Contents

CHAPTER IV

FIELD ARRANGEMENTS FOR GAS DEFENSE AND THE CARE OF GAS CASUALTIES

The officers particularly concerned in administrative details for gas defense from the Medical Department standpoint and in treating gas casualties were the medical director Chemical Warfare Service, the chief gas consultant, the division surgeons. and the division medical gas officers. The subjects of the present chapter can best be described in their own words. In order to accomplish this the more important reports of the officers in question are quoted more or less in full. Selection has necessarily been exercised in respect to the inspection reports of the medical director and to the reports of the division surgeons and division medical gas officers. only typical reports having been chosen for publication. In addition to those mentioned, the report of the Medical Gas Warfare Board appears here. The report of the 42d Division and that of the Medical Gas Warfare Board include supply tables. Another supply table, however, was actually in effect for a large part of the time during which we participated actively in the war. This appears at the end of this chapter in the report of a medical officer who acted as a representative of the chief Surgeon at General Headquarters, American Expeditionary Forces.

ACTIVITIES OF OFFICE OF MEDICAL DIRECTOR

HISTORY OF THE OFFICE OF THE MEDICAL, DIRECTOR. CHEMICAL. WARFARE SERVICE, AMERICAN EXPEDITIONARY FORCES, FRANCE

1. INTRODUCTION

Col. J. R. Church, Medical Corps, reported for duty to the chief of Gas Service on August 22, 1917, to become medical director of the Gas Service. Prior to his reporting for duty with the Gas Service, Colonel Church (then major) had submitted to the Chief of staff American Expeditionary Forces, on July 26, 1917, a suggested organization for a Gas Service. He remained on duty with the Gas Service until December 14, 1917, when he was relieved by- Lieuit. Col. H. L. Gilchrist, Medical Corps (later colonel).

Prior to receiving orders, the following telegram was received by Lieutenant Colonel Gilchrist from the office of the chief surgeon, American Expeditionary Forces:

Lieut. Col. I. L. Gilchrist, commanding officer, No. 9 General hospital. Orders issued today assigning you to the Gas Service at the headquarters. Get all information possible in regard to defensive gas work before your orders arrive and before reporting for duty. Acknowledge. (Signed.) Bradley.

In view of the above, Lieutenant Colonel Gilchrist spent several days at the British gas school at Rouen, France, studying defensive gas measures, etc., in connection with the conk- templated work.

* * * * * *

The first few weeks were devoted to a careful study of the situation; and after surveying the entire field from a medical point of view, it was decided that the matter of greatest importance, and the one requiring immediate attention, was the establishment of a medical gas instruction campaign for the purpose of instructing medical officers in the medical aspects of gas warfare.

* * * * * *

The instruction included the following:
1. A general explanation of the methods of chemical warfare employed by the enemy.
2. Symptomatology of gas poisoning, including a description of lesions caused thereby.
3. The diagnosis of gas poisoning.
4. Treatment.

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With these objects in view, a hurriedly prepared article, entitled “Symptomatology, pathology, and general treatment of gas cases," was published by Lieutenant Colonel Gilchrist and distributed to the medical officers of the American Expeditionary Forces. This was the first article of the kind on the subject published in the American Expeditionary Forces, and appeared on February 8, 1918. Following the publication and distribution of this article, many others were published from time to time in the form of bulletins, in order to keep medical officers of the American Expeditionary Forces conversant with the latest developments in medical gas matters.

III. LECTURES

The medical director visited most of the divisions and many of the hospitals, and lectured to the officers and other personnel on the subject of warfare gases from a medical point of view, laying special stress on the subjects of prevention and treatment. Before the medical consultant board was organized in the American Expeditionary Forces, the only instruction promulgated along these lines was that given out from the office of the medical director of the Gas Service.

IV. PRELIMINARY WORK

Shortly after the medical director reported for duty, an attempt was made to incorporate into the Gas Service a medical division, as one of the departments of this service. In the plan of organization suggested, it was contemplated to have specially trained medical officers with all divisions as division medical gas officers, to act under the medical director of the Gas Service. All medical gas research and laboratory work was to be under this division. The medical division was to be in close liaison with the Medical Department of the American Expeditionary Forces. This plan, however, was disapproved in the general organization of the Gas Service.

After the 42d Division had been subjected to several gas attacks which resulted in a considerable number of casualties, the division surgeon succeeded in having a division medical gas officer appointed by order of the division commander. Fortunately, one of the medical officers in the command, Capt. Jasper Coughlan, had received instruction in medical gas matters in the States, and had given the subject much study. He was appointed division medical gas officer and organized a thorough and systematic method for handling gas cases in the division. This plan proved highly successful.

V. DIVISION MEDICAL GAS OFFICERS

The necessity for having division medical officers was apparent from the beginning * * *. Our gas casualties were constantly increasing; and large numbers of men claiming to be gassed were being evacuated to the rear, where, upon examination, it was found that they were not gassed. This condition resulted in much undue labor and greatly weakened the strength of front-area organizations.

Inspectors general reported that the rank and file were not properly instructed in medical gas matters. Reports were also made that no one in the front areas assumed charge of this important work. After these facts were clearly understood, authorization for division medical gas officers was made, by Paragraph VIII, General Order 144, General Headquarters, American Expeditionary Forces, dated August 29, 1918. As soon as the order was published, the matter of the appointment of these officers was taken up; and after the subject had been discussed with the chief medical consultant of the American Expeditionary Forces, it was decided to allow each division surgeon to select the medical officer he desired as division medical gas officer. [See Chap. II, p. 46.]

* * * * * *

Due to delays in the mail, constant movement of troops, etc., many of these communications were not delivered, and replies in some cases were lost in transit. As a result, much delay was occasioned in the selection of these officers. However, by the first Week of October, 1918, the division medical gas officers had all been appointed. * * *

VI. COURSE FOR DIVISION MEDICAL GAS OFFICERS

The next matter of importance to be considered was the instruction of these officers. Because the nature of the work was entirely new, it was decided to give them a special course of training before assigning them to their new duties. This course, which was conducted Very successfully, was given in Paris, and lasted four days, commencing October 7, 1918. [See Appendix, p. 838.]

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VII. PORTABLE TUNNELS FOR NEUTRALIZATION OF MUSTARD GAS CASES

In January, 1918, the French reported that they were neutralizing mustard gas clothing by the use of chlorine. Based on this, the medical director made recommendation to the chief, Gas Service, that portable tunnels be constructed and mounted on trucks, and that, following mustard gas attacks, they be rushed to the sector involved and there erected. Those exposed to the fumes of mustard gas would then be compelled to apply their respirators and to enter the tunnel, into which was to be thrown a strong concentration of chlorine gas. This plan was approved by the chief of Gas Service, and the tunnels were erected under the direction of the medical director. This method was presented to the Interallied Gas Conference which met in March, 1918. The tunnels, however, were never put to use in the field.

VIII. DEGASSING STATIONS

In view of the importance of early bathing in connection with the treatment of men exposed to the fumes of mustard gas, and the fact that bathing facilities were scarce along large sections of the front occupied by our forces, plans and specifications of a motorized mobile degassing plant were prepared by the medical director and later approved by the general staff and authorized by Paragraph VIII, General Order 144, General Headquarters American Expeditionary Forces, dated August 29, 1918. Two of these plants were authorized for each divisions.^a [See Fig. 1.]
Description of motorized degassing stations. - The degassing station, devised by Col. H. L. Gilchrist, Medical Corps, medical director of Chemical Warfare Service, American Expeditionary Forces, constructed under authority of memorandum from A. C. of S., G-4, G. H. Q., A. E. F., June 2, 1918, and successfully tried out on July 24, consists of the following:
(a) One motorized tank car capable of carrying 1,200 gallons of water with rotary pump attachment for filling the tank and Stanley heating device attached at the rear end for heating the water and generating the steam.

Twenty-four shower heads, each capable of ejecting 4 quarts of water per minute, attached to 1½-inch tubing and arranged in three independent section frames, each containing eight shower heads. These section frames are 10 feet long and 30 inches wide, with independent valves. The sections are connected together by means of 2-inch tubing 10 feet long, to which is attached the hose leading from the heater. The shower heads are supported on a portable iron frame made from 2-inch tubing with sliding joints. The frame, erected, is 7 feet 6 inches high. Different lengths of hose are carried for the purpose of connecting the heating device with the showers.

All the above equipment is carried on the tank car, thus rendering it an independent bathing unit in itself.

The above station is intended for use only where no available water is at hand. At places where water can be found the tank car with water is replaced by a smaller car equipped with the same heating device, suction pump, showers, etc. With this equipment the water is pumped directly through the heating device into the showers. Equipments b, c, and d are the same with both stations.
(b) One 3-ton truck of standard make for transporting clothing and equipment.
(c) One motorcycle with side car attachment for the commanding officer.
(d) One 50-foot ward tent with uprights and pins for furnishing cover.

The above station is intended for use only where no available water is at hand. At places where water can be found the tank car with water is replaced by a smaller car equipped with the same heating device, suction pump, showers, etc. With this equipment the water is pumped directly through the heating device into the showers. Equipments b, c, and d are the same with both stations.
Objects of degassing stations. -These stations are intended to give hot baths and clean clothing to those subjected to the fumes of mustard gas at the nearest possible points to where gas bombardments take place.
Distribution of degassing stations. -Two of these degassing stations are assigned to each division when in the front area.
Control of the degassing stations. -The degassing stations, when assigned to a division are under direct control of the chief surgeon of the division, who dispatches them to the places where most needed.
Responsibility for the administration of the degassing stations. -The commanding officers of the degassing stations are held directly responsible for their administration, both at the base and when in action.
Departments of the mobile degassing stations. - The mobile degassing stations are divided into sections, as follows:

^a Only one experimental plant was constructed before the armistice and this was not actually employed in combat. - Ed.

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FIG. 1 - Plan of mobile degassing station. American Expeditionary Forces, designed by Col. H.L. Gilchrist, Medical Corps U.S.A., Medical Division, Gas Services, June 1918. Note - Tent erected only in case other shelter is not available.

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(a) Reception department for the receiving of all men to be bathed.
(b) Bathing and irrigation department.
(c) Clothing and evacuation department.

Advantages of degassing stations. - The particular advantages of degassing stations are as follows:
(a) Being mobile, they can be taken to the men, instead of compelling the men to march to a fixed bathing point.
(b) Hot baths can be given to men when most needed.
(c) They are so arranged that bathing places can be erected in a few minutes in abandoned houses or in the open.
(d) They can be used not only for degassing men subjected to the fumes of mustard gas, but also for bathing men infected with lice and vermin and for bathing medical and surgical casualties, at the front.
Operation.- With the degassing station 24 men can be bathed in one minute and a half, and if water supply is at hand there is no limit to the number of men that can be bathed. If no water is available in the vicinity, 700 men can be bathed with that transported on the tank car. (In trying out this establishment with untrained men it required 17 minutes to pitch the tent, arrange the interior, and start the baths. The plant was dismantled in 9 minutes. Establishing the plant without the tent required 2 minutes.)
Organization and distribution of personnel of mobile degassing stations. -
1 captain or first lieutenant, Sanitary Corps, general supervision, reports, records, and returns.
1 sergeant first class, Medical Department, in general charge of records and clothing.
1 sergeant, Medical Department, in charge of bathing section.
1 sergeant, Medical Department, chief chauffeur and mechanic.
7 privates first class, or privates, Medical Department.
1 private first class to be chauffeur.

Method of employment of degassing stations. - When these units are used for degassing patients, the following plan is carried out:

All men reporting to the station are carefully scrutinized for signs of gas poisoning. Those presenting gas symptoms are treated immediately and evacuated. The others are divided into sections of 24 men each, for bathing. The members of these sections them stack arms, remove all loose equipment, and lay it on the ground in front of them. They then proceed to the lime box, where their hands are disinfected with dry lime. The same method is used for disinfecting their shoes. Blouses are then removed and disposed of according to directions, after which they proceed to the tent and stand in front of their designated numbers on the canvas, where they are instructed in the manner of taking baths. Prior to entering the tent they dip their helmets in a tank of lime water for the purpose of disinfection.

Method employed in disrobing. - In disrobing, the following plan will be adhered to:
(a) The helmets are placed on the numbered canvas sections in front of the men and used as a receptacle for holding valuables, small trinkets, etc.
(b) Their flannel shirts are removed and disposed of according to directions.
(c) Shoes and socks are removed and placed with the other equipment in front of the men.
(d) The underclothing is removed and placed in the proper receptacles.

When men are disrobing, they do not sit down, but remain standing, thus avoiding all possibility of infecting the places which are to be used when rearranging their clothing.

After all members of the squad are disrobed and their clothing and equipment have been properly disposed of, they march in column of files to the bathing department, where each man takes his place under a shower head. Before the showers are turned on, the mien spray themselves with liquid soap. At a given time the showers are turned on, and 15 seconds are allowed for wetting the body. When time is a factor, three-fourths of a minute will be allowed for scrubbing the body, following which the showers will again be turned on for 30 seconds. After the bath clean towels are issued, and after their use they are placed in proper receptacles. Passing from the showers, the men's eves, noses, and throats are sprayed with a solution of bicarbonate of soda, 5 per cent strength. They then proceed to the clothing and evacuation department, where each man is issued a clothing kit. The men then return to their places and readjust their clothing.

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During the time the men are stripped they are again examined by the commanding officer and, if possible, by a medical officer for signs of gas poisoning. Those exhibiting genuine signs are immediately evacuated to the hospital. After the men have dressed themselves they return to their command.
In order to avoid delays, sections of 24 men must be ready to proceed to the baths as soon as they are vacated.
Designation. - The degassing stations are designated during the daytime by the displaying of a large blue flag and at night by a blue lantern.
Equipment. - The equipment consists of two parts:
1. An extra supply of clothing and the necessary equipment for the personnel at the base station, which is moved only when the unit changes station.
2. The equipment actually necessary when the station is erected at the front; this equipment is carried on the truck.

The amount of clothing at each degassing base station is in proportion to the number of men in the division. According to recent experience 5 per cent of the total number of men will be exposed to poisonous gases, and clothing should be provided for this number at the beginning. New phases of gas situation may cause an alteration of these figures from time to time. Of this amount, 500 complete suits or uniforms should be carried with the stations, and the remainder should be stored at the unit base station, ready for emergency use.
(1) Clothing carried with station:
500 blouses, assorted sizes.
500 breeches, assorted sizes.
500 flannel shirts, assorted sizes.
500 undershirts, assorted sizes.
500 underdrawers, assorted sizes.
500 pairs puttees (woolen leggins).
500 towels, hand.

The above clothing carried in gas-proof bags.
(When overcoats are worn, this article will be added to the clothing kit. No new issues of helmets, belts, socks, and shoes are made at the degassing stations.)
(2) Equipment carried with station: 1 ambulance guidon on lance staff; 1 flag (blue); 4 ax heads; 6 ax helves; 4 spades (secured to truck); 6 lanterns (two with blue globes); 3 pick axes, with helves; 3 buckets, galvanized iron; 4 litters, with slings; 1 hospital ward tent; 1 portable shower apparatus with 24 shower heads; 2 vermored sprayers; 2 barrels of lime; 4 small oxygen tanks; 4 Haldane masks; 1 bag, water, sterilizing; 4 cans, galvanized iron; 1 box soap, 1-ounce cakes; bicarbonate of soda.

IX. INSTRUCTION OF PERSONNEL FOR MOBILE DEGASSING STATIONS

In order to have a sufficient number of trained officers and enlisted men for duty with the degassing stations, a school of instruction was established at a large ch?teau near Vouvray (Indre et Loire). The school was placed under the command of First Lieut. Herbert D. Snyder, Medical Corps. Only men having special training in motors, steam fitting, plumbing, etc., were selected for the work.

X. MEDICAL GAS WARFARE BOARD

On October 18, 1918, a special board to be known as the Medical Gas Warfare Board was organized under provisions of paragraph 128, Special Orders, 291, General Headquarters, American Expeditionary Forces. The composition of this board was: Col. H. L. Gilchrist, Medical Corps; Lieut. Col. H. H. M. Lyle, Medical Corps; Maj. Richard Dexter, Medical Corps; Capt. Jasper Coughlan, Medical Corps.

The duties of this board were to consider all medical gas matters. The board held its first meeting November 5, 1918, at Headquarters, First Army, and considered several matters referred to it by the chief surgeon, American Expeditionary Forces. * * * [See Appendix, p. 829.]

XIII. STERILIZATION OF CLOTHING OF GASSED PATIENTS

Proper provision for sterilization of clothing and equipment of gas casualties is a serious proposition, and to that end it is believed that the only feasible method is the use of the steam sterilizer. In places where the mobile degassing unit can not be assigned to the hos-

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pital, a portable water heater with shower heads can be attached to the steam sterilizer and will meet most requirements. With this apparatus 100 cases may be bathed in one hour with approximately 1 gallon of water to each man.

* * * * **

XVI. HYPERSENSITIVENESS OF SOME TO MUSTARD GAS

In investigating gas attacks it has been apparent that many men go through mustard gas attacks and suffer severe skin infections or burns, while others subjected to the same attacks under like conditions escape. The conditions may be likened to those produced by poison ivy; while some are highly hypersensitive and suffer from it, the majority of the persons escape from the poison with no apparent bad effects.

It has also been observed that those with fair skin suffer greatest from the direct action of the fumes.

XVII. LONG HAIR IN RELATION TO EYE AND RESPIRATORY TROUBLES

In examining large groups of mustard gas cases it was noted, with few exceptions, that those cases having severe eye lesions and lung irritation had long, shaggy hair on their heads. As a result, an investigation was made by several medical officers, and it was definitely decided that long hair harbored the fumes of the gas and was directly responsible to a great degree for the severity of the conditions.

XVIII. SELF-INFLICTED GAS BURNS

After a careful study of the question of self-inflicted gas burns, it is believed that many casualties entering the hospitals with severe eye lesions infect different parts of the body with fingers contaminated by discharge from the eyes.

XIX. MALINGERING

The question of malingering was introduced early in the year. There can be no doubt, because of the excessively high casualty list and low mortality, that a large number of gas casualties heretofore reported were not actually gassed. The British and French show that their mortality from gas casualties runs from 3 to 4 per cent. In our armies it is less than 2 per cent (to be exact, 1.7 per cent). This condition is not believed to be due to any better treatment received in our hands than that given by our Allies, but due wholly to the fact that a large number of reported gas casualties were suffering from other causes.

In this connection attention is invited to a report of one field hospital in which 281 men were being treated as gas casualties. Due to the utter lack of symptoms in the majority of these cases, the commanding officer of the hospital asked for a board of medical officers to examine the cases. The report of this board showed that but 90 of the 281 cases were suffering from gas poisoning, and as a result the others were returned to duty. Numerous similar reports have been received from other sources. There is no doubt that many men have claimed they were gassed in order to get out of the front lines; that a still larger number thought they were gassed and were suffering from conditions which might be called gas mania; and that others smelled the odor produced by the explosions of ordinary shell and became panic-stricken in the belief that they were gassed. In view of the low mortality mentioned above, it is believed, if the true facts were known concerning our gas casualties, that they would not be over one-third those actually reported.

XX. PERSONNEL OF OFFICE OF MEDICAL DIRECTOR

Commissioned:
Col. H. L. Gilchrist, Medical Corps, medical director, from December 14, 1917, to November 25, 1918.
Maj. Richard Dexter, Medical Corps, assistant to medical director, from March 11, 1918, to June 7, 1918.
First Lieut. George W. Perry, Sanitary Corps, assistant, from July 16, 1918, toAugust 16, 1918.
First Lieut. Herbert D. Snyder, Medical Corps, assistant, from October 15, to November 25, 1918.
Enlisted:
Corpl. H. M. Valley, Medical Department, stenographer and in charge of office records, etc., from June 25, 1918, to November 25, 1918.

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APPENDIX No. l ^b

[Copy of memorandum submitted by Lieutenant Colonel Gilchrist to chief surgeon, American Expeditionary Forces, suggesting duties of medical director, Gas Service, and plan of organization of the Medical Corps for handling gas casualties.]

MEDICAL DIRECTOR OF THE GAS SERVICE

Owing to the importance of medical gas warfare measures, a specially trained medical officer will be appointed by the commanding general, American Expeditionary Forces, upon the recommendation of the chief surgeon, American Expeditionary Forces, to be known as the director of medical gas warfare, American Expeditionary Forces, who will be charged with the organization and control, under the direction of the chief surgeon, of these different measures.

In view of the close relationship existing between the Medical Department and the Gas Service, American Expeditionary Forces, in connection with the subject of gas warfare, he will, for purposes of coordination, be assigned to duty with the Gas Service as its medical representative. He will act as the liaison officer between these two services and with the medical gas services of our Allies. All transactions between the services will be conducted through this officer.

The director of medical gas warfare will be the medical adviser of the chief of Gas Service and the gas adviser of the chief surgeon of the American Expeditionary Forces. Besides the duties already specified, he will collect for the chief of the Gas Service, American Expeditionary Forces, all physiological and medical information having any bearing on the problems of gas warfare; he will supply the chief surgeon such information as comes into the hands of the chief of Gas Service which has any bearing on the medical aspects of gas warfare, especially concerning new treatment of gas casualties, with reference to combatting the effects of the enemy gas, not only from a therapeutic, but also from a prophylactic point of view. To this end the chief of Gas Service will supply the medical director all information concerning gas warfare which has any bearing on medical matters.

He will prepare for publication and distribution to medical officers and others, extracts from reports pertaining to medical gas matters sent to the gas service of chief surgeon. All expenses in connection with such publications will be borne by the Medical Department.

He will be prepared to lecture to medical officers and others on the subject of gas poisoning. He will cooperate in every way possible with the chief consultant, medical services, American Expeditionary Forces, and keep him thoroughly acquainted with all new or suspicious symptoms following gas attacks.

He will arrange for direct telephonic or telegraphic intercourse with the division medical gas officers and others, whereby the chief surgeon and the chief of gas service can be notified immediately following gas attacks.

He will inspect, from time to time, troops in the front area, hospitals, hospital trains, etc., as to methods and facilities for the care of gassed cases.

When the chief of gas service or the chief surgeon deems it necessary to obtain fuller information in regard to a gas attack, the medical director will proceed to the gassed sector for the purpose of obtaining all possible information concerning the attack. Being a member of the gas service, he will represent the chief of Gas Service in his interview with gas officers. Being a medical officer, he will represent the chief surgeon, American Expeditionary Forces, in his transactions with medical officers; and, when necessary, he will examine carefully the casualties.

When conditions warrant, he will call upon the director of laboratories for a pathologist, to proceed to the designated place for duty in connection with special investigations. Copies of reports from the pathologists immediately following such visits will be submitted directly to the medical director of the gas service, who will incorporate them with the general report of the gas attack to be made to the chief of gas service, a copy of which will be furnished to the chief surgeon.

During the investigations the medical director will cooperate from a medical standpoint with the personnel of the gas service in the study of any clinical manifestations which may suggest the employment of new gases, and in the investigation of their effect

^b See p. 153, Vol. II, History of Chemical Warfare Service, American Expeditionary Forces.

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Any important information obtained by the medical director during these investigations will be communicated immediately to the chief of Gas Service and the chief surgeon of the American Expeditionary Forces by telephone or telegraph; a full written report will follow immediately upon return to his station.

Any important information obtained, together with suggestions regarding treatment, received either through reports sent to the Gas Service or based upon experimental information coming into possession of the Gas Service, will be forwarded immediately to the chief surgeon in order that it may be submitted to the chief consultant, director of general medicine, and medical officers of the American Expeditionary Forces.

The same information will be simultaneously supplied to our Allies through proper channels.

MEDICAL ORGANIZATION

In order to combat the results of this specialized warfare, a strong and coordinated medical organization is required to combine all natural divisions of relief including organizations in the zone of the advance, organizations along the lines of communication, organizations at the base, and organizations for general research and development.

To perform properly the duties assigned to the Medical Department, the following measures looking toward the better prevention and treatment of gas casualties are hereby ordered:
(a) The institution of all practicable protective measures to prevent the depletion in strength of the fighting forces from avoidable causes in connection with gas warfare.
(b) The establishment of courses of instruction for intensive training of medical officers, nurses, and enlisted men of the Medical Department in the best methods of treating the gassed.
(c) The establishment of special centers for the treatment of gassed cases. The designation of the centers or hospitals will be made in orders from time to time.
(d) The appointment of specially trained medical gas officers with divisions; these officers to be known as division medical gas officers.
(e) The establishment at advanced aid stations of an efficient system and proper equipment for the administration of first aid for the gassed.
(f) The prompt evacuation of all gas casualties
(g) The supervision of the treatment of gassed cases entering all hospitals.
(h) The instruction of the rank and file in the theory and practice of first aid to gassed men.

H. L. GILCHRIST,
Colonel, Medical Corps.

INSPECTION REPORTS OF MEDICAL DIRECTOR, CHEMICAL WARFARE

SERVICE ^c

HEADQUARTERS, GAS SERVICE, OFFICE MEDICAL DIRECTOR,
June 18, 1918.

From: Medical director of the Gas Service.
To: The chief surgeon, American Expeditionary Forces.

Subject: Extract from memorandum. chief of staff, 2d Division.

The following pertaining to the Medical Department, 2d Division. was extracted from memorandum, chief of staff, 2d Division, concerning the recent gas attack during which nearly 800 casualties occurred:

The evacuation of wounded. hospital service, and general efficiency of the Medical Department has been beyond criticism and has been just as well as it could have been done in my opinion, in a complicated map problem.

All gassed men were promptly bathed at the dressing stations, their clothing taken away, and they were sent wrapped in blankets to the field hospitals.

H. L. GILCHRIST,
Colonel, M. C.. National Army

^c With a view to betterment in gas defense methods an important duty of the medical director. Chemical Warfare Service, especially early in our front-line work, was investigation of gas attacks on our troops, with subsequent reports and recommendations. The two reports which appear here are typical save that several of the early reports of the medical director show gas defense methods in certain organizations to have been fair inferior to those described here. - Ed.

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AMERICAN EXPEDITIONARY FORCES,
HEADQUARTERS, SERVICES OF SUPPLY,
OFFICE CHIEF OF GAS SERVICE, A. E. F.,
June 20, 1918.

From: Medical director, Gas Service.
To: Chief of Gas Service, American Expeditionary Forces.

Subject: Report of recent gas attack on 2d Division.

1. I am submitting report of the recent gas attack on the 2d Division, during which over 800 casualties occurred, principally among the members of the 6th Marines, 5th Marines, and the 23d Infantry.

2. The troops subjected to the gas attack were holding a very important sector along the American front, extending from Bois to Belleau, and were ranged from left to right in the following order:
2d Battalion, 6th Marines.
2 companies of the 6th Marines, M. G. Battalion.
1st Battalion, 6th Marines.
3d Battalion, 23d Infantry.
2 companies, 5th Marines, M. G. Battalion.
1 company of the 1st Battalion, 2d Engineers.

The first three mentioned organizations were in the thickest of the gas attack and, as a result, furnished the greatest number of casualties.

3. The area bombarded was about 232 km. long by 1 km. wide, in a sloping ravine, heavily wooded with a thick underbrush. The gas attack began about 2 a. m. on the morning of the 15th and lasted until nearly daybreak. During this time, mustard gas alone was used. The shells were thrown over at a very rapid rate, it being estimated that from 2,000 to 5,000 were exploded during the attack. In this connection, attention is invited to extract copied from the divisional diary relative to this attack:

June 14. During the night and continuing throughout the day, the entire front line and many points in the back area of the division sector were intermittently shelled with gas, intermixed with some high-explosive shells. The gas shelling was with mustard gas. Up to 11 p. in. reports received indicated the evacuation of 700 gas casualties and the evacuation not completed. 11.30 p. m. gas bombardment along the entire front and back areas still continues. On account of the gas in the Bois-de-Belleau, the eastern edge of these woods was held by a thin line, the remainder of the battalion being withdraw n to the vicinity of Hill 181, which was free of gas.
June 15, 1918. The shelling of our front line and numerous points of our back area with gas and high-explosive shells continued, but with decreased intensity. The casualties due to this shelling up to 6 a. m. June 15 were 771.

4. Gas discipline. - The general gas discipline and morale of the troops during the bom- bardment was good. From all accounts, proper gas alarms were sounded in ample time for the adjustmnent of respirators, but in view of existing conditions--a pitch dark night, exploding shells on all sides, heavy underbrush, expected attack from the enemy, and the fact that the troops were worn out from several days of incessant fighting during which time they had little or no rest-they were in a state of physical depression and in fit condition for the action of poisonous gases. Again, many were scattered throughout the area asleep on the ground, and during the rush and darkness a few of these men were not awakened in time to apply their respirators. Some of the men had their respirators knocked off by the explosion of shells, colliding with trees, underbrush, etc. Many were compelled to remove them in order to see, still others removed the facepiece alone, and retained the mouthpieces and nose clip. From a careful study of all conditions connected with this gas attack, it is the opinion that little, if any, criticism can be offered concerning the actions of the officers and men during the attack.

5. Of the total number evacuated, perhaps 200 were slightly, if at all, gassed, but considering everything-their run-down condition and the fact that they had been subjected to the fumes of poisonous gas at periods when their masks were removed--it is the opinion that the action taken in removing these men to the hospitals was wise and resulted ill saving many of them.

6. Up to the present but 4 deaths have occurred from this attack, hut from the appearance of some of the cases seen by me, there will probably be 10 or 12 others. The principal reason for this low mortality was e to the excellent method of evacuation, the early removal of

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clothing and administration of baths, and the close proximity of the hospital to the gassed area. (See report of the chief of staff, 2d Division, marked "Inclosure A.")

7. The casualties resulting from this attack were immediately taken to the dressing station, where they were disrobed, bathed, wrapped in blankets, and later removed to the gas evacuation hospital at Luzancy, some 12 to 14 km. from the gassed area. At this hospital 775 gassed cases were received on June 14.

8. From the hospital at Luzancy, the cases were evacuated to Evacuation Hospital No.7, at Montanglaust; Evacuation Hospital No. 8, at July, and several hospitals in the vicinity of Paris. I was present at the gas hospital at Luzancy on Sunday afternoon, at which time a large evacuation was taking place. The chief surgeon of the division was present and had taken personal charge of the evacuation, which was handled in a very excellent manner. I visited the Evacuation Hospital No. 7, at Montanglaust, and examined 250 cases. The cases seen here presented symptoms of a slight nature, and it is the opinion that the large majority of them will be ready for duty within a week or 10 days. At the evacuation Hospital No.8, at July, I saw 153 cases. These cases presented symptoms of a much more severe nature than those seen at the former. (See analysis chart following.)

9. Attention is invited to the following table, which is the analysis of the symptoms of the cases seen under treatment at the above-mentioned hospitals:

Evacuation Hospital No. 7

CHART

From this table it will be noticed that 77 percent of the cases had eye infections, 81 per cent respiratory symptoms, 40 per cent burns of the scrotum, and 40 per cent had vomited.

10. The symptoms. - The symptoms presented by the casualties were typical of those produced by mustard gas. They were characterized at the beginning in a majority of cases by lachrymation and smarting of the eyes. The eruption in some cases occurred quite early, but in the large percentage was delayed for 48 hours or later.

11. The group of cases seen presented a large number of body burns, which can be accounted for as follows: Although the night was dry, the men were perspiring badly, and due to the conditions existing at the time of the gas attack they were obliged to crawl around among the thick underbrush, which was thoroughly saturated with the gas. In many cases their clothing was torn from their bodies, their hands and faces scratched, masks brushed from their faces, etc. Nearly all were obliged to lie down at some time during the attack.

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12. Respiratory tract. - Of the cases seen, 81 percent had symptoms of irritation of the respiratory tract. Laryngitis and bronchitis were present in a large percentage of the cases, especially in Evacuation Hospital No. 8, where a few cases were developing bronchial pneu-monia. I think the face burns examined were of a much more severe nature than any yet seen, and in all cases the men acknowledged that their respirators were either removed or knocked off sometime during the bombardment.

13. Lesions of the eyes. - At Evacuation Hospital No. 8 a large number of the cases presented inflammation and puffing of the eyes, with the usual conjunctival irritation.

14. Summary. - (1) The large percentage of casualties resulting from this attack was not due to lack of proper discipline and gas morale.
(2) That the low mortality was due to the excellent method of evacuation and to treatment that cases received when arriving at the hospitals.
(3) That the results of this gas attack show most emphatically the necessity of the early removal of clothing and bathing of all men subjected to mustard gas attacks; also the importance of having gas hospitals as close to the front as possible, where advance treatment can be given.

15. During this investigation every assistance was offered me by the officers of this division. Major General Bundy, in command of the division, was highly pleased at a visit from a representative of the Gas Service to conduct this investigation.

H. L. GILCHRIST, Colonel, Medical Corps.

HEADQUARTERS SECOND DIVISION (REGULAR),
AMERICAN EXPEDITIONARY FORCES,
France, June 16, 1918.
Memorandum for Colonel Gilchrist, Medical Corps:

The gas discipline of the men is excellent, and every man had and used his mask. The casualties were largely due to body burns, caused by clothing saturated with mustard gas. These we consider unavoidable casualties, when it is recognized that the troops occupied wooded and thickly grassed positions which had to be held.
The evacuation of wounded, hospital service, and general efficiency of the Medieal Department has been beyond criticism and has been just as well as it could have been done, in my opinion, in a complicated map problem.
All gassed men were promptly bathed at the dressing stations, their clothing taken away and they were sent wrapped in blankets to the field hospitals.
The approximate number of gas casualties is 900, hut it must he borne in mind that the division is under a constant and violent bombardment of gas and high explosive of all calibers, with gas mixed in with shell and shrapnel.

PRESTON BROWN,
Colonel, General Staff, Chief of Staff.

HEADQUARTERS 2D DIVISION,
AMERICAN EXPEDITIONARY FORCES,
France, June 16, 1918.

From: Chief gas officer, 2d Division.
To: Commanding general, 2d Division.

Subject: Gas attack.

1. A severe bombardment of high-explosive shrapnel and gas shell occurred on the morning of June 14.
2. The area bombarded was about 2 kin. long by I wide, in a wooded ravine extending east of Lucy-le-Bocage along the southeastern edge of Bois de Belleau.
3. This bombardment began about 2 a. m., while a relief was taking place. For two hours the shelling was very intense, one officer estimating a rate of 10 shells per minute per 100 square yards; another, "as fast as it was possible to put them over." It continued less intensely during the entire day. Mustard gas used extensively.
4. The troops subjected to this were the 5th and 6th Marines and part of the 23d Infantry, with some men of the 2d Engineers, 6th Machine Gun Battalion, 1st Field Signal Battalion, and Medical Department. About 2,500 men were in the area. These troops were either men who had been holding this line for 15 days or freshly arrived replacements, under fire for the first time.

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5 The morale was on the whole good, the gas alarm being given and respirators being adjusted, but in their anxiety to get out of the terrific fire many removed their respirators, or merely the facepiece, so as to be able to see more clearly and thus get out of the shelling more quickly.
6. The majority of the casualties occurred among these troops, who, although not remaining in the area for a great length of time, had been under such a strain for the past two weeks and were physically in such a weakened condition that a slight amount of gassing, which ordinarily would not have affected them, proved too much for their run-down systems.
7. Fully 200 out of the total of 850 were evacuated who really were not gassed, but showed slight signs of being affected, and it was deemed best to send them back rather than have them become serious casualties later on.
8. Two companies in the edge of the woods, where the gas was not so thick, remained in their position until 5 p. m., when they received authority to evacuate it. The troops here wore their respirators for three or four hours and intermittently the balance of the day, but gradually felt the effects of the dilute concentration, and many were slightly gassed.
9. Apparently comparatively few showed signs of lung irritation, the majority being affected in the eyes or burned on the body. These burns are accounted for by the men being compelled to crouch down in the gas-affected ground or push their way through bushes and undergrowth which had been splattered with gas.
10. In summing up, I should say that under the conditions the casualties are not excessive. Under the same conditions, moreover, had the men been fresh instead of worn out, the number of slight casualties would have been greatly reduced.

RUGER W. HAY, Captain, Engineers, U. S. R.

AMERICAN EXPEDITIONARY FORCES,
HEADQUARTERS SERVICES OF SUPPLY,
OFFICE MEDICAL DIRECTOR, GAS SERVICE,
July 2, 1918.

From: Medical director, Gas Service.
To: Office chief surgeon, Services of Supply, American Expeditionary Forces.

Subject: Report of gas attack.

1. Herewith inclosed report of investigation of gas attack on the 2d Division June 23, 1918.

H. L. GILCHRIST,
Colonel, Medical Corps, N. A.

AMERICAN EXPEDITIONARY FORCES,
HEADQUARTERS, SERVICES OF SUPPLY:
OFFICE CHIEF OF GAS SERVICE,
July 1, 1918.

From: Medical director. Gas Service.
To: Chief of Gas Service, American Expeditionary Forces.

Subject: Report of second serious gas attack in 2d Division.

1. I wish to make the following report relative to the gas attack which took place Sunday evening, June 23, in the 2d Division, from which resulted 414 casualties. This is the second gas attack which has taken place in the division during the present month, the former one occurring on the nights of June 14 and 15, resulting in over 800 casualties.

2. The recent gas bombardment took place in the sector of the line midway between Bouresches and Vaux, and covered an area ½ km. front by 2 km. deep. The part bombarded was in a heavily wooded valley, with much underbrush, and was occupied by troops from the 9th and 23d Infantry.

3. The bombardment began at 10 p. m. and lasted an hour during which time shells were discharged at the rate of about 15 per minute The night was warm and dry, with a slight breeze blowing from the north, which later changed to the northwest Following the bombardment there was a hill of nearly three hours during which time occasional shrapnel and artillery shells were exploded. At about 1 a. m. the gas bombardment was renewed with increased vigor. This attack lasted about 50 minutes, during which time gas shells were discharged at a greater rate than during the earlier attack. "Mustard' seems to have been the principal gas used, with a possibility of a slight mixture with other gasses.

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4. The following extract was taken from the war diary at division headquarters relative to this attack:
June 24, 6 a. m. Attack of the 3d Battalion, 5th Marines against the northern part of Bris-de-Belleau on the evening of June 23 proved successful. During the night the 3d Brigade, 9th Infantry, and 23d Infantry was subjected to a heavy gas bombardment inter-mixed with high-explosive shells for a period of seven hours. The Boise-des-Clerambouts was evacuated and is held only by a few patrols.

Gas casualties reported:
9th Infantry.......................................................... 152
23d Infantry.......................................................... 162
5th Machine Gun Battalion......................................................... 25
Casualties not all reported.

5. The casualties resulting from the bombardment were removed to the dressing station at Bezu-le-Guery, about 5 km. behind the line and from there evacuated to the special division gas hospital at Luzancy, some 8 km. farther back.

6. Up to the time of my visit, which was three days following the bombardment, no deaths had been reported as result of this attack, but from the serious condition of many of the casualties examined by me it is the opinion that several will succumb

7.Due to the excellent system of evacuation of wounded from this division, a large number of the casualties had been transferred to distant hospitals before my arrival; as a result I was permitted to examine a limited number. The following table is an analysis of the symptoms of those examined:

Total number of cases examined, 46.

Number Percent Number Percent
Those representing symptoms of Burns of the -
Respiratory Tract................................41 90
Chest.................................
Eyes.................................................41 90
Arms.................................1 2
Vomited............................................26 57
Axilla..................................
Nose bleed........................................48
Scrotum..................................17 37
Burns of the - Thighs...........................48
Face..................................................5 10
Buttocks.............................. 1 2
Neck.....................................................2 4
Hands................................
Back......................................
Feet.................................

8. The symptoms presented by the casualties were typical of those produced by mustard gas and nothing unusual was noted. It might be well to state, however, that the respiratory conditions appeared to be more severe than those seen on former groups.

9. The principal causes of the casualties (340 cases needing medical care) during this attack were as follows:
(1) Delay in applying respirators, and their promiscuous removal during and premature removal following the bombardment.
(2) Relying on poorly constructed dugouts.
(3) Failure to awaken sleeping men.
(4) Permitting men to enter an old mill in the gassed area and to remove their masks.

10. After careful analysis of the conditions associated with this attack it is the opinion that many of the casualties were the result of individual carelessness and, to a certain extent, poor company gas discipline. Of course, the fact must not be lost sight of that the members of these organizations were heavily engaged with the enemy for the past two or three weeks, during which time they have been subjected to many hardships, which has resulted in a general lowering of their physical condition, thereby rendering them in a fit state for the actions of poisonous gases. Nevertheless, considering everything in connection with this bombardment--the lowered physical condition of the men, the nature of the attack, darkness, heavy underbrush, poorly constructed dugouts, and permitting men to enter a gas-saturated building, etc.-it is the opinion that with proper care many of these casualties could have been averted.

11. From interviews with casualties resulting from this attack few seemed to be familiar with the question of mask removal during and following gas attacks. Some were of the opinion that they removed their masks immediately after the bombardment ceased; others stated they did not remove them until they saw their officers without masks, and still others said they removed them at intervals during the bombardment for the purpose of obtaining better vision or because the respirators were uncomfortable. Few had received orders of any kind from officers or others relative to removal of masks.

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12. The dugouts appear to have been one of the principal causes for the gas casualties. These dugouts, from all accounts, were but mere holes of different sizes dug in the side of the trenches, some capable of holding two men, others more; all were protected by hanging curtains made of shelter halves dropped in front. The men entered these places thinking they were safe and removed their masks; as a result many became gassed.

13. Many men were gassed in an old mill which was in the midst of the gassed area. Following the bombardment the men entered this place, removed their masks, and laid down on the gas-saturated hay-covered floor to rest. All stated the odor of gas was very strong at the time, but inasmuch as their officers were present without masks they thought the place safe. Many men were gassed because they were not awakened when the gas attack began. Others stated they smelt the gas long before any gas alarm was sounded.

METHOD OF EVACUATING GAS CASES AND THEIR TREATMENT

14. The method of evacuation of gassed casualties and their treatment at the dressing station has been carried out so successfully in this division that a brief description of the methods will be given. When gas casualties occur they are immediately removed to the dressing station, which at present is established at Bezu-le-Guery and is operated by Field Hospital No. 1, United States Army. It occupies the church adjoining schoolhouse and two or three near-by buildings. It is divided into sections-the operating section, dressing section, degassing section, and administrative section. Two tents have been erected adjoining a small building fitted up as a bathhouse, which are used for gassed casualties. Here they are stripped and assigned to the baths, those presenting serious symptoms are not permitted to get up but are bathed on litters in a reclining position; the others are marched into the bathhouse, where they are given hot baths. The bathhouse is equipped with a portable heating apparatus connected with six shower heads. After the men have been bathed and dried, their eyes, noses, and throats are sprayed with a solution of bicarbonate of soda, following which they are re-dressed in pajamas and removed to the church, which is fitted up asa temporary hospital. From here they are evacuated to the special gas hospital at Luzancy as soon as possible. The administrative and operating part of the dressing station is located in the schoolhouse.

15. At the commencement of a gas bombardment the commanding officer of the dressing station is notified by messenger, thereby giving him ample time to prepare for the reception of the casualties. A special medical officer, with enlisted assistants, has charge of the degassing tent and baths; another is responsible for the irrigations; and others are responsible for administration of proper nourishment, etc. The men in the degassing section wear rubber gloves and aprons when handling the patients and when handling the seriously gassed wear the French M. 2 masks. The success of the organization depends upon simplicity of methods, strict discipline, and thorough organization.

16. Attention is again invited to the subject of long hair in connection with gassed cases. This matter has been taken up before and recommendation made that all men in the front area be compelled to have the hair on their heads closely cropped. I am firmly convinced that long hair on the head has much to do with the harboring of poisonous gasses, thereby being responsible for many men being gassed after the removal of their masks. All medical officers interrogated relative to this subject are of the same opinion. It is again recommended that all men serving in the front areas be compelled to have their heads closely cropped.

17. Gassed casualties in this division. - It might be well to invite attention to the number of gassed casualties that have occurred in this division since the 1st of June, which will serve the purpose of giving some sort of an idea of what may be expected from other divisions after they enter the front area. From figures obtained from the division commander it appears that from June 1 to 6 a. m. on the morning of June 27 there had been 1,924 casualties in this division from the effects of poisonous gasses. At present it is impossible to state the number of deaths, but from the available figures obtained from the office of the chief surgeon, American Expeditionary Forces, and other souces it appears that the mortality list will be between 2 and 2½ per cent. The commanding general of this division is greatly interested in gas matters and it appears has made every attempt to enforce rigid obedience of gas orders; notwithstanding there have been cases of apparent lack of gas discipline on the part of individual company commanders which have resulted in gassed casualties.

H. L. GILCHRIST,
Colonel, Medical Corps, N. A.

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REPORTS OF DIVISION SURGEONS, 42d Division. ^d

FIRST REPORT

GAS PROTECTION AND INSTRUCTION

The use of gas in modern warfare had become extensive and, unless great precautions were taken, produced so many casualties that it became one of the big problems with which we had to deal. Shortly after arrival at the front it became evident that there were certain essential features connected with gas warfare that could not possibly be handled by line officers acting as the divisional gas officers. It was seen that a medical officer specially elected and trained was an absolute necessity in order to properly cover the medical aspects of the case. This idea was followed; an officer was selected, sent to the British front for instruction, and then attached to the division surgeon's office, but without any official definite status. His work, however, proved of such value that he was designated division medical gas officer by a division order (Memorandum 148, H. Q., 42d Division, April 23, 1918). This was the beginning of the division medical gas officers of the American Expeditionary Forces, inasmuch as the idea was adopted by higher authorities and the office authorized for each division in the American Expeditionary Forces by a general order from General Headquarters. His duties consisted in instructing medical personnel, commissioned and enlisted, in gas defense, supervision of gas protection of medical dugouts, aid and dressing stations and field hospitals, and particularly to instruct medical personnel, commissioned and enlisted, in the early symptoms, diagnosis, and treatment of gas casualties of all types. In modern warfare this work is extremely important, and if properly followed will result in the saving of many lives, of the shortening of the period of disability in a large number of cases, as well as altogether preventing the occurrence of gas casualties in many instances.

Memorandum No. 118.

HEADQUARTERS 42D DIVISION,
OFFICE OF THE SURGEON, A. E. F.,
April 24, 1918.

DEFENSE MEASURES AGAINST GAS, MEDICAL DEPARTMENT
To surgeons of all organizations:

1. Every officer is responsible that the men under his command are carefully instructed in defense measures against gas that they will properly protect themselves and intelligently aid those who have become casualties from exposure to gas.
Familiarity through continuos training with the means supplied to combat gas attacks and with the procedures necessary for the successful relief of those affected by poisonous gas is required of all officers and men.

2. Standing orders on defense against gas, April 18, 1918, must be strictly adhered to, and special orders here detailed must be rigorously enforced.
A. Standing orders which should be given special attention are:
I. Carriage of respirators and masks in prescribed zones.
II. Training in quick adjustment of respirators.
III. Practice in the use of antigas appliances.
IV. Alarms and warnings.
B. Special orders on defense against gas:
I. Besides the usual inspection of respirators and masks, there shall be an additional inspection before sanitary troops proceed into forward Areas.
II. Proficiency must be acquired in the quick adjustment of respirators and masks, especially as concerns holding the breath both at inspiration and expiration. A deep breath may fill the lungs with air contaminated with gas with disastrous results.
III. Practice in adjustment of respirators and masks to those impersonating helpless men is required twice weekly.

⁴ The first of these reports was made by Lieut. Col. J. W. Grissiniger, M.C., division surgeon; the second and third by Col. D. S. Fairchild, Jr., M. C., who succeeded the former officer as division surgeon - Ed.

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IV. In the event of a cloud gas attack or gas-shell bombardment-
(a) Gas-proof dugouts will be closed immediately.
(b) Fires in dugouts will be extinguished and chimneys closed.
(c) A sentry will be posted inside the entrance curtain to prevent the entrance of men whose clothing is known to be contaminated with gas, until such clothing is removed.
(d) Litter bearers will completely close the outer curtain, before opening the inner one, when entering medical dugout.
Drill with loaded litters, observing these precautions, is required.
V. Medical dugouts should be sprayed frequently and the blanket protection kept moist with a solution containing-
Hexamine......................................................................grams...70
Sodium sulphite..................................................................do.......115
Sodium thiosulphite (hypo)..............................................do.......195
Water........................................................................liters.....4
Heat slightly to dissolve.
This solution will neutralize small amounts of gas admitted during frequent entrance to dugouts. Tissol respirators should be worn, if necessary.
For ordinary moistening of blankets the following solution should be used:
Sodium carbonate (washing soda)...................................grams..240
Sodium thiosulphate (hypo)...............................................do.......480
Water.......................................................................liters......4
Owing to the corrosive action of these mixtures they must not be kept in vermoral sprayers, as the apparatus will be ruined.
VI. Care must be taken that men sleeping in closed spaces are not gassed by long exposure to small quantities of gas unknowingly brought in on their clothing or equipment.
VII. No man affected by gas, however slightly, will be allowed to walk to a dressing station or to exert himself physically in any way.
VIII. Precautions will he taken to protect surgical instruments and appliances from the corrosive action of gas.
IX. Lyster bags must be carefully and completely covered to prevent contamination from gas.
X. It is forbidden to use water from shell holes for drinking, cooking, washing, or bathing.
XI. Food which has been exposed to gas must be destroyed.
XII. To provide for clearing of dugouts by fire, a waterproof receptacle must be kept in each dugout containing dry wood, chips, and paper, together with a 4-ounce bottle of kerosene. (A bacon can supplied with a good cover will answer the purpose.)

3. Mustard gas: I. Anyone close to the burst of the gas shell may have some of the liquid sprayed on his clothes. When possible, the clothes will be removed.
II. If mustard gas is present, the area is dangerous usually for one or two days, and sometimes for four days, or even longer. The area is to be regarded as dangerous as long as the odor of mustard gas can be detected. The danger of mustard gas lies in its insidious nature, because no appreciable irritation either of the eves, throat, or skin is produced at the time.
III. If there is a suspicion that mustard gas has touched the skin, it should be powdered with chloride of lime and then washed thoroughly with soap and water. If these are not available, thorough washing with pure water will aid materially.
IV. Do not put the fingers in the eyes or mouth, scratch the skin, or touch the genitals or anus, and thus risk contamination with mustard gas, unless the hands have been disinfected.
V. Mustard gas is promptly diffused in the presence of heat. Therefore no mail wear-ing or bearing contaminated clothing will enter any heated room or dugout.
VI. The use of latrines in an infected zone should be immediately forbidden until they have been disinfected and washed with chloride of lime.
VII. With a view of obtaining, in the methodical disinfection of ground bombard(led by mustard-gas shells, the most complete results possible, it is necessary to give particular instruction to a certain number of men wvho will form detachments furnished with all necessary materials.

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A disinfecting detachment comprising one noncommissioned officer and six privates should be used, provided they are not required for the service of the wounded. In the latter event, disinfection will be accomplished at the earliest possible moment.
VIII. Those who handle gas cases and their discarded clothing and equipment must be properly protected by gas masks, antigas clothing, and oilcloth mittens and be provided with tongs or pincers.

4. Antigas stores: ^e

Alarm devices. Gas caps. Sodium chloride.
Box respirators. Gas coats. Ammonia ampules.
Masks. Oilcloth mittens. Camphor in oil.
Extra eyepieces. Soap. Morphine.
Tissot respirators. Needles. Cocaine.
Gas-proof coverings for dug-outsThread. Medicine droppers.
Vermoral sprays Tongs or pincer Ambrine.
.Solution jars. Nails. Oxygen tanks and connections
Buckets. Shovels. Catheters for oxygen administration
Antigas fans. Chloride of lime. Rubber tubing
Fuel for clearing dugouts. Hexamine. Gauze.
Four-ounce bottles for kerosene Sodium thiosulphate (hypo). Sodium bicarbonate..
Oilcloth.Sodium sulphite. Sodium carbonate.

BANDAGES

Commanding medical officers of units relieving one another are responsible that the stores are properly taken over.

The divisional medical gas officer will make arrangements for the weekly inspection of all antigas stores. Commanding officers should take this opportunity to inform the D. M. G. 0. or his N. C. 0. of any stores which are deficient or damaged.

5. Treatment of gas casualties:
A. Aid stations -
(1) Retain masks on patients until danger is over.
(2) Avoid unnecessary movements.
(3) Ammonia inhalations by litter bearers to all cases with dyspnea.
(4) Loosen or remove clothing; remove equipment.
(5) Encourage vomiting by tepid salt water.
(6) Avoid atropine.
(7) Attention to eyes of mustard-gas cases.
(8) Administer oxygen, if necessary.
(9) Evacuate promptly as litter cases.

B. Dressing stations-
(1) Keep patient recumbent in open air if possible.
(2) Ammonia inhalations.
(3) Oxygen, if possible.
(4) Morphine for restlessness.
(5) Treat eyes of mustard-gas cases (cocaine 2 per cent, if necessary).
(6) Retain shock cases for treatment (warmth, camphor in oil).
(7) Evacuate cyanosed cases quickly for oxygen treatment.

C. Gas hospitals -
(1) Relieve of equipment in receiving room.
(2) Remove clothing in disrobing room.
(3) Bathe under hot-water showers, using an alkaline soap (lying and sitting cases).
(4) Irrigate eyes and burns with alkaline solution, and supply with clean clothing or blankets.
(5) Remove to wards on litters.
(6) Separate mild from serious cases.
(7) Treat shock (heat, camphor in oil, pituitrin).
(8) Morphine for restlessness.
(9) Ammonia inhalations during first 24 hours only.

^e For other supply lists fee Appendix, pp 831, 832. - Ed.

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(10) Posture for edema: Raise the foot of the bed.
(11) Pure oxygen for chlorine and phosgene cases.
(12) Venesection for congestive cases.
(13) Liquid diet first day.
(14) Mild purge third day.
(15) Expectorants after second day.
(16) For cough, mild sedatives and spray of albolene and eucalyptus.
(17) Treat burns with ambrine when necessary; use no fatty ointments.
(18) Wounded cases to have special attention.
(19) Reserve masks to the number of 20 per cent of the maximum bed capacity to be always on hand.
(20) A mask or respirator will be hung at the head of the bed of every patient, for emergency use.
(21) Contaminated clothing will be sterilized and laundered before being reissued.

6. Solution for irrigating eyes of mustard-gas cases:
Sodium bicarbonate...............................................................grams...........150
Sodium chloride......................................................................do....................70
Water..............................................................litres..................5
Apply warm as an irrigation to eyes and nose, and use on compresses continuously in the acute stage.

7. It is directed that a copy of this memorandum be furnished each medical officer in your command.

J. W. GRISSINGER,
Lieutenant Colonel Medical Corps, U. S. A.,
Division Surgeon.

SECOND REPORT

FIELD HOSPITAL AS GAS HOSPITAL

Before entering this engagement (Aisne-Marne), guided by the large number of gas casualties reported by the divisions in the line, it was decided to set aside one field hospital, to function entirely as a gas hospital, whose duty it would be to produce a teamwork system that would insure both speed and efficient care in the treatment of the gassed. Field Hospital Company 167 was designated as the gas hospital, and ever after during active operations continued to specialize in this line. The scheme devised by this organization was crystallized into its final form during the operations at Bezu-St. Germaine and is described briefly below.

Upon assuming the functions of a divisional hospital for the treatment of gas casualties it became necessary for Field Hospital Company 167 to modify and add to its equipment and to specialize its personnel. Additions to the equipment were as follows: A portable bath equipment; additional oxygen tanks and connections; chemicals required for the various alkaline solutions; clothing surplus; oilcloth gloves and clothing for protection of personnel.
(1) For a receiving ward, a ward tent was alwavs used so that when weather permitted the walls could be rolled up and adequate ventilation be thus obtained. Here the patient, always recumbent, was examined and his clothing was removed, during which time records were taken and field cards started by a force of clerks circulating among the patients. As quickly as possible all hair was clipped and the patient was wrapped in blankets. At this time a bag was supplied for personal effects, which always accompanied the patient, thus eliminating the checking system which at all times, and especially in rushes, was found to be most unsatisfactory. The patient was given a 2-ounce dose of an alkaline solution internally and was then carried to the next room.
(2) The bath and treatment room was usually in a ward tent, though when available a building was sometimes used. Here patients were placed on horses [wooden] under shower heads, the litters being protected by rubber blankets. Conveniently placed was a series of irrigating vessels with rubber hosing and nozzle attachments. By means of these, alkaline irrigation of the eyes, ears, nose, mouth, axillac, and genitals was accomplished while the rest of the body was being treated with alkaline soap. Then a full bath in comfortably warm water was given. This finished, other details were ready to dry, powder, and provide clean hospital clothing.

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(3) The patient was then ready to be taken to his ward and put to bed. In so far as possible, the cases were placed and classified according to severity and also to kind of poisoning. Each ward was provided with oxygen, stimulants, heating appliances, and blood-letting outfits. Here the patient remained until it was deemed advisable to remove him to the (4) evacuation ward. This system was so devised that the current of patients and attendants was always in one direction. Every effort was made to obtain a rapidly moving and smoothly working system so that, when necessary, a large number of cases could be passed through as quickly as possible. The personnel was divided into various teams, each with a definite part of the work to perform. So adept did these teams become that when the occasion arose it was possible to pass patients through at the rate of one every three minutes.

THIRD REPORT

MEDICAL GAS DEFENSE

The duties of the Medical Gas Department before and during the service of the 42d Division in the Lorraine sectors consisted of instructing and training members of the division in the methods of defense against gas warfare.

Some knowledge of the various kinds of gases already in use, as well as the markings of projectiles and containers, was made known, and definite information regarding protection against new gases was supplied to all medical officers and gas N. C. O.'s who were established in the areas exposed to gas.

In the matter of protection, all troops were instructed thoroughly and frequently in drill with respirators and masks, which were inspected daily in the alert zone and weekly in the ready and precautionary zone. Five per cent extra gas-mask equipment was kept on hand, together with antigas stores.

All stretcher bearers and first-aid men carried ammonia ampules, and were instructed in their use; they were also warned of the necessity of the proper adjustment of respirators to casualties within the gassed area; and for even mild cases, were advised of the danger from exertion.

To render dugouts tenable, they were constructed so that all chimney openings could be sealed perfectly, and no passage was constructed which was not protected by double doors, these doors being 3 feet wide and placed at least 8 feet apart, to permit the entrance of an occupied litter, so that the outer blanket could be properly arranged before the inner one was opened. Blankets for these openings were made sufficiently long to cover the frame without touching the ground, and were 4 to 6 inches wider than the frame, so that when they were in place they would fall over the edges. By nailing a lath to the top of the frame, tearing was prevented; another lath, tacked at the bottom, made a core upon which the blanket was rolled when not in use at the top of the frame, the rolled blanket being held in position by a string tied in a slip knot to allow of instant dropping in emergency. Weights were sewed into the free edges of the blanket to secure perfect closing. These curtains were kept impervious to gas by saturation with water or other fluid. For this purpose a Vermoral sprayer was kept at hand to be used twice daily, or as often as necessary.

Within the dugouts at least two Ayrton flappers for cleaning the approaches were kept, together with a moisture-proof tin box, containing dry wood, paper, and a small bottle of kerosene for clearing the chambers by fire. Approximately 1 pound of fuel to 200 cubic feet of air space was required. A bright-burning fire, without smoke, 6 inches off the floor, in the center of the room, was found to be the best means for clearing it from gas which may have entered at some opening or have been carried in on the clothing of casualties or litter bearers. In addition, the interiors of the chambers were sprayed occasionally with a Vermoral sprayer containing a solution of-
Hexamine........................................................ounces.........2½
Sodium sulphite............................................do.................3¾
Sodium hyposulphite...................................do................6½
Water.............................................................gallon...........1

The solution was heated in the making and thereafter kept in stoppered jugs, or other nonmetallic containers. On account of its corrosive action, it was not kept in Vermoral sprayers.

The treatment of gas casualties at the front consisted in administering ammonia to those with dyspnea, relieving the constriction of clothing and equipment, removing clothing contaminated with gas before entering the dugout, and using precautions against chilling.

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Oxygen was supplied through fresh air or artificially. There was kept on hand a number of small tanks of oxygen, with tubing attached, containing sufficient gas to last during a part at least of the time of transportation to evacuation hospitals.

For the burning effects of mustard gas, bleaching powder, in the proportion of 4 ounces to the gallon of water, was used, recent experiments having proved its efficacy. Treatment generally aimed to accomplish the following: (1) To diminish the respiratory activity of all gassed cases as 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 up the circulation; (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.

With the removal of casualties to hospitals, treatment was instituted immediately, bearing in mind that as little exertion as possible should be made by those gassed. Those of congestive type were relieved by venesection, 1 or 2 pints of blood being removed, care being taken subsequently to restrict the fluid intake. Administration of oxygen over a considerable period of time, 4 minutes out of every 15, was of paramount importance. The Trendelenburg position relieved some of the embarrassment of respiration by draining the bronchii and thereby also relieving the cough. Artificial respiration and stimulation with ammonia, camphor in oil, and strychnine were given in emergency. Morphine was useful as a sedative, and mild expectorants for the cough. Atropine and digitalis were contraindicated.

Various schemes for the administration of the oxygen were devised, mostly with the idea of supplying a large number of cases from a few tanks of gas. The multiple tube attachments seemed most desirable, those of the overhead piping giving the cases at the end of the line a dearth of gas.

The treatment of mustard-gas casualties required a totally different procedure, and the one followed by the French was adopted. A building set apart was subdivided, and an entrance room for the reception of cases contained benches and a number of slotted tables, where all clothing was removed from those gassed, both simple cases and those cases complicated by wounds, a numbered bag being issued to each man for his personal belongings. A communicating shed contained tanks, 10 by 10 by 10 feet, filled with water or a solution of bicarbonate of soda, in which clothes were allowed to soak from 3 to 12 hours before being hung in the open. This solution was not allowed to boil, for steam vaporized the mustard gas. From the receiving room the men were taken to the shower room, which was heated and where a thorough bath with hot water and soap was given, particular attention being paid to hairy parts. The wounded were bathed on slotted tables placed under the showers and, after bathed, were given fresh clothing or blankets and removed to the wards for warmth and local treatment. The eyes were flushed frequently with a solution of -
Carbonate of soda........................................grams.............150
Sodium chloride............................................do.....................70
Water............................................liters..................5

Cocaine and ice compresses were used for the relief of pain.

These cases suffered considerably from involvement of the areas most plentifully supplied with sweat glands, most notably the genital and axillary regions, and a soothing ointment with a fatty base, lanoline with chloramine-T for the mild and ambrine for the severe type of dermatitis was used with good results.

Men detailed to handle and to treat the contaminated material wore special gloves which had been saturated with boiled linseed oil; soft soap rubbed into canvas gloves gave protection for a short time.

The gas casualties while on the Lorraine front were 517 between February 23 and March 25, 1918. The report of the number of gas casualties on the night of March 20 and 21 showed 5 officers and 197 men, the gas used principally mustard, although there were clinical reasons to prove that other gases also were sent over either individually or in combination with mustard gas. The containers were gas shells.

There were definite reasons for this large casualty list, some legitimate, but, for the most part, preventable; first, there was shown to be insufficient training in gas defense, and, second, disciplining was insufficient. The element of ignorance of the definite rules for gas defense as expressed in the various ways was shown by the character of the casualties and the excuses given. The majority of the eases showed burns over the entire face and lung involvement of a serious nature, proving conclusively that respirators were adjusted too late, not worn

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at all, or removed too soon. An analysis of the excuses for gassing showed that the serious consequences possible were not considered by many in the event of small amounts of gas which were put over at the same time as high explosives, and explained some legitimate casualties, and besides the atmospheric conditions were ideal for the use of gas.

The gas casualties at Baccarat, on the Lorraine front, were 430 between April 23 and June 19, 1918. An effort was made in each individual case to verify the symptomatology, and to ascertain if possible the exact conditions, circumstances, and time when patients received the gas. As an example, the 150th Field Artillery were shelled by gas on May 2 and 3, resulting in 16 casualties. Observations were made as follows: One man received gas by running into an unprotected dugout, opening into a shell pit, after the air in the open was apparently clear. Another was badly burned in repairing telephone wires which had been put out by a gas shell. Still another was gassed while running by a field piece which had received a direct hit. One was gassed in a gun pit, while working on the gun, by a shell which struck the side of the pit and sprayed the piece. The next man, from symptomatology, was probably gassed the day before by a shell that struck less than 10 feet away. Another was gassed by coughing off his gas mask, while bringing up shells. One case was asleep in the kitchen when it received two direct hits, the first spraying the front door with gas, the second landing directly on top. Two were probable malingerers.

The symptoms were as follows: Three cases had burns which were their most prominent symptom; a number of others complained of respiratory embarrassment, first noticed when walking away from the guns after relief, but attributed at the time to fatigue; still others complained of sore throat and said, "They felt as though their throats were extremely dry and parched," and one man was burned from knee to ankle by a contaminated puttee.

Aside from the medical interest, it was rather remarkable that these men were able to operate their guns continuously throughout the period of action, although practically deluged with gas five times within 36 hours, the last shelling being mixed with high explosives in the ratio of about 1 to 4.

The next engagement was on the Champagne front, from July 12 to July 19, 1918; while of short duration the bombardment from the enemy was most intense. The damage, however, from a gas standpoint was of little importance, our casualties being only 116 in number, mostly slight cases. The proportion of high-explosive to gas shells used here was greater than usual, and the type of gas used less dangerous.

The Chateau Thierry front, where the type of warfare changed from defensive to offen- sive, necessitated also a change in the divisional methods of handling gas casualties. In the Luneville and Baccarat areas, patients had been evacuated to the evacuation hospitals, which were in neither case over 12 miles from the line. Here, however, and on later fronts, these hospitals were so far in the rear that it became necessary to use one of the four divisional field hospitals for the care and treatment of gas casualties, and it became known as the division gas hospital.

In the St. Mithiel sector, from September 12 to 21, 1918, the casualties were slight, only 78 gassed cases being received in the divisional gas hospital, of which 31 were returned to duty in from one to three days.

From October 8 to the time of the signing of the armistice, the division was on the Argonne front, and casualties from gas were high, due in part to the wooded nature of the country. Of the 1,129 cases received at the advanced dressing station, 481 were returned to duty from the division gas hospital after from one to five days of treatment and observation.

From experience, it is the belief that a gas hospital may be successfully operated either as a stationary or as a movable unit, with the present personnel of a field hospital as indicated in the Tables of Organization, if augmented by a sufficient number of teams thoroughly trained in the treatment of acute poison-gas casualties and certain necessary additions to equipment.

A field hospital under canvas commanded by a major, assisted by 5 junior officers and an enlisted force of 83 men, is capable under ordinary circumstances of caring for as many gas casualties as may be transported by the 48 ambulances of a division, if the capacity of the hospital is limited to its maximum of 400 patients. If, however, such a unit be in tents, barracks, or permanent buildings should he called on to care for more than its tent capacity of 400 patients, sufficient hell) could be obtained by the temporary assignment of Previously trained teams of three medical officers and 5 nurses for each 200 patients.