieces and nose clips being used; (9) respirators knocked off during engagement or excitement; (10) failure to adjust respirator; (11) testing for gas by one noncommissioned officer given as cause for his being gassed (eye case).
7. We feel that while gas casualties are bound to occur, there is no doubt manv could have been avoided by greater precaution and stricter adherence to gas discipline.
8. During the first 6 days after the opening of the hospital all cases were evacuated after various periods of rest and treatment ranging from 24 to 36 hours. After the first 6 days, severe cases alone were evacuated and the remaining cases were returned to their commands after periods ranging from 12 hours to 5 days in the hospital.
_
b Only four organizations are given below, with totals for all, the purpose being merely to show the method employed for reporting astialties.- Ed.


823

9. By reference to the attached scheme it will readily be noted that the large number of cases returned to their commands; that the measure alone of holding and treating these mild cases has retained for the division a considerable number of its fighting force. Of casualties retained and treated, the following comprises an approximate list: (1) Over 80 mustard-gas burns of first, second, and third degree were returned to duty, cured; (2) approximately 200 eye casualties were returned to duty, cured; (3) approximately 200 slight chest involvement cases were returned to duty, cured; (4) 40 cases of aphonia (loss of voice from laryngeal involvement) returned to duty after 4 to 5 days' treatment; (5) 11 cases of epistaxis (nosebleed) due to mustard-gas inhalation returned to duty; (6) effort syndrome (D. A. H.) 15 cases returned to duty; (7) venesection (bleeding) 17 cases returned to duty, all mustardgas cases, severe.
10. The average stay in hospital of all cases returned to duty has been three days. A number of aphenic cases were returned to duty before entire return of voice. This was done for a twofold purpose: (1) To overcome a notion in the minds of a number of these cases that their voices would not return, thereby overcoming a possible permanent psychic influence. (2) Since the aphonia is purely functional and not organic, and all physical distress having disappeared, together with the fact that these cases linger in the aphonic state for periods ranging from two to three weeks, it was decided that the man could do duty with his command and thus be of service to the division without any material injury to himself, treatment having but little beneficial effect after the first four or five days, depending upon, of course, the presence or nonpresence of ulceration.

HOWARD C. HARPER,
Captain, Medical Corps, Divisional Medical Gas Officer.

CHART


824

Total admission...............................................1,422
Evacuated ........................................................ 849
Returned to duty................................................550
Remaining............................................................ 23

THE 90TH DIVISION

TRIAGE, 90TH DIVISION, A. E. F.,
France, November 15, 1918.
From: The division medical gas officer.
To: The division surgeon.
Subject: Final report.

1. I am handing herewith a brief summary of the work accomplished in medical gas defense in this division. Also a complete report of gas casualties occurring in the division from August 25, 1918, to November 15, 1918, inclusive.

2. The organization of the medical gas defense in the 90th Division was begun and accomplished and some difficulties. The work was not undertaken until the division had taken over its sector in the St. Mihiel salient. Only a few medical officers and noncommis- sioned officers had had the advantage of a course of instruction at the gas school. After having been designated division medical gas officer, organization and instruction of the medical officers and the enlisted personnel of the Medical Department of the division was immediately begun. The division being very short on transportation, and the tables of organization providing none, made it next to impossible to accomplish anything at the outset. There was also great difficulty in obtaining antigas supplies, drugs, oxygen, etc. This difficulty was overcome later by the division medical supply officer, and an ample supply of everything was obtained so that modern treatment was available in every instance. The transportation problem was overcome by the division surgeon detailing his own side car in the beginning and later detailing one exclusively for this work.

Field Hospital No. 358 was designated as the division gas hospital. The officers and enlisted men of this institution were instructed and drilled in degassing and treatment of gas casualties, members of the personnel impersonating patients.

The officers and personnel of the ambulance companies were instructed in the degassing and treatment of gas casualties at the ambulance dressing stations. They were also instructed in the transportation of these cases.

Regimental and battalion surgeons, their enlisted personnel, and litter bearers were instructed in first aid to the gassed. This was all accomplished while the division was holding the sector, and instruction was kept up during and after the drive of September 12 and 13, 1918.

Full and complete instructions covering every conceivable detail in the handling of a gas casualty, from the time he was picked up in the field until he was discharged from the hospital, was published by your office and sent to every medical officer in the division.

It was found that each medical officer was alert to the situation; and after the organization was completed, each mustard case had had eyes, nose, and throat irrigated, armpits and genitals bathed with alkaline solution at the battalion aid station (one battalion surgeon handling over 150 such cases in one day). At the ambulance dressing stations the degassing of these cases was completed, so that on arrival at the division gas hospital practically every mustard gas case had been degassed.

In order to keep sufficient antigas supplies at the battalion aid stations an antigas kit was devised. An ambulance food box was marked "antigas equipment" and filled with the necessary articles required in administering first aid to the gassed. Each battalion surgeon was issued one of these kits. Each ambulance carried one at all times, and a stock of these kits were kept on hand at the division medical supply depot. Exchanges were made in the usual way.

During the activities on both fronts only two cases were brought to my attention that were not gassed. A second lieutenant who hadl pulmonary tuberculosis and gave no history of gas; the other a cook who was promptly returned to duty. Not only did we not have gas malingerers in the division but we had many men who fought with their mouthpieces anil nose clips adjusted, eyes being exposed (because of fogging of eyepieces), and who later


825

developed trouble with their eyes, reported to battalion aid stations for treatment and voluntarily returned to duty. Also on one occasion when a battalion suffered more than 150 casualties the remainder of the battalion continued to do duty until relieved from the St. Mihiel salient. On reporting in the Meuse sector the battalion surgeon requested that this battalion be examined to ascertain its fitness for active field service. It was found by a board of medical officers (appointed by the division surgeon) that 3 officers and 130 men had suffered to such an extent that it was necessary to evacuate them from the division. None of these men had reported to the battalion aid station while in the St. Mihiel sector.

The type of gases employed by the enemy varied. He usually employed lacrymators and stenutators well mixed with diphosgene. The division was subjected to two severe mustard-gas bombardments while in the St. Mihiel sector. There were 460 mustard-gas cases as the result of the bombardments. Little mustard was used by the enemy in the Meuse sector, only 59 cases occurring, all of which was by contact and none by inhalation.

Nearly all cases of gas poisoning by inhalation were caused by gas shells bursting near men who were caught unawares without their respirators adjusted or by the men removing their masks because of the fogging of the eyepieces. Many men were gassed during advances when they took refuge in fresh gas shell holes. There were some inhalation cases developed by men being in extremely low concentrations of gas for a long period of time and, not realizing the danger, did not adjust their masks.

In the St. Mihiel sector no case was evacuated from the division until he had been under observation at the gas hospital one week or longer and only when it appeared that it would require weeks for him to recover. Neither was a case sent to duty until he had been up and about 24 hours and tested for "effort syndrome." This resulted in few cases being returned from their command.

The only disaster inflicted by the enemy occurred in the early morning of September 27, 1918, when he secured a direct hit with a diphosgene shell on a dugout in which our men were sleeping. The men were caught unawares and evacuated the place through a valley that had been previously shelled with mustard gas. All these men were, therefore, gassed first by inhalation of diphosgene, and those who were unable to adjust their masks also got mustard by inhalation. All were severely burned. Under the circumstances the men nec- essarily received heavy concentrations of both gasses. The prompt evacuation of the area and the prompt evacuation of the men to the gas hospital where they received heroic treatment no doubt saved the lives of many. There were 17 fatalities.

A visit to the gas hospital at Toul, and later to La Morlette, revealed the fact that all cases evacuated from the division were of moderate severity. At the time of the visit no deaths had occurred among men from this division.

There was a total of 1,390 gas casualties in the St. Mihiel sector, 844 of which were returned to duty from the division gas hospital, 529 evacuated from the division, and 17 fatalities. There was a total of 785 gas casualties in the Meuse sector, 10 of which were returned to duty from the division gas hospital, and no fatalities, making a grand total of 2,175 gas casualties occurring in the division during all of its activities, 854, or 39.27 percent, being returned to duty, 1,304, or 59.95 percent, were evacuated from the division, and 17 fatalities, or 0.78 percent. The large number of evacuations from the Meuse sector was due to the rapid advance making it impossible to hold cases sufficient length of time in the division gas hospital. The low percentage of fatalities was due to gas discipline, prompt and proper evacuation, early and definitive treatment.

This being the final report from this office, may I not express my appreciation of the whole-hearted cooperation on the part of the division surgeon, all regimental and battalion surgeons, medical officers of all ambulance companies, the division medical supply officer and the officers and men of Field Hospital 358.

(Signed)
CHARLES M. HENDRICKS, Major, M. C.
[First indorsement]
HEADQUARTERS 90TH DIVISION, 0. D. S.,
AMERICAN EXPEDITIONARY FORCES,
France, November 16, 1.918.

To the Chief Surgeon, A. E. F.
(Through commanding general, 90th Division.)

1. Forwarded. Attention invited to the excellent record in the treatment of gas cases in this division. A mortality of only 0.78 percent of the total cases is the best index of the efficiency of the training of the personnel, both in gas discipline and the intelligent handling of those gassed.


826

2. I wish to commend the work of Maj. Charles M. Hendricks, M. C., through whose efforts the medical personnel of the division reached a high degree of proficiency in the treatment of gas cases.

P. S. HALLORAN,
Colonel, Medical Corps, Division Surgeon.


REPORT OF CONSULTANT IN GENERAL MEDICINE FOR GAS POISONING
OFFICE OF THE CHIEF CONSULTANT,
MEDICAL SERVICES, AMERICAN EXPEDITIONARY FORCES,
U. S. ARMY, P. 0. 731,
France, December 17, 1918.

From: Consultant in general medicine for gas poisoning.
To: Chief consultant, Medical Services, American Expeditionary Forces.
Subject: Report of activities of section of gas poisoning.

1. According to instructions contained in letter from chief surgeon, American Expeditionary Forces, to the director of professional services, American Expeditionary Forces, of November 16, 1918, following report is submitted:

2. The activities of the section of gas poisoning have been as follows:
(a) Instruction.
(b) Treatment and hospitalization.
(c) Actual supervision of the care of the gassed.

3. Instruction was carried out either by circularization or by lecture. Circular No. 34, chief surgeon's office, which had to do with the treatment of gassed patients, was prepared in this office. Other circulars in regard to the treatment of gas poisoning were from time to time prepared in this office. Either the consultant in general medicine, in charge of gas poisoning, or other representatives of this office gave lectures on the subject of the care and hospitalization of the gassed. These lectures were given to medical officers either in divisions or at the Army sanitary school at Langres.

4. The large question of the hospitalization and of treatment of gassed patients, especially in division and army areas, was given much study. An endeavor was made by advice and conference with those in authority to emphasize the important but simple principles involved and to achieve their acceptance throughout the American Expeditionary Forces. After comparatively little study it became obvious that the question of the care of the gassed was largely an administrative one. From the clinical point of view the question is simple. The diagnosis of the two main "gas diseases"--i. e., the "suffocative gas disease" and the "vesicant gas disease"--offers little difficulty. Also the treatment is simple and only calls for the exhibition of a sound knowledge of medicine and of ordinary common sense.
Stress has always been laid by this office on the importance of early bleeding in those poisoned by suffocating gases. From clinical observation it is deemed probable that bleeding is the one most important factor in the successful treatment of these conditions; second in importance is the inhalation of oxygen administered through the proper apparatus.
The treatment of those poisoned by vesicant gas is purely symptomatic, and the main bject has been to impress upon medical officers the necessity of not overtreating these cases. It has been the aim of this office to disseminate a knowledge of the simple essentials of the treatment of the gassed.

5. The question of the hospitalization of the gassed was a more complicated one. Like the wounded soldier, the gassed soldier needs early examination and treatment, and it soon became obvious that each division in active warfare must have a mobile gas hospital as a part of its sanitary train. This need was met by utilizing one field hospital per division which was supplied with the necessary extra equipment to care for the gassed. Much correspondence and conference with those in authority finally led to a simple and standard equipment which could be used in divisional gas hospitals. The matter of the secondary hospitalization of gassed cases was complicated by the promulgation of the principle that gassed cases were not to be cared for in evacuation hospitals (fourth indorsement to letter from senior consultant in general medicine to chief consultant, Medical Services, May 7, 1918), although it was recognized that the gassed need special care in a hospital at the level of the evacuation hospital, quite as do the wounded.


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The application of this principle led to the establishment of special hospitals for the gassed. During the actions which preceded the St. Mihiel and Argonne-Meuse battles there were no special hospitals for the care of the gassed. Gassed cases were passed through the evacuation hospitals rapidly and often received their first hospital treatment at the bases, a system which was unsatisfactory at best. In the St. Mihiel action one gas hospital was established at the Justice hospital center at Toul and one in the French gas hospital at Rambluzin. The personnel of these hospitals was composed of casuals or of officers and men loaned from base or evacuation hospitals, ambulance companies, etc. In each hospital one officer thoroughly conversant with the principles of the care of the gassed was stationed. At Toul, Lieut. R. M. Wilder, M. C., was in charge of the care of the gassed, and at Rambluzin Lieut. D. P. Barr, M. C., was director. The consultant in general medicine for gas poisoning had general supervision of the clinical work in both hospitals.

6. During the battle of the Argonne, five hospitals were designated by the chief surgeon to receive gassed cases. These were:
Capacity beds
Rambluzin..................................................................250
La Morlette ...............................................................550
Julvecourt .................................................................400
Rarecourt ..................................................................250
Villers-Daucourt ......................................................200

The officers and personnel of these hospitals as in the previous action, were largely casual officers and men from ambulance companies, evacuation hospitals, etc. Early in September, 1918, the consultant in general medicine for gas poisoning was appointed director of gas hospitals in the First Army by verbal order of Lieut Col. L. C. Garcia, M. C., representative of the chief surgeon, First Army. He acted in this capacity until the cessation of hostilities on November 11, 1918. Lieut. D. P. Barr, M. C., was made commanding officer and clinical director of the hospital at Julvecourt, and Lieut. R. M. Wilder, M. C., held the same position at Rarecourt. These hospitals were both enlarged by the addition of tentage and became the most important gas hospitals in the area.
It is proper here to point out the very high character of the services rendered by these two officers. Their commands were new to the gas problem and inadequate in numbers, yet they developed their hospitals to a very high degree of efficiency, exhibited talent for leadership and administration, in the meantime directing the clinical work of the hospitals. Their enthusiasm lent a fine spirit to their respective organizations, and under their command these two hospitals attained a high state of efficiency.
After the first rush was over these five gas hospitals carried on the care and treatment of the gassed in an eminently satisfactory manner. It was unfortunate that, owing to a shortage of nurses, only two nurses were available for use in these gas hospitals during the period from September 26 to November 11.

7. These hospitals received upward of 20,000 patients from the 26th of September, 1918, to the 11th of November, 1918. The cases were about equally divided between those who had been actually exposed to gas and those who, though they entered the hospital with a diagnosis of "gassed," had in all probability never been exposed to toxic warfare gases. The bulk of gas cases were due to mustard gas (dichlorethylsulphide), a small proportion were due to suffocative gases (phosgene or chloropicrin) and many were due to the inhalation of mixed gases (sneezing or tear gas, with or without one of the lethal gases). The large, number of cases who could not be classified as "gassed" were due principally to exhaustion neuroses, light respiratory infections, or other unimportant conditions. The great proportion of these men could have been returned to duty without having left the army area had the proper machinery for this existed. In order that these light cases shall be returned to duty, rest camps must exist. Only one of the three corps in the First Army established a rest camp where men presumably fit for duty could be returned from the gas hospital and be further observed and tested before returning to the replacemnent battalion and the line.
One corps had a replacement battalion and no rest camp, while the third had neither replacement battalion nor rest camp. With this imperfect machinery it is natural that large numbers of men who could have been returned to duty perforce were evacuated to the bases.

8. The effect of the treatment received in the army gas hospitals during this period on the condition of the men sent to the bases was apparent. There were found in the bases less


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serious eye conditions than ever before, burns of the skin were in better condition, and cases of lung involvement were received in better general condition. Each case of definite pulmon- ary irritation was considered as a possible pneumonia and was held at the gas hospital for observation and treatment until it was deemed safe for the case to be evacuated.

The lessons learned during this period lead to the following conclusions:
(a) At least 1,000 beds for gas cases should be provided for each corps during active mobile warfare such as that of September and October of this year.
(b) To facilitate evacuation and to economize personnel, not more than one hospital to a corps area is considered advisable. Experience has shown that the principle of having gassed cases cared for in special isolated hospitals is not a wise one. These hospitals were usually far from a railhead, and off the main traffic routes. This necessitated much extra ambulance carriage, and increased the length of time that patients were in the ambulances. As no provision for gas hospitals was found in the Tables of Organization, these scattered units had to be operated as annexes to evacuation hospitals. This arrangement complicated the administration of these hospitals, and required duplication of administrative personnel. Experience has shown that the recommendation to the effect that gassed be cared for in evacuation hosptials with augmented equipment and personnel, made in the letter of May 7, 1918, from the senior consultant in general medicine to the chief consultant, Medical Services, was sound, and should be accepted as a guiding principle in the matter.
(c) The personnel of gas hospitals should be proportionately the same as that of an evacuation hospital. The staff of medical officers need not be large; no surgeons are necessary. A chief of Medical Service expert in the problems of the diagnosis and treatment of the gassed and in the sorting of those presumably fit for duty is essential. The rest of the officers may be young men of ordinary capacity. Nurses are absolutely necessary for the proper care of the gassed.
(d) In order that men may be returned to duty, rest camps where the men may be observed for a time and tested by simple exercises to determine their fitness for duty are necessary. Whether the rest camp shall be under the immediate management of the corps or of the army is still open to discussion. Attention is invited, however, to the fact that while divisions change rapidly and frequently from one corps to another, they do not as frequently or as rapidly leave an army area. For this reason it would appear that the army would be able to return the men to their proper organizations better than could the corps.

10. In June, 1918, after conference between the medical director of the Chemical Warfare Service, American Expeditionary Forces, the chief consultant, Medical Services, American Expeditionary Forces, and the consultant in general medicine for gas poisoning, it was recommended that each division have one officer whose especial duty was to take charge of the organization of the treatment, care, and evacuation of the gassed within the divisional areas. The officer was to be known as the divisional medical gas officer. This recommendation was accepted and authorized by General Order No. 144, paragraph 8, subparagraph (b), August 29, 1918. Owing to the late date at which the divisional medical gas officers were authorized, many divisions never received the full benefit of the services of such an officer. In those divisions where an officer functioned as medical gas officer the care of the gassed immeasurably improved.
It is impossible to leave this subject without mention of Capt. Jasper Coghlan, M. C., who, under the authority of Col. J. W. Grissinger, M. C., functioned as medical divisional gas officer to the 42d Division and later as medical gas officer to the First Corps. Owing to the wisdom, foresight, and energy of this officer, the care of the gassed has been, first in the 42d Division and later in the organizations passing through the First Corps, the best in all the American Expeditionary Forces. It is the opinion of the writer that Captain Coghlan performed a most distinguished service and exerted a most important effect in the development of the early treatment of the gassed in the divisions throughout the American Expeditionary Forces.

11. Little is known of the late results of gassing. We do not know whether any of these men will become permanent invalids or not. It was hoped that opportunity would be found to study these cases in France, so that this qluestionm, which will be an important one to the Nation, might be definitely decided. The changes incident upon the cessation of hostilities defeated this aim.


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It is therefore recommended that a sufficiently large group of soldiers who are in Class B, C, or D as a result of gassing should be sent to United States General Hospital No. 9, at Lakewood, N. J., for study and treatment. This office is ready to undertake the selection of these cases, and to supply the personnel necessary for the work. The transfer can be arranged by the system of tagging now in operation at United States Base Hospital No. 8, Savenay.

RICHARD DEXTER,
Lieutenant Colonel, M. C.

REPORT OF MEDICAL GAS WARFARE BOARD

AMERICAN EXPEDITIONARY FORCES,
HEADQUARTERS SERVICES OF SUPPLY,
OFFICE OF CHIEF SURGEON,
October 31, 1918.

Memorandum for Col. H. L. GILCHRIST,
President, Medical Gas Chemical Warfare Board.

In connection with Special Orders 291, paragraph 128, the chief surgeon desires that the following subjects be carefully considered and that recommendations be made covering the same:
1. Methods to segregate gas cases from malingerers or suspected gas cases.
2. Standardize the equipment for treating gas cases in the following:
(a) Camp infirmaries (par. 867, M. M. D.).
Regimental hospitals (par. 872, M. M. D.).
Ambulance companies (par. 874, M. M. D.).
Field hospitals (par. 879, M. M. D.).
Camp hospitals (par. 886, M. M. D.).
Evacuation hospitals (par. 891, M. M. D.).
Base hospitals.
Hospital trains.
(b) In considering these different units, recommendation will be made for such additional equipment to treat gas casualties, in all cases the equipment to be assembled as separate and distinct so that it can be removed at any time.
3. Consider the equipment for medical officers in treating gas cases in the advanced areas at the base.
4. Consider the equipment for the enlisted men of the Medical Department on duty with advanced units at the base.
5. Consider the subject of publishing orders dealing with the handling of gas cases from the time they are subjected to the fumes of poisonous gases until finally disposed of.
6. Consider the subject of awarding wound chevrons for men gassed; if entitled to chevrons for being gassed, should a time element be considered.
7. Consider the subject of training the troops in first aid to the gassed, etc.

WALTER D. MCCAW,
Colonel, M. C., United States Army,
Chief Surgeon, American Expeditionary Forces.

AMERICAN EXPEDITIONARY FORCES,
HEADQUARTERS, FIRST ARMY,
November 5, 1918.

From: The medical gas warfare board, American Expeditionary Forces.
To: The chief surgeon, American Expeditionary Forces.
Subject: Report of meeting.

1. In compliance with Special Orders 291, paragraph 128, General Headquarters, Ameri- can Expeditionary Forces, October 18, 1918, copy herewith inclosed, the medical gas warfare board of the American Expeditionary Forces convened at headquarters, First Army, November 5, 1918, all members of the board being present.


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2. Letter of instructions from the chief surgeon of the American Expeditionary Forces to the president of the board and subjects to be considered were taken up and action taken as follows:

Paragraph 1. All gas cases received at divisional gas hospitals should be examined by the personnel of the hospital; all doubtful cases should be referred to the division medical gas officer, who shall consult with the division psychiatrist where there is any question of gas, shock, or exhaustion. After a maximum period of 24 hours those cases showing no symptoms of contamination with gas shall be returned to duty. All cases showing signs of the toxic effects of gas shall be evacuated to army gas hospitals, where a redistribution shall be made in the shortest possible time to either base hospitals, battalion replacement stations, or corps rest hospitals. This procedure is deemed necessary in view of the fact that approximately 80 percent of the cases received at the field gas hospitals are suffering from causes other than gas; i. e., shock and exhaustion, influenza, etc.

Paragraph 2. One field hospital in each division shall be designated as a gas hospital. Additional to equipment C for field hospitals, Medical Department Manual, 1917, paragraph 897, certain extra equipment will be supplied to these hospitals. One additional truck must be provided to carry this additional equipment. Appended is a list of extra equipment needed for the care of gassed in the different stations and hospitals in divisional and army areas.

Paragraph 3. In the advanced area medical officers shall carry, in addition to regulation equipment, 1 box of ammonia ampules; medical officers at base need no extra equipment.

Paragraph 4. It is recommended that noncommissioned officers in all organizations in forward areas be required to carry 1 box of ammonia ampules for the first aid to suffocative gas cases. Instruction in the use of above will be given by division medical gas officers. No extra equipment required at base.

For enlisted men, in excess of the present equipment, 1 box of ammonia ampules is required; for all litter bearers, 1 M-2 French mask, in addition to the box respirator, is to be carried and to be applied to casualties who are unable to retain the mouthpiece of the box respirator.

Paragraph 5. Space in present report too limited for detailed requirements of paragraph 5. It is suggested that special circular to division medical gas officers be issued through the medical director, Chemical Warfare Service, to the chief surgeon, American Expeditionary Forces.

Paragraph 6. Covered by separate report.

Paragraph 7. No remarks.

MEDICAL GAS WARFARE BOARD,
H. L. GILCHRIST,
Colonel, M. C., United States Army,

H. H. M. LYLE,
Lieutenant Colonel, M. C., United States Army,

RICHARD DEXTER,
Major, M. C., United States Army,

JASPER COGHLAN,
Captain, M. C., United States Army.


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CHART- List of extra equipment needed for the care of gassed in the different stations and hospitals in divisional and army areas a


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APPENDIX No. 8 c
AMERICAN EXPEDITIONARY FORCES,
HEADQUARTERS FIRST ARMY,
France, November 5, 1918.

From: The medical gas warfare board, American Expeditionary Forces.
To: The chief surgeon, American Expeditionary Forces.
Subject: Wound chevrons for gassed cases.

1. In compliance with Special Orders, 291, paragraph 128, General Headquarters, American Expeditionary Forces, October 18, 1918, the medical gas warfare board convened on November 5, 1918, for the purpose of considering the question of the awarding of wound chevrons to men who have been gassed.
2. After carefully considering the subject, it is the opinion of the board that those who have become actually incapacitated from the effects of enemy warfare gases through no fault of their own should be given the same recognition as those who have been wounded. It is, however, the opinion of the board that certain restrictions must be made in awarding wound chevrons to gas casualties, for the reason that under the present system of award many men who have never been incapacitated by enemy gas are wearing the distinctive mark of those wounded on the field of battle.
3. In order that wound chevrons may be justly awarded, it is recommended that no soldier be given a wound chevron who has not been treated in an army hospital for a period of at least 10 days, and then only on the recommendation of the commanding officer of such hospital or hospitals.
4. It is further recommended that this principle be retroactive for the period during which the American Expeditionary Forces have been on active duty in the present conflict.

MEDICAL GAS WARFARE BOARD,

H. L. GILCHRIST,
Colonel, M. C., United States Army.

H. H. M. LYLE,
Lieutenant Colonel, M. C., United States Army.

RICHARD DEXTER,
Major, M. C., United States Army.

JASPER COUGHLAN,
Captain, M. C., United States Army.

LIST OF ARTICLES REQUIRED BY DIVISIONS FOR THE TREATMENT OF GAS CASES e GENERAL HEADQUARTERS,
AMERICAN EXPEDITIONARY FORCES,
France, June 27, 1918.

Memorandum to those concerned from representative of the chief surgeon with G-4, G. H. Q.

These articles should always be immediately available, and preferably turned over in bulk to one of the field hospitals of each division which under present conditions is specially designated for the treatment of this class of cases. It should be pointed out that we can not wait until gas cases begin to flow in before ordering up this necessary equipment. It should be furnished at once and kept at the front in the hospitals mentioned.

CHART
_
c This part of the report of the medical gas warfare board appears as an appendix. p. 170. Vol. II, History of Chemical Warfare Service, American Expeditionary Forces.-Ed. * For other supply lists see pp. 76, 77, 831.- Ed.