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Chapter III

Contents

CHAPTER III

Chemical Warfare

George R. Greenwood, M.D.

    Although active chemical warfare was never initiated in World War II preparation for it was begun early by various agencies of the Federal Government and was continued on an increasing scale until the end of the war with Japan. This was only logical. It was well known that the enemy was equipped to institute this kind of warfare. Furthermore, the argument was frequently heard that the U.S. Army would be justified in instituting it in order to prevent unnecessary casualties among its own troops. Had either of these contingencies come to pass, it would have been the responsibility of the Medical Department to care for the casualties of chemical warfare. Even before the United States entered the war, therefore, planning along these lines had been undertaken

CHEMICAL WARFARE BRANCH, OFFICE OF THE SURGEON GENERAL

    When the United States entered World War II, the Army Medical Department owned and financed, but did not operate, the medical laboratory at Edgewood Arsenal, Md. (fig. 9). This laboratory, which conducted research studies on the treatment of casualties caused by chemical agents, maintained liaison

FIGURE 9. - Army Medical Laboratory, Edgewood Arsenal, Md.


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with the Chemical Warfare Service of the Army and kept The Surgeon General informed on current developments. At that time, no medical officer was assigned to his office.1

Appointment of Medical Liaison Officer

    After 7 December 1941, when the possibility of chemical warfare became an acute reality, the volume and pace of the work done at the medical laboratory at Edgewood Arsenal increased, and a corresponding need arose for direct representation of the Chemical Warfare Service in the Office of the Surgeon General. To meet this need, Lt. Col. (later Col.) John R. Wood, MC,2 chief of the medical laboratory at Edgewood Arsenal, was appointed to the Surgery Division, Office of the Surgeon General, on 21 May 1942, and was officially designated as liaison officer representing The Surgeon General to the Chemical Warfare Service.3 On 18 December 1942, however, Colonel Wood was transferred to Edgewood Arsenal, and, from then until August 1943, there was no representative from the Office of the Surgeon General to the Chemical Warfare Service.

    In November 1942, when research in chemical warfare was being expanded rapidly in response to the potentially urgent need of the Arm, three groups were engaged in the study of the medical aspects of this type of warfare, as follows:

    1. Office of Scientific Research and Development had two committees at work in this field. The National Defense Research Committee investigated the effects of new chemical agents. Clinical studies were conducted when they were practical, and the agents were studied experimentally, by observation of the physiologic mechanisms involved and the possible immunochemical reactions. The Committee on Medical Research developed methods of treatment for chemical injuries.
    2. The Medical Research Laboratory, Edgewood Arsenal, in addition to carrying out a variety of peculiarity military scientific functions, made studies similar to those made by both the committees of the Office of Scientific Research and Development. In other words, the functions of the former duplicated those carried out by the civilian agency.
   3. The Medical Department of the Army had the responsibility of treating injuries due to toxic and incendiary agents.

The development of chemical agents and the protection of troops against them was the responsibility of the Army Chemical Warfare Service.

1Office Order No. 87, Office of the Surgeon General, U.S. Army, 18 Apr. 1941.
2 Office Order No. 175, Office of the Surgeon General, U.S. Army, 1 June 1942.
3 Letter, Chief, Medical Research Division, to Commanding General, Edgewood Arsenal, 10 July 1942, subject: Medical Research Division, Edgewood Arsenal, Md.


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Permanent Organization

   Chemical Warfare Service. - Reorganization was effected by the creation of the Medical Division, Chemical Warfare Service, the director of the Division being made directly responsible to the chief of that Service.4 The research laboratory at Edgewood Arsenal, which had been controlled and financed but had not been operated previously by the Medical Department of this Army, was transferred to the Chemical Warfare Service and became an integral part of the new Medical Division. The Division was activated on 3 July 1943, 5 though the transfer of the laboratory to it was not effected until 15 July 1943.6

The newly created Medical Division had several missions, as follows:

    1. Its medical mission was to carry out such research work as was necessary to develop adequate methods of treating injuries due to toxic and incendiary agents likely to be used in war.
    2. Its toxicologic mission was to study the biologic effects of these agents and to develop adequate measures for the protection of troops against them.
    3. Its liaison mission was twofold. First, it was to maintain such close contact with civilian laboratories, particularly with laboratories receiving financial support from the Office of Scientific Research and Development, as would make possible the utmost practical application of the work done in them in the fields of chemical warfare. Second, it was to keep The Surgeon General completely informed on all medical aspects of chemical warfare.

   Office of the Surgeon General. - To permit the performance of the latter mission more effectively, the Chemical Warfare Branch was established in the Surgery Division, Professional Service, Office of the Surgeon General, on 12 August 1943, with Maj. (later Lt. Col.) Albert McG. Johnston as its head.7 The functions of the Branch were (1) to maintain liaison with the Medical Division, Chemical Warfare Service, Army Service Forces, on matters pertaining to chemical warfare as related to the Medical Department of the Army, (2) to prepare information concerning, and directives for, the care of casualties caused by chemical warfare agents, and (3) to assist in the planning of field equipment used in the prevention and treatment of chemical warfare casualties.8

The new distribution of functions assigned to the Chemical Warfare Branch. Office of the Surgeon General, certain responsibilities which had here-

4 Memorandum for file, 29 Apr. 1943, subject : Proposed Medical Division for the Chemical Warfare Service. Submitted by representatives of the Chief, Chemical Warfare Service, and The Surgeon General.
5 Office Order No. 48, Office of the Chief, Chemical Warfare Service, Army Service Forces, 3 July 1943.
6 Letter, D. C. Sapp. Adjutant General, Office of the Adjutant, Army Service Forces, to Commanding General, Chemical Warfare Center, Edgewood Arsenal. Md., The Surgeon General, and Chief, Chemical Warfare Service, 5 Aug. 1944, subject : Transfer of Medical Department Research Laboratory, Edgewood Arsenal, Md.
7 (1) Office Order No. 572. Office of the Surgeon General. U.S. Army. 12 Aug. 1943. (2) Organization Chart. Office of the Surgeon General, U.S. Army, 3 Feb. 1944.
8 Manual of Organization and Standard Practices, Office of the Surgeon General, Army Service Forces, 15 Mar. 1944.


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FIGURE 10. - Maj. George R. Greenwood, MC, Chief, Chemical Warfare Branch, Surgical Consultants Division, Professional Service, Office of the Surgeon General, and Consultant to The Surgeon General.

tofore belonged to the Chemical Warfare Service. One of the most important was the preparation of literature on first aid for, and on treatment of, gas casualties and on the detection of chemical agents in food and water. This branch was also assigned the provision of equipment to implement the procedures described. The literature issued and the equipment specified were based on recommendations made by the Medical Division, Chemical Warfare Service.

    Major Johnston, the first consultant for the newly established Chemical Warfare Branch, was succeeded in March 1944 by Capt. (later Maj.) George R. Greenwood, MC, (fig. 10) who served until 17 September 1945, when the activities of this branch were suspended.

    Policies. - The basic policy of the Chemical Warfare Branch was to keep fully abreast of all developments in this field which might eventually have some sort of impact on the Medical Department. In line with this policy, Major Greenwood usually paid three or four visits each week to the office of Col. Cornelius P. Rhoads, MC, Chief, Medical Division, Chemical Warfare Service, to discuss current problems relating to projects under way or to


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secure information for articles to be prepared by the Medical Department dealing with first aid or other treatment for casualties of chemical warfare. The Medical Research Laboratory, Edgewood Arsenal, was also visited at least once a week.

    These direct contacts and the intimate knowledge which was thus secured greatly expedited the solutions of many medical problems which otherwise might have temporarily floundered in administrative red tape after they had reached the Office of the Surgeon General. The cooperation received from Colonel Rhoads and from Colonel Wood, chief of the Medical Research Laboratory, Edgewood Arsenal, and later from Colonel Rhoads' successor, was always cordial and useful.

    In the Office of the Surgeon General, Major Greenwood's chief contacts, outside of the Surgical Consultants Division, were with the Technical and Training Divisions, Operations Service, of that Office. The personnel of these divisions were also most cooperative. They offered technical help whenever it was necessary, and they willingly accepted recommendations on medical matters made by the Chemical Warfare Branch.

    Major Greenwood also maintained close contact with research activities of civilian laboratories. He received reports from the National Research Council and the Office of Scientific Research and Development, and he attended the meetings at the University of Chicago, at Rockefeller Center, New York, N.Y., and in Washington, D.C. where the latest research developments were presented.

EQUIPMENT FOR PROTECTION AGAINST GAS WARFARE

    Two important changes were made during World War II in equipment used for the protection and treatment of gas casualties. They had to do with the gas casualty set and the field oxygen equipment.

Gas Casualty Set

    Reports from the Office of the Surgeon General, the Office of the Air Surgeon,9 and the Surgeon, Army Ground Forces,10 as well as verbal discussions with numerous medical officers during the first months of United States participation in World War II, indicated that the gas casualty set which was standard at the beginning of the war was undesirably heavy and unwieldy. A report from NATOUSA (North African Theater of Operations, U.S. Army) in 1943 stated that., because of their weight and bulk, these sets were not carried forward of the most rearward division medical units. Revision of the equip-

9 Letter, Headquarters, Army Air Forces, Washington, D.C., to The Surgeon General, Washington, D.C., 26 Apr. 1943, subject: Gas Casualty Set.
10 Letter, Maj. A. P. Thom, MC, Assistant Surgeon, Army Ground Forces, to Lt. Col. John R. Wood, MC, Director, Medical Research Laboratory, Edgewood Arsenal, 29 Apr. 1943.


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ment to meet these objections was therefore recommended.11 In response, a new, streamlined, light-weight gas casualty set (fig. 11) was developed by the Medical Research Laboratory, Edgewood Arsenal, and was standardized by the Army Service Forces on 9 May 1944. It was described in the July 1944 issue of the Bulletin of the U.S. Army Medical Department.

    The new set weighed only 45 pounds, in contrast to the 160 pounds of the former gas casualty chest. It was made up of a gas casualty treatment kit and two inserts, each of which contained three impermeable aprons and three pails of impermeable gloves. The basic unit (Kit, Treatment, Gas Casualty, Medical Department Item No. 97767) was an expendable item, resembling a small suitcase and weighing only 17 pounds. The contents of the kit were. sufficient to care for the chemical casualties of one infantry battalion during 24 hours of active chemical warfare.

    The new kit had other advantages in addition to its light weight. The rubber gasket lining the seam between the lid and body made it waterproof. Inside time lid was a graphic representation showing the exact location of each item of the contents. A booklet, entitled "Notes on Treatment of Casualties From Chemical Agents," was provided listing the symptoms, pathologic changes, and diagnostic points useful in the management of these injuries. All basic items were provided for the treatment of all varieties of gases likely to be encountered in modern chemical warfare.

    The kit also included equipment for water testing with a book of directions. Small units were thus supplied with a simple device for screening out sources of water so contaminated with chemical agents that they could not be made potable by the usual methods of treatment in the field, such as chlorination in the Lyster bag.

    Before the gas casualty treatment kit reached field units, however, a major change had to be made, which caused considerable consternation in the Technical Division, Operations Service, and in the Supply Service. All of the work on the kit, including its contents, had been carried out before March 1944, when Major Greenwood became chief of the Chemical Warfare Branch. Shortly after his arrival in the Surgical Consultants Division, he was summoned to the office of Col. (later Brig. Gen.) Fred W. Rankin, MC, Chief Surgical Consultant, to explain why a discrepancy existed between the policy of treating burns caused by chemical agents and that of treating those caused by more usual agents.

    The gas casualty kit included a number of tubes of 5 percent sulfathiazole ointment, with instructions that the ointment be used in the treatment of both incendiary and vesicant burns. This policy, however, although it was in accordance with earlier instructions issued by the Office of the Surgeon General, had been changed because of certain toxic effects caused by the ab-

11 Report, Capt. Louis Venet, MC, and 2d Lt. Matt J. Oehlberg, Chemical Warfare Service, undated, Report No. 14, Medical Research Laboratory. Edgewood Arsenal : A Gas Casualty Set for Medical Units.


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FIGURE 11 - Gas casualty set, M-2. A. Soldier wearing complete pack. B. Unit medical equipment pack opened to show packing of (from top to bottom) impermeable apron, impermeable gloves, and complete gas casualty treatment kit, Medical Department item No. 97756. C. Exposed contents (from top to bottom) gas casualty treatment kit, impermeable gloves, and impermeable apron.


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sorption of sulfathiazole when it was used in burns involving large body surfaces. The current policy eliminated the ointment and directed the use of pressure dressings over petrolatum-impregnated dressings. There was no reason, as Colonel Rankin pointed out, why the same policy should not be used in the treatment of gas casualties, it being a well-established fact that burns sustained by vesicant agents did not differ from other burns in any respect, including therapy.

    Major Greenwood, who had just come to the Chemical Warfare Branch in the Surgical Consultants Division from a field unit, could not explain why the changes in therapeutic policies had not been reflected in the components of the gas casualty treatment kits. Fortunately, although the kits had already been manufactured, they were still in warehouses and had not been distributed to field units, so petrolatum could be substituted for sulfathiazole ointment.

    On Colonel Rankin's instructions, printing was also stopped on a revision of War Department Technical Manual (TM) 8-285, treatment of Casualties From Chemical Agents, until the directions in the manual for the treatment of vesicant burns could also be altered.

Field Oxygen Equipment

    In an effort to place in the field sufficient equipment for the treatment by oxygen of the large number of injuries due to lung irritants which might be expected in the event of gas warfare, the Army Service Forces, in March 1944, had standardized apparatus for the administration of oxygen (Oxygen Therapy Outfit, 20 Dual Outlet, with Hose Line Assembly, complete, Medical Department Item No. 9364200) (fig. 12). With this apparatus, a single source of oxygen could be used for the treatment of 20 gas casualties, each of whom would receive 8 liters of oxygen per minute, or for the treatment of 40 casualties, each of whom would receive 4 liters per minute.

    Shortly after this item had been standardized, it became evident that the apparatus was inadequate to furnish 100 percent oxygen to the number of casualties it had been designed to treat.12 A study of accidents at various chemical plants and of the casualties caused by the leakage of chlorine at the widely publicized accident in Brooklyn on 1 June 194413 made this quite clear. Reports from these sources showed that the average respiratory volume of gassed subjects was 10 to 12 liters per minute and that in some instances the volume ranged as high as 15 liters per minute.

12(1) Letter, Director, Medical Research Laboratory, Edgewood Arsenal, to Chief, Medical Division, Office of Chief, Chemical Warfare Service, 16 June 1944. subject: Report of Test on Oxygen Therapy Outfit Hose Line Assembly, 20 Dual Outlets. (2) Letter, Chief, Medical Research Laboratory, Edgewood Arsenal, to Capt. George R. Greenwood, 23 June 1944, subject: Oxygen Requirements of Individuals With Lung Damage.
13 Brooklyn Chlorine Accident, a Technical and Medical Report. Prepared for the Medical Division, Chemical Warfare Service, under contract W-49-036-cws-1 with New York University College of Medicine, 1 July 1944.


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FIGURE 12. - Demonstration of use of oxygen therapy outfit, 20 dual outlet, with hose assembly, at South Post, Fort Myer, Va., October 1944.

    The recommendation of the Medical Division, Chemical Warfare Service,14 that the equipment be modified to provide for an increase in the flow of oxygen, was concurred in by the Chemical Warfare Branch, Surgical Consultants Division, Professional Service, and was forwarded to the Technical Division, Operations Service, for appropriate action on 11 July 1944.15

    It was fully realized, when the recommendation was made, that the increase in the rate of flow permitted by the new apparatus to overcome the deficiencies of the former apparatus would double the logistic and supply problem of the Army with respect to oxygen. The various theaters of operations were notified of the new developments and were offered sufficient supplies of cylinders for their probable needs. Some theaters at once requisitioned large additional supplies. At the same time, steps were taken to increase the number of cylinders allotted to units which had as part of their original equipment the apparatus which had proved inadequate.16

14 Letter, Chief, Medical Division, Chemical Warfare Service, to Office of the Surgeon General, attention: Capt. George R. Greenwood, 5 July 1944, subject: Further Tests of Oxygen Hose Line.
15 Memorandum, Surgery Division, for Director, Technical Division, Office of the Surgeon General, 11 July 1944, subject: Oxygen Hose Line.
16 Memorandum, Capt. George R. Greenwood, Surgical Consultants Division, for Director, Technical Division, Office of the Surgeon General, 12 Dec. 1944, subject : Allowance of Oxygen Cylinders for Gas Team. (2) War Department Table of Organization and Equipment No. 8-126, 11 Nov. 1944.


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    While these developments were taking place, the possibility of the use of liquid oxygen was also being investigated, to determine whether it was practical to use it in the apparatus their standardized. If it could be used, a large volume of oxygen could be provided in a relatively small space, and the heavy, cumbersome oxygen cylinders currently in use could be dispensed with.

    The project was dropped for two reasons. The first was that, contrary to the original belief, the supply of cylinders proved available for all purposes. The second was that liquid oxygen could not be used satisfactorily in equipment then on hand, which did not provide enough pressure for the desired rate of flow. An additional disadvantage was that from 3 to 4 percent of the volume of liquid oxygen was found to be lost during each 24 hours of storage.17

PROTECTION OF PERSONNEL AGAINST GAS

    In World War I, the protection of Army personnel against chemical agents was the responsibility of the Medical Department until the organization of the Chemical Warfare Service in July 1918. In World War II, this task was always the responsibility of the Chemical Warfare Service. The Medical Department, however, was concerned in all aspects of the matter and frequently participated in conferences.

    One of its deepest concerns was the provision of a gas mask which would adequately protect casualties who could not wear the regular Government-issue mask because of head injuries requiring bandages. After several conferences participated in by the Chemical Warfare Branch, the development Branch (Technical Division, Office of the Surgeon General), and representatives of the Chemical Warfare Service, a model for this purpose was selected and was standardized after proper testing.

    Certain shortcomings of this model were recognized when it was adopted. Since it covered the entire head and neck, heat and moisture tended to accumulate within it. Also, there was always a fairly large dead space within it, no matter how carefully it was applied. To meet these objections, the Chemical Warfare Service recommended on 5 December 194418 that a forced draft blower, to be connected to six masks and to serve as a collective protector, should be made part of the head wound gas mask equipment. The Chemical Warfare Branch approved the equipment in theory but suggested service testing.19 When this had been carried out satisfactorily, the Office of the Surgeon General recommended that the equipment be standardized.

17 Report, Medical Research Laboratory, Edgewood Arsenal, to Chief, Medical Division, Chemical Warfare Service, at Oct.1944. subject: Tests of Liquid Oxygen Vaporizer.
18 Letter. Chief, Technical Division. Office of the Chief, Chemical Warfare Service, to Office of the Surgeon General, attention: Lt. Col. John B. Klopp, 5 Dec. 1944, subject: Head Wound Gas Mask.
19
Letter, Chief, Technical Division, Office of the Chief, Chemical Warfare Service, to Office of the Surgeon General, attention : Lt. Col. John B. Klopp. 5 Dec. 1944, subject: head Wound Gas Mask, endorsement thereto, dated 15 Dec. 1944.


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FIGURE 13. - Fitting gas mask inserts (optical lenses) in the field, 69th General Hospital, Mediterranean theater, 1945.

    Masking of helpless patients. - The Chemical Warfare Branch was actively interested in the application of gas masks to casualties who could not apply their own, either because they were unconscious or because they could not use their hands. A standard procedure for this purpose was obviously highly desirable, so that, in the event of gas warfare, masks could be expeditiously applied by hospital and other personnel to this group of casualties.

    The procedure eventually recommended was suitable to the several types of gas masks (fig. l3) then in use (the lightweight service mask, with M-3 and M-4 facepieces, the combat mask, with M-5 facepiece, and the older service mask with M2A1 or M2A2 facepiece) . The technique was described, with illustrations, in War Department Technical Bulletin (TB MET)) 169, issued in June 1994.

DETECTION OF CONTAMINATED FOOD AND WATER

    At the beginning of United States participation in World War II, the Medical Department, although charged with the responsibility of determining the potability of water, did not possess suitable equipment for identifying possible contaminants in it. Two kits were eventually developed for this purpose by the Medical Research Laboratory, working in cooperation with the


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FIGURE 14. - M-4 water-testing kit--post-World War II Chemical Corps modification of the World War II water-testing kit. The World War II Medical Department kit was packed in a wooden box with fittings for all bottles containing liquids.

National Defense Research Committee. One kit (Kit, Water Testing, Screening, Medical Department Item No. 9931000), standardized on 9 July 1943, served as a qualitative screening kit. The other kit (Kit, Water Testing, Poisons, Treatment Control, Medical Department Item No. 99307) consisted of a large suitcase which contained apparatus and chemicals in sufficient quantities to perform quantitative analyses of contaminated water (fig. 14). Instructions for the use of these kits were published in War Department Technical Bulletin (TB MED) 37 on 28 April 1944 and were revised on 30


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August 1944.20 Copies of the original instructions and the revision were placed in each kit.

    Although means for decontamination of food had long been known, no standard equipment was available to determine whether it was contaminated by the agents likely to be used in chemical warfare. It was therefore not possible to determine either the degree of contamination or the efficiency of the decontamination procedures until sonic means for thus purpose had been devised. On 30 August 1944, the director of the Medical Research Laboratory forwarded to the Medical Division, Office of Chief, Chemical Warfare Service, a preliminary report on a kit for use in detecting chemical contaminants in dangerous amounts on food packages and in foods.21 The use of a kit of this kind in the field would prevent the indiscriminate disposal of supposedly contaminated food supplies and would keep losses at a minimum in the event of gas warfare. The kit in question was approved by the Chemical Warfare Branch and was standardized by the Army Service Forces on 17 February 1945 (fig. 15). Various manufacturing difficulties, however, delayed progress, and hostilities ceased about the time that two manufacturers were ready to embark on full-scale production.

TRAINING LITERATURE AND FILMS

Publications

    Numerous publications, in addition to those dealing with professional policies, served to disseminate training information concerning the medical aspects of chemical warfare. TM 8-285, Treatment of Casualties From Chemical Agents, first issued on 10 July 1941, was successively devised on 14 February 1942,22 on 27 November 1942, on 15 April 1944, and in April 1945. Each revision brought up to date the changes in therapeutic policies developed in the Office of the Surgeon General as new information became available. In the last revision, two appendixes were added. One appendix, well illustrated with photographs, dealt with the disposition of personnel with blister gas burns. The other dealt with general principles in the handling of patients contaminated by chemical agents.

    The Bulletin of the U.S. Army Medical Department was utilized to provide for medical officers short, concise reviews of the treatment of mustard

20 War Department Technical Bulletin (TB MED) 169, Changes 1, 30 Aug. 1944.
21 Letter, Director Medical Research Laboratory to Chief, Medical Division, Office of Chief. Chemica1 Warfare Service, 30 Aug. 1944, subject: Kit for the Detection of Contaminating Chemical Warfare Agents on Foods and Food Packaging Materials, with enclosure, dated 26 August 1944.
22
War Department Technical Manual (TM) 8-285, Changes No. 1, 14 Feb. 1942.


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FIGURE 15. - Food testing and screening kit, a post-World War II Chemical Corps modification of the World War II Medical Department kit.

burns,23 mug irritations,24 and burns of the eye.25 Information was also presented in this bulletin concerning exposure to chlorine26 and concerning pulmonary damage caused by FS (sulfur trioxide-chlorosulfonic acid) smoke.27

23 Prevention and Treatment of Mustard Burns. Bull. U.S. Army M. Dept. 80:1, September 1944.
24
Treatment of Casualties due to Lung Irritants. Bull. U.S. Army M. Dept. 81:3-4, October1944.
25
Infected Chemical Burns of the Eye. Bull. U.S. Army M. Dept. 83:8. December 1944.
26 Chemical Study of Exposure to Chlorine. Bull. U.S. Army M. Dept. 80:2. September 1944.
27
Pulmonary Damage caused by FS Smoke. Bull. U.S. Army M. Dept. 84:6, January 1945.


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Films

    In 1943, following a number of changes in policy concerning first aid to chemical warfare casualties, the existing training film on this subject was declared obsolete and was replaced by a new film, TF 8-1180, First Aid for Chemical Casualties. Additional changes in first aid policies were made the following year, and in December 1944 it was brought to the attention of the chief of the Medical Division, Chemical Warfare Service, that the 1943 film was outdated in several important respects.28 In February 1945, a representative of the Navy informally approached the Training Division, Office of the Surgeon General, with the suggestion that a joint Army-Navy film be prepared on the subject.

    Certain differences in policy between the two Services had to be reckoned with before this could be accomplished. The Navy procedure for decontamination of liquid blister gas on the skin differed from the Army procedure, and the ointments issued by the two Services were different. It was believed that these differences could readily be overcome in the film. When the lecture upon which the scenario was to be based was prepared, however, it became clear that there would be considerable difficulty in presenting both decontamination procedures in the same film.

    It was believed then that this obstacle could be overcome by filming two separate versions of the procedure and issuing the appropriate version of the film to each branch of the Services.29 Army Service Forces headquarters however, when this idea was presented, ruled that under the circumstances the film could no longer be classified as a joint Army-Navy project.30

    The original plan, therefore, was amended to provide the Navy with a copy of the Army film, into which a sequence presenting the Navy decontamination procedure and shot separately, could be spliced.

    The lecture containing the technical information was then sent to the Signal Corps. Their writers, stationed in the Eastern Division studios of the Army Pictorial Service at Astoria, Long Island, N.Y., prepared the scenario. When the first effort of these writers was reviewed by the chief of the Chemical Warfare Branch, who had been selected to serve as technical adviser for the film, it was found that they had overemphasized the horrors of chemical warfare. This was an important item contrary to present policy, and the scenario therefore had to be rewritten.

28 Memorandum for the record, Medical Division, Chemical Warfare Service, 27 Feb. 1945, subject: Training Films on First Aid for Gas Casualties Due to Chemical Agents.
29
Memorandum, Chief, Chemical Warfare Branch, Surgical Consultants Division, for Director, Training Division. attention: Colonel Ainlay, 2 May 1945, subject: Training Film on First Aid for Gas Casualties.
30
(1) Memorandum. Brig. Gen. R. W. Bliss, Chief, Operations Service, for The Commanding General. Army Service Forces, attention: Director, Training Requirements Division, 27 Mar. 1945, subject: Request for Training Film, second endorsement thereto, dated 8 May 1945. (2) Letter, Director, Military Training. Army Service Forces, to Chief, Bureau Medicine and Surgery, Navy Department, 23 May 1945, subject: Training Film on ''First Aid for Gas Casualties.''


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After several more consultations with the writers at both Astoria and Washington, an acceptable scenario was prepared.31

    The Signal Corps decided that their Western Division studio in Hollywood, Calif., would be the scene of the filming. Production was about to begin when hostilities ended on 14 August 1945, and the whole project was canceled.

    In view of the changes in policy concerning treatment of gas casualties, the Chemical Warfare Branch recommended to the Training Division, Office of the Surgeon General, in April 1945, that the Filmstrip FS 8-80, The First Aid Kit for "Gas Casualties," be declared obsolete. It was decided that this strip should be replaced by a strip dealing with first aid as the individual soldier was taught to practice it. Frame descriptions had been submitted to Carlisle Barracks for sketching when hostilities ended.

PROFESSIONAL POLICIES IN WORLD WAR II

    Although toxic gases were never employed against U.S. troops in World War II, it was necessary to be as fully prepared against them from the medical standpoint as from the military standpoint. To teach the soldier to protect himself against them, and to teach him first aid in the event of their use, it was necessary to demonstrate the action of certain gases.

    Tear gas, a favorite chemical agent for training purposes, made the soldier proficient in the use of the gas mask. Other gases, such as phosgene, lewisite, and mustard, were also used in dilute quantities to acquaint the soldier with the odors of various toxic agents. In the medical officers' courses at the Chemical Warfare School, Chemical Warfare Center, Edgewood Arsenal, Md., trainees saw the effect of mustard on their own skin when it was applied in a small quantity. Furthermore, they saw the effects of many of the gases on experimental animals.

    The most massive exposure of Allied troops to gas occurred at Bari, Italy,32 when enemy bombing resulted in the release of a large quantity of mustard gas which was in one of the Allied ships in the harbor. Many casualties resulted. Informative reports on the pathologic processes in these casualties were forwarded to the Medical Division, Chemical Warfare Service, by the Chief Medical Gas Officer, NATOUSA.

    In anticipation of possible gas warfare on some of the jungle islands of the Southwest Pacific, the Chemical Warfare Service had established an experimental station on a previously uninhabitable tropical island in the Archipiélago de las Perlas in the Gulf of Panama.. The aims were to determine the feasibility of carrying on offensive gas warfare in a jungle climate and to learn if Army protective equipment would be efficient in its primary purpose while it

31 Memorandum, Chief, Chemical Warfare Branch, Surgical Consultants Division, for Director, Training Division, attention: Lt. Col. R. J. Moorehead, 23 July 1945, subject: Comments on Training Film. First Aid or Self Aid in Chemical Warfare.
32
Report, Lt. Col. Stewart F. Alexander, MC, Consultant, Chemical Warfare Medicine, Office of the Surgeon, NATOUSA, to Director, Medical Service, Allied Force Headquarters, and to the Surgeon. NATOUSA, 27 Dec. 1943, subject : Toxic Gas Burns Sustained in the Bari Harbor Catastrophe.


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still permitted troops to carry on their normal, every day and night living and duties.

    One of the largest of the field tests was conducted on this island in August 1945. Two companies of volunteer troops from the Canal Zone maneuvered for 24 hours in an area on the island which had previously been bombed with mustard from B-24 bombers. The troops were fully protected with standard protection equipment. The area was bombed in a concentration of 180 tons per square mile, far greater than any field of battle concentration experienced in World War I. The chief of the Chemical Warfare Branch and several other medical officers from the Army and Navy, whose primary military interests lay in the field of chemical warfare, were invited to attend this test as observers.

    At the end of the 24-hour period, the troops engaged in the test were all thoroughly examined by medical officers. There was not one casualty. There was no opportunity to see any first aid executed, but it was comforting to know that Army protective equipment was so efficient.

    First aid. - The teaching of first aid in chemical warfare was extremely difficult. Most chemical agents required separate rituals, and it was necessary for the soldier to be able to distinguish between different gases at a time when circumstances would make the differentiation difficult if not impossible. Instruction on these matters during the war was gradually made as simple as possible, with the idea that if the soldier did not bear in mind all the details he had been taught at least he would remember certain essential points.

CLASSIFICATION OF CHEMICAL AGENTS

    For medical purposes, the most useful classification proposed for agents of chemical warfare segregated them according to their primary physiologic action. On the other hand, such a classification, while satisfactory from this standpoint, made no allowance for the secondary effects of which many of these agents were capable, nor did it include either the incendiaries (white phosphorus, magnesium and its alloys, thermites, and oils) or the screening smokes (HC (hexachloroethane) mixture, titanium tetrachloride, and sulfurtrioxide-chlorosulfonic acid solution).

    On the basis of their physiologic action, toxic chemical agents used in warfare were classified as follows:

    1. Vesicants (blister gases), which included mustard, nitrogen mustard, lewisite, ethyldichlorarsine, and phenyldichlorarsine.
    2. Lung irritants (choking gases), which included phosgene, chloropierin, and chorine.
    3. Sternutators (vomiting gases), which included diphenylaminechlorarsine, diphenylchlorarsine, and diphenylcyanarsine.
    4. Systemic poisons (blood and nerve poisons), which included hydrocyanic acid, cyanogen chloride, and arsine.


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    5. Lacrimators (tear gases), which included chloracetophenone, chloracetophenone solutions, and brombenzylcyanide.

    Two of the gases in this list, the nitrogen mustards and cyanogen chloride, were first described in the course of World War II. Information concerning the nitrogen mustards was released in War Department Training Circular No. 86 on 13 November 1942, and information concerning cyanogen chloride was released in April 1944.

Vesicants

Evolution of policies

    The treatment of mustard burns varied considerably in the course of the war, as the various editions of TM 8-285 show. In the July 1941 version, tannic acid and silver nitrate were recommended for local use. In the November 1942 version, amyl salicylate and sulfadiazine ointment were recommended for the same purpose. In the April 1944 version, the use of these agents was prohibited, only mild ointments were advised, and the use of local pressure dressings with petrolatum jelly was the treatment of choice.

    One of the most notable advances made during World War II in the field of chemical warfare was the discovery of the compound known as BAL (British Antilewisite). Its value as a specific in first aid and in the later treatment of casualties caused by lewisite and other arsenical vesicants was first recognized in 1941,33 but it was not until 1943 that the Medical Division, Chemical Warfare Service, recommended that BAL eye ointment be standardized.34 This was accomplished on 8 July 1943, and 3-gm. ophthalmic tubes were prepared for individual issue.

    The value of BAL ointment in decontamination of the skin after lewisite contamination was not questioned. It was considered to be more judicious, however, rather than to encumber the soldier with another tube of ointment for the skin and thus complicate first aid measures further, to continue the use of M-5 protective ointment (which was used primarily for mustard contamination) for the arsenical vesicants also, since it was fairly effective against the latter chemical agents. In September 1943, BAL ointment, in 3/4-ounce tubes, was approved for issue in Kit, First Aid, Gas Casualty, (fig. 16) and Kit, Treatment, Gas Casualty.

    By the close of the war, in an effort to standardize first aid procedures when the eyes were contaminated by any liquid gas, the application of BAL eye ointment, followed by massage and irrigation, was recommended for all contamination of the eyes by liquid vesicants. 35 In 1941, irrigation alone had

33 Medical Department (Edgewood Arsenal) Memorandum Report 39, C. B. Marquand, O. E. McElroy, and T. W. Kethley, 15 Dec. 1941, subject: The Use of Beta-Gamma-Dimercapto-PropylAlcohol (DTH) in the First-Aid Treatment of Liquid Lewisite Burns.
34
Medical Department (Edgewood Arsenal) Memorandum Report 88, F. Dickson Brown and B. P. McNamara, 1 May 1943, subject: The Effectiveness of Self Eye Medication During Pain and Blepharospasm.
35
(1) War Department Technical Bulletin (TB MED) 153, First Aid for Liquid Blister Gas Contamination of the Eye, March 1945, (2) Liquid Vesicant Contamination of the Eyes. Bull. U.S. Army M. Dept. 86:30-31, March 1945.


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FIGURE 16. - Complete first aid gas casualty kit. Medical Department item No. 9776400. A. Container for kit. B. Packing of contents. Eye and nose drops carton and BAL ointment tubes removed to show packing of eye solution and protective ointment on bottom level.


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been recommended for mustard contamination. Lewisite contamination was not mentioned in the first edition of War Department Technical Manual 8-285, which was published in that year. In 1942, the application of eye ointment M-1 was recommended for lewisite. In 1944, BAL eye solution M-1 was recommended for lewisite contamination, and in 1945 this preparation was recommended for mustard contamination also.

    For many years, it had been believed that the fluid in blisters caused by lewisite was both vesicant and toxic, and, on this basis, aspiration of the blisters was advised, to prevent the possibility of arsenic poisoning. A thorough investigation of the subject during the war permitted the statement in 1944 that, although the fluid does contain a trace of arsenic, it is neither vesicant nor toxic and aspiration is therefore not necessary.36

    With the discovery of the effectiveness of BAL in decontamination of the eye and skin after contamination with lewisite and other arsenical blister gases, much effort was expended in an endeavor to determine its effectiveness in the treatment of systemic poisoning caused by these agents. Because of BAL's ready absorption by the skin, it was recommended in 1944 that this compound be used as an inunction under these circumstances. BAL in oil, which had been studied for a considerable time for possible systemic use, was standardized by the Army Service Forces on 22 May 1944, and information concerning it was disseminated in War Department Technical Bulletin (TB MED) 101, Use of BAL in Oil and BAL Ointment in Treatment of Systemic Poisoning Caused by Lewisite and Other Arsenical Blister Gases, dated 4 October 1944, and also in the November 1944 issue of the Bulletin of the U.S. Army Medical Department.

Final policies and practices

    At the close of the war, the following data and instructions concerning poisoning by vesicants, as detailed in TM 8-285, April 1945, represented the current therapeutic practices in the U.S. Army Medical Department:

    Vesicants as a group act primarily on the eyes and skin. When inhaled, they cause injury to the respiratory tract. When absorbed, they cause systemic poisoning.

    Mustard. - The eyes are more vulnerable to mustard than is any other part of the body. Symptoms do not immediately follow exposure, and the latent period varies from 1 or 2 hours to 12 hours, depending upon the degree of exposure. Resulting lesions vary from mild conjunctivitis to severe injuries of the cornea with opacification, ulceration, and vascularization.

    If the eyes have been exposed to mustard vapor only, no decontamination procedure is of any value. When contamination involves liquid gas, however, first aid procedures employed within 2 minutes will be of value. BAL ointment should be squeezed directly into the lower conjunctival sac, after which the eye should be massaged for 1 minute and then irrigated for from 30 seconds

36 War Department Technical Manual (TM) 8-285. 15 Apr. 1944.


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to 2 minutes. The application of ointment, even if previous symptoms are lacking, is followed by pain and blepharospasm, but the pain will be relieved on entirely controlled by irrigations.

    Mild conjunctivitis is treated symptomatically. Sulfacetimide (Sulamyd) sodium solution (2 drops) in 3 percent solution is instilled every 4 to 8 hours to prevent infection. In more severe cases, with edema of the lids, photophobia, blepharospasm, and other obstruction of vision, pain is likely to be persistent and morphine or other systemic sedation must be used to control it. Mydriasis should be effected by the use of atropine in 1 percent solution.

    Infection can be prevented by the instillation of a few drops of Sulamyd sodium in 3 to 10 percent solution every 4 hours, or by the use of penicillin (1,000 units per 100 cc.) or of sulfathiazole ophthalmic ointment. Secretions can be removed by gentle irrigations with isotonic saline solution. Established infections should be treated by the instillation of Sulamyd sodium in 10 percent solution every 2 hours, or by the local use of penicillin or of sulfathiazole ophthalmic ointment every 4 hours.

    No immediate symptoms follow the exposure of the skin to mustard vapor or liquid, but at the end of a latent period lasting from 1 to 12 hours erythema develops, with itching and some burning, followed by vesication in all but mild exposures. Liquid mustard on the skin requires prompt decontamination. The excess liquid should be blotted off, M-5 protective ointment applied freely, the excess wiped off, and additional ointment applied and allowed to remain until it can be washed off with soap and water. Erythema should be treated symptomatically. Blistered and denuded areas should be treated by the application of sterile petrolatum and covered by sterile pressure dressings. A sterile technique is essential, and frequent changes of dressing should be avoided.

    Specific antibacterial therapy should be employed according to the indications. Penicillin, which is the drug of choice, should be given intramuscularly in doses of 25,000 units every 3 hours as long as indicated.

    Symptoms following the inhalation of mustard vapor come on slowly. They begin with hoarseness and possibly aphonia and progress to cough, fever, and dyspnea. Lesions range from mild hyperemia of the laryngeal and tracheobronchial mucosa to congestion of the pulmonary parenchyma, with mild patchy edema, emphysema, and focal atelectasis. Bronchopneumonia is a frequent complication.

    Cough and irritation should be treated symptomatically. Bronchitis should be treated with steam inhalations. When chemical evidence of severe respiratory tract injury exists, penicillin should be given prophylactically, in the hope of preventing bronchopneumonia. Should pneumonia develop, the usual treatment for it should be employed.

    Absorption of mustard through the skin or the ingestion of mustard contaminated food or water may cause severe gastrointestinal disturbances associated with pain, nausea and vomiting, diarrhea, and sometimes fever and


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prostration. When the quantity absorbed approaches the lethal dose, the hematopoietic tissue may be damaged, as evidenced by leukopenia and thrombocytopenia in the peripheral blood.

    Treatment consists of infusions as indicated to maintain the fluid and electrolyte balance; barbiturates to control restlessness and discomfort; and morphine, if necessary, to reduce gastrointestinal activity.

    Nitrogen mustards. - The eyes are affected more quickly by nitrogen mustards than by mustard, though not as quickly as by lewisite. The lesions are, in general, similar to those caused by mustard, but the symptoms may be more severe, and local necrosis of the cornea may terminate in rupture of the globe. Decontamination and treatment are carried out as described under the heading of mustard. The same holds for the management of skin lesions and lesions of the respiratory tract.

    The most pronounced effects of the absorption of nitrogen mustards through the skin or the respiratory or gastrointestinal tracts are on hematopoietic tissue and lymphoid tissue. Degenerative changes in bone marrow may be followed by involution of the thymus, spleen, and lymph nodes, with resulting lymphopenia, granulocytopenia., thrombocytopenia, and anemia. If vomiting and diarrhea occur, as they frequently do, they should be treated by transfusions of whole blood and the use of other parenteral fluids as indicated.

    Lewisite. - Liquid lewisite is extremely damaging to the eyes. Pain and blepharospasm occur immediately following exposure, and there is immediate searing of the cornea, with edema and closure of the eye within an hour. The degree of corneal injury depends upon the degree of exposure. Healing may occur without permanent defects, but the more severe exposures are likely to terminate in pannus formation or massive necrosis.

    Decontamination and therapy should be carried out as for mustard. In contrast to its effect in mustard poisoning, however, BAL ointment immediately relieves pain and blepharospasm caused by lewisite. If it is used within 1 minute of exposure, healing usually occurs without permanent damage. If it is used within 10 minutes, healing will occur, but there will be some residual effects. Used after 30 minutes, the ointment is of no value.

    Contact of liquid lewisite with the skin produces, within a few seconds, a stinging pain, which quickly increases in severity. The pain is followed within about 30 minutes by erythema and within about 12 hours by vesication. Tissue damage is in general more severe than that caused by mustard.

    Ideally, lewisite can be decontaminated by BAL ointment, which is spread on the skin in a thin film, rubbed in, and allowed to remain for a minimum of 5 minutes. By this method of application, any lewisite which has been absorbed is neutralized, as is the lewisite on the skin. The reasons for not using it, however, have already been set forth (p. 84). Treatment of lewisite poisoning is similar to that for poisoning by mustard.

    Inhaled lewisite vapor is extremely irritating to the respiratory tract and causes lesions similar to those caused by mustard. Therapy is a combination


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of the treatment recommended for mustard injuries of the respiratory tract and the treatment recommended for systemic arsenical poisoning.

    Systemic poisoning with lewisite may result from its absorption from skin contamination or from absorption of vapor from the respiratory tract. Loss of fluid from damaged capillaries may be severe enough to cause hemoconcentration, shock, and death. Focal necrosis of the liver may be the result of oxidized products and lewisite, and pulmonary edema may follow direct inhalation of the vapor as well as absorption from the skin.

    Therapy directed toward systemic lewisite poisoning is indicated in the presence of any of the following manifestations:

    1. Any evidence of pulmonary edema, such as a. cough with dyspnea and frothy sputum.
    2. Any skin burn the size of the hand, or larger, if decontamination has not been effected within 15 minutes of exposure; skin contamination of 5 percent of the body surface if evidence of skin damage has appeared within 30 minutes of exposure; and blisters the size of the hand or larger.

    When lewisite has been absorbed through the skin, BAL ointment should be rubbed into the infected areas and permitted to remain. BAL in oil (10 percent solution) should be given intramuscularly into the buttocks, the dosage being adjusted to the estimated body weight (2.5cc. for 125 pounds, 3.0cc. for 150 pounds, 3.5cc. for 175 pounds, 4.0cc. for 200 pounds). Four doses are given at 4-hour intervals, through in severe cases the interval between the first and second dose is shortened to 2 hours. A single daily dose in half the original amount is then given for 3 or 4 days.

    A wide variety of symptoms and signs may occur from 15 to 30 minutes after the injection of BAL in oil. The most serious of these is a transient rise in blood pressure. Reactions may last 30 minutes, but, unless they are prolonged or unduly severe, the full course of treatment should not be interrupted.

    Ethyldichlorarsine and phenyldichlorarsine. - The lesions and symptoms caused by these agents are similar to those described for lewisite, and the same treatment is required.

Lung Irritants

Evolution of policies

    The treatment and disposition of personnel exposed to lung irritant, gases, as prescribed in succeeding issues of TM 8-285, Treatment of Casualties From Chemical Agents, underwent three definite modifications during the course of the war.

    In the 1941 edition of the manual, prompt, absolute rest was advocated, even in the latent stage. The administration of morphine was forbidden, even though the patient might be restless and apprehensive. Venesection was advocated as probably the best available therapy for phosgene poisoning during the cyanotic stage.


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    In the 1942 revision, it was left to the discretion of the commanding officer of the battalion, with the advice of the surgeon, to determine whether or not a soldier who had been subjected to lung-irritant gas should continue in combat, due account being taken of the possible risk of pulmonary edema.

    In the 1944 revision, the definite policy was adopted that men might continue at their duties pending the appearance of clean-cut symptoms. In the same year, it was recommended that morphine be given whenever the administration of oxygen failed to quiet the patient. Venesection was no longer advocated, on the ground that it undoubtedly did harm during the shocklike stage and was of doubtful value at any time.

Final policies and practices

    At the close of the war, the following data concerning the effects and treatment of lung irritants, as prescribed in TM 8-285, April 1945, represented current U.S. Army medical policy:

    Of the important lung irritants, phosgene produces its primary effects on the pulmonary parenchyma, while chloropicrin and chlorine are more likely to injure the trachea and bronchi.

    Phosgene. - Initial damage to the capillaries of the pulmonary parenchyma after the inhalation of phosgene is followed by loss of fluid from the capillaries and by early, massive, pulmonary edema. Loss of plasma into the alveoli results in hemoconcentration. Pulmonary edema reaches its maximum 12 to 14 hours after exposure, and gaseous exchange in the lung is inhibited. Death from anoxemia may occur within from 24 to 48 hours. In cases which go on to recovery, edema begins to subside at the end of 48 hours. To prevent secondary bronchopneumonia, which may develop from 3 to 5 days after exposure, specific antibacterial therapy, preferably penicillin, may be given prophylactically when edema begins to subside.

    The early symptoms of phosgene poisoning, which include coughing, choking, or vomiting, are not a prognostic yardstick. In some cases, a latent period of from 2 to 24 hours is followed by signs of pulmonary edema, of which cyanosis is the most ominous. The condition may become steadily progressive, and the patient eventually passes into a shocklike state. If signs and symptoms of respiratory distress appear in a person who has been exposed to phosgene and has continued with his duties, he must be put at complete rest immediately, kept comfortably warm, and given oxygen in as high concentration as possible. If distress continues, morphine may be given cautiously, in small doses. Codeine is useful if cough is the most prominent symptom.

    Drugs tested and proved useless or even harmful in the treatment of phosgene poisoning include atrophic and cardiac and respiratory stimulants such as epinephrine (Adrenalin), ephedrine, amphetamine (Benzedrine) sulfate, nikethamide (Coramine), pentylenetetrazol (Metrazol), and alcohol. Plasma and parenteral fluids are not useful. Venesection is also not useful and is definitely harmful if practiced during the shocklike stage.


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    Chloropicrin. - The effects of this agent are essentially the same as those of phosgene, except that chloropicrin is quite irritating to the eyes and more destructive to the bronchiolar epithelium. Symptomatic treatment is sufficient if the ocular injury is mild. Otherwise, therapy is the same as for phosgene.

    Chlorine. - The immediate symptoms of chlorine poisoning, which include burning in the throat, coughing, and a sense of suffocation, are the result of injury to the upper respiratory tract. The gas is extremely irritating to the entire respiratory tract. Therapy is the same as for phosgene poisoning.

Sternutators

    Measures against sternutators, the effect of which, while temporarily incapacitating, is transient, underwent only one change during the course of the war. The original treatment was to inhale the vapors from a bottle containing bleach powder. Later, chloroform vapor was substituted.

    Sternutators are dispensed by heat in the form of smoke. The medical effect of all three gases in the group is similar. They irritate the nose, sinuses, throat, and eyes. Symptoms include pain and a sense of fullness in the nose, headache, a sensation of burning in the throat, a sense of tightness in the chest, very severe coughing and sneezing, lacrimation, frequently nausea and vomiting, and sometimes mental depression.

    Except during the act of vomiting, the gas mask should be worn during exposure to these agents. The inhalation of chloroform may give considerable relief, but, whether it is used or not, prompt recovery is the rule in all cases.

Systemic Poisons

Evolution of policies

    The treatment of cyanide poisoning by amyl nitrite was considerably modified in the course of the war. In the July 1941 edition of TM 8-285, it was recommended that amyl nitrite fumes be inhaled for 15 to 30 seconds every 3 minutes until sodium thiosulfate could be given intravenously. In the November 1942 revision, it was recommended that the number of ampoules used in a given case be reduced to four, and, in the April 1944 revision, the number was reduced to two. However, since the purpose of the medication is to form methemoglobin and since a greater concentration than could be produced by these dosages was desirable, the April 1945 revision of the manual recommended that a total of eight ampoules be given in four doses of two ampoules each. This amount is adequate to combat the effects of the cyanide gases, and the vasodepression which follows its use is not dangerous.

    With this exception, no serious modifications in the therapy of systemic poisons were made during the course of the war.


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Final policies and practices

    Hydrocyanic acid.- This agent produces its effects by combination with an enzyme essential for oxidation within the tissues. The respiratory center is particularly susceptible. Exposure to high concentrations of the gas results, within a few seconds, in an increased depth of respiration, followed within 20 to 30 seconds by convulsions and within 60 seconds by cessation of respiration. The heart continues to beat for several minutes longer.

    As soon as the gas mask is applied, two ampoules of amyl nitrite are crushed and placed beneath the facepiece. The procedure is repeated every 3 or 4 minutes until eight ampoules have been given. The nitrite immediately forms methemoglobin, which competes with the enzyme in taking up the cyanide. When it is available (it was an item in short supply during World War II, sodium nitrite (10 cc. of 1 percent solution) should be injected intravenously over a period of 1 minute at 10-minute intervals until a total of 50 cc. has been given. Each injection of sodium nitrite is alternated with the injection by vein of 10 cc. of 10 percent sodium thiosulfate solution. Artificial respiration should be attempted if respiration ceases.

    Cyanogen chloride. - The immediate action of this agent is similar to that of hydrocyanic acid, but it also acts on the respiratory tract as phosgene does. Treatment is similar to that prescribed for hydrocyanic acid and phosgene.

    Arsine. - After arsine is absorbed from the respiratory tract, its first effect is to produce hemolysis, evidenced by anemia, hemoglobinemia, methemoglobinemia, and hemoglobinuria.. It also affects the liver and kidneys by way of its presence in the circulating blood. Death results from anemia or from hepatic or renal failure.

    Treatment consists of intravenous fluids, blood transfusions as indicated, and injections of BAL in oil as in the treatment of systemic lewisite poisoning.

Lacrimators

    No change was made in the treatment of contact with lacrimators in the course of the war. All gases in this group cause immediate pain, blepharospasm, and lacrimation, and they also irritate the skin and nose.

    The most effective first aid measure is immediate masking. The eyes must not be rubbed; if they contain liquid contaminant., they should be washed out with water. Superficial skin burns should be treated symptomatically. A 0.25-percent solution of sodium sulfite neutralizes these agents.

CHEMICAL BURNS

    White phosphorus ignites spontaneously when it is exposed to air, and if the flaming particles hit the skin they are always difficult to remove. Copper sulfate in 5 percent solution was recommended as a first aid measure. The


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flame could be extinguished and the particles could be kept from reigniting by repeated applications of water until the copper solution could be applied.

    The usefulness of copper sulfate is twofold. It coats phosphorus particles with copper phosphide, so that they do not reignite on exposure to air, and it makes them visible in the burned areas of the skin, with the result that they are more readily removed.37

    Early in 1944, reports from ETOUSA (European Theater of Operations, U.S. Army)38 suggested that gauze or double-napped cotton flannel impregnated with copper sulfate would be useful in the equipment of the individual soldier, since wetting the, pad with water from his canteen would immediately provide copper sulfate solution. On requisition from this theater, an issue of nonstandard double-napped flannel pads, 3 by 3 inches, impregnated with copper sulfate and packed three to an envelope, was approved. After thorough investigation, standardization of the item was accomplished on 5 February 1945.39 The pad was described in the July 1945 issue of the Bulletin of the U.S. Army Medical Department.

    Reports from the Southwest Pacific in 1945 were to the effect that casualties caused by white phosphorus were steadily increasing in number and that some patients had developed what was believed to be systemic phosphorus poisoning. Medical officers in the field reported difficulty in securing information on the subject, which was not surprising in view of the paucity of material in the literature. Because of this lack, and because of the apparent increase in casualties from phosphorus, the Medical Division, Chemical Warfare Service, was requested to compile all available information on the subject to be forwarded to the theaters in the form of a technical bulletin and to be published in the Bulletin of the U.S. Army Medical Department.40 Hostilities ended before these plans could be carried out.

    Thermite, magnesium, and magnesium alloys. - The only medical problems associated with these agents were the removal of metal particles from the tissues and the treatment of the, resulting burns. in which approved methods were always employed.

    Oil incendiaries. - Oil incendiary bombs and flamethrowers introduced the usual problem of burns. In addition, they caused pulmonary damage and laryngeal and glottic edema if used in enclosed spaces. They also reduced the oxygen content of the air. Treatment consisted of the introduction of fresh

37 Informal Monthly Progress Report. Medical Research Laboratory, Medical Division Office of the Chief, Chemical Warfare Service. 15 Sept. 1944.
38
(1) Sanitary Report. 8th Infantry Division, XV Corps. ETOUSA. March 1944. (2) Report, 1st Lt. Hugo E. Vivadelli and 2d Lt Alex Schlesinger, 44th Chemical Laboratory, ETOUSA. 7 June 1944, subject : Study of the Preparation and Use of Copper Sulfate - Impregnated Pads as First Aid Against Burning White Phosphorus in the Skin.
39
(1 ) Memorandum, Capt. George R. Greenwood. Surgical Consultants Division, for Chief, Medical Division, Chemical Warfare Service, 16 Aug. 1944, subject Project Specifications for Copper Sulphate Pads. (2) Letter, Medical Research Laboratory, to Chief, Medical Division, Office of the Surgeon General, 11 Dec. 1944. subject: Copper Sulfate Pads, with first Endorsement thereto, 13 Dec.1944.
40
Letter, Chief Consultant in Surgery, Surgical Consultants Division, Office of the Surgeon General, to Chief, Medical Division, Chemical Warfare Service, Army Service Forces, 19 June 1945, subject Systemic Phosphorus Poisoning.


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air and, when possible, the use of oxygen in high concentrations. Burns were treated as if they were ordinary thermal burns. Artificial respiration was sometimes necessary.

SCREENING SMOKES

    HC (hexachloroethane) mixture. - Serious or even fatal consequences may follow exposure to this smoke in enclosed spaces on near its point of production in the open. The zinc chloride it contains has a damaging effect on the respiratory tract and may produce coughing, choking, and asthma-like symptoms at once, as well as pulmonary edema later. Immediate symptoms are relieved by the intramuscular injection of 0.5 cc. of Adrenalin (1: 1,000). Pulmonary edema is treated as if it were caused by phosgene. If exposure has been particularly heavy, BAL in oil is given in appropriate doses, as in lewisite poisoning.

    FM (titanium tetrachloride). - This liquid produces acid burns of the skin and eyes, which are relieved by washing with water.

    FS (sulfur-trioxide-chlorosulfonic acid solution).--This liquid causes acid burns, and in heavy concentrations it may seriously affect the eyes, skin, and respiratory tract. Minor lesions are treated symptomatically after they have been washed with water. The treatment of burns of the skin, eyes, or respiratory tract depends upon the severity of the damage.