WAR DEPARTMENT TECHNICAL MANUAL 
TM 8-285 
This manual supersedes TM 8-285, 15 April 1944. 
TREATMENT 
OF CASUALTIES 
FROM 
CHEMICAL AGENTS 
WAR DEPARTMENT 
APRIL 1945 
United States Government Printing Office 
Washington: 1945 WAR DEPARTMENT 
Washington 25, D. C., 30 April 1945 
TM 8-285, Treatment of Casualties from Chemical Agents, is 
published for the information and guidance of all concerned. 
[AG 300.7 (7 Mar 45)] 
By order of the Secretary of War: 
Official : 
J. A. ULIO 
Major General 
The Adjutant General 
G. C. MARSHALL 
Chief of Staff 
Distribution : 
AAF (Surgeon) (6) ; AGF (Med Sec) (12) ; ASF (2) ; Dept. 
(4) ; Arm & Sv Bd (1) ; S Div ASF (1) ; Tech Sv (12) ; 
Tech Sv (Tng Div) (4) ; SH (5) ; USMA (10) ; ROTC Med 
Units (12) ; D 1, 2, 7, 17, 44, 55 (3) ; B 2, 4, 5, 6, 18, 44, (5) ; 
R 2-11, 17, 18, 44, 55 (5) ; Bn 8 (3) ; C 8 (5) ; W (5) ; G (5). 
Refer to EM 21-6 fcr explanation of distribution formula. CONTENTS 
Paragraphs Page 
SECTION I. GENERAL 1-3 1 
II. LUNG IRRITANTS 4-7 3 
III. VESICANTS 8-14 9 
IV. LACRIMATORS 15 30 
V. VOMITING GASES (NOSE GASES, IRRITANT SMOKES, 
STERNUTOTORS) 16-18 31 
VI. SCREENING SMOKES 19-23 33 
VII. INCENDIARY AGENTS 24-28 35 
VIII. SYSTEMIC POISONS 29-32 38 
IX. INCIDENTAL GASES 33-37 42 
X. OXYGEN DEFICIENCY 38 46 
XI. ANIMAL CASUALTIES 39-46 48 
APPENDIX I. A GUIDE FOR DISPOSITION OF PERSONNEL WITH 
BLISTER GAS BURNS 54 
II. GENERAL PRINCIPLES IN HANDLING OF CASUALTIES 
CONTAMINATED BY CHEMICAL WARFARE AGENTS 95 
III. MEDICAL DEPARTMENT ITEMS FOR FIRST AID AND TREAT- 
MENT OF CHEMICAL WARFARE CASUALTIES 102 
IV. CARE OF CONTAMINATED CLOTHING AND EQUIPMENT AT 
MEDICAL INSTALLATIONS 105 
V. TREATMENT OF BURNS Ill 
VI. DETECTION OF CONTAMINATED WATER AND ITS PURIFICATION 114 
VII. CHEMICAL AGENT CONTAMINATION OF FOOD, FORAGE AND 
GRAIN 121 
INDEX 126 This manual supersedes TM 8-285, 15 April 1944. 
SECTION I 
GENERAL 
1. Introduction 
a. Chemical warfare agents are used to produce casualties, to 
render food, water, and material unusable, to make terrain im- 
passable or untenable, to provide concealment and to start fires. 
b. The scope of chemical warfare is broad. It aims at groups 
rather than individuals. Gas can penetrate dugouts, emplacements 
and trenches. With the help of the airplane, chemical agents may 
produce casualties and destruction well back into the rear areas. 
c. The purpose of this manual is to acquaint medical personnel 
with the treatment of casualties produced by chemical agents. 
Since medical units are themselves subject to chemical attacks, the 
medical officer must be familiar with the tactics of, and defense 
against, these attacks, as presented in FM 3-5 and 21-40. 
2. Classification of Agents 
Chemical warfare agents are classified accrding to their phy- 
siological action, persistency, and tactical use. 
a. Classification by Physiological Action. (1) Lung irri- 
tants (choking gases) primarily irritate and damage the respi- 
ratory tract (Example: phosgene). 
(2) Vesicants (blister gases) injure the eyes, produce redden- 
ing and blistering of the skin, when inhaled damage the respiratory 
tract, and when absorbed cause systemic poisoning (Example: 
mustard). 
(3) Lacrimators (tear gases) act primarily on the eyes, causing 
tears and intense, though temporary, pain (Example: chloraceto- 
phenone). 
(4) Irritant smokes or sternutators (vomiting gases) irritate 
the nose, throat, and eyes. They may produce temporary prostra- 
tion (Example: diphenylaminechlorarsine (adamsite)). 
(5) Systemic poisins (blood and nerve poisons) stop essential 
physiological processes (Example: hydrocyanic acid). 
b. Classification by Persistency. The ability of an agent to 2 
maintain an effective concentration under field conditions is called 
its persistency. 
(1) Presistent agents are dangerous longer than 10 minutes, 
and may last for days or weeks. They are used to neutralize or 
force evacuation of certain areas (Example: mustard). 
(2) Nonpersistent agents usually are dangerous less than 10 
minutes. They do not render ground untenable after the cloud has 
passed (Example: phosgene). 
c. Classification by Tactical Use. (1) Casualty agents in- 
jure personnel (Example: mustard and phosgene). 
(2) Harassing agents force the wearing of masks and thus im- 
pede operations (Example: irritant smokes). 
(3) Screening agents produce obscuring smoke to prevent ob- 
servation (Example: white phosphorus). 
(4) Incendiaries ignite materiel and produce burns on personnel 
(Example: thermite), 
3. Fundamentals of First Aid and Treatment 
a. First Aid. (1) Immediate first aid following contamination 
with liquid blister gases is the all important factor in reducing the 
number of casualties since there are definite time limits after which 
first aid measures are useless. Decontamination combines both 
neutralization and removal of the agent before serious injury oc- 
curs. Unless incapacitated, each man will care for himself. 
(2) If the soldier has been contaminated by liquid blister gas, 
as from an airplane spray or bomb burst, he will be confronted 
with the problem of carrying out several first aid or protective 
measures as rapidly as possible. With due regard to the prac- 
ticability of carrying out these measures under the existing tactical 
situation, the following order of procedure is recommended: 
(a) Apply first aid measures for eyes contaminated with liquid 
blister gas and follow by discontamination of the face. Hold breath 
until masked if at all possible. 
(b) If wearing eyeshields, remove and discard. Discontaminate 
face and then apply gas mask. Hold breath until masked if at all 
possible. 
(c) Remove or cut away clothing which is heavily contaminated 
with liquid blister gas. 
(d) Decontaminate areas of skin which have been contaminated 
by liquid blister gas. 
b. Treatment. Treatment designed to promote healing after 
injury has occurred, should be distinguished from first aid. Treat- 
ment is the function of the Medical Department. SECTION II 
LUNG IRRITANTS 
4. General 
a. The most important lung irritants are phosgene, chlorpicrin 
and chlorine. In general, the gases which are the most irritating, 
such as chlorine and chlorpicrin, are most likely to injure the 
trachea and bronchi, but also may cause pulmonary edema. Those 
which are less irritating such as phosgene, produce their major 
effect on the lungs and cause pulmonary edema. In addition to the 
above-designated lung irritants, vesicants, certain systemic poisons 
and incidental gases also damage the respiratory tract. (See secs. 
Ill, VIII, and IX.) 
b. Troops exposed to a lung irritant gas need not be withdrawn 
during combat unless signs of pulmonary distress are apparent. 
The surgeon should so advise the responsible field commander. 
c. Any service mask with M9A2 or later model canister the col- 
lective protector affords adequate protection. 
5. Phosgene (CG) 
a. Pathology. Aside from mild conjunctival irritation, the di- 
rect effects of exposures to phosgene gas are confined to the lungs. 
Changes in other organs are secondary to the pulmonary altera- 
tions and are relatively unimportant. The outstanding pathologic 
feature in the early stage is massive pulmonary edema; this results 
from the passage of fluid into the alveoli from capillaries whose 
permeability has been affected by the action of the agent. It is pre- 
ceded by damage of the bronchiolar epithelium, the development of 
patchy areas of emphysema and partial atelectasis, and edema of 
the perivascular connective tissue. The epithelium of the trachea 
and larger bronchi is not significantly damaged. The lungs are 
large, edematous and darkly congested; edema fluid, usually frothy, 
pours from the bronchi and exudes from the sectioned lung tissue. 
Hemoconcentration results from the loss of plasma into the alveoli. 
The edema usually reaches a maximum 12 to 24 hours after gassing, 
and results in interference with the interchange of oxygen and 
waste products between the alveolar air and the capillary blood, 
so that in most instances of lethal exposure, death occurs within 
3 4 
the first 24 or 48 hours from the resulting anoxemia. With very 
high exposures, death may ensue in 5 hours, or possibly even less. 
In surviving individuals the edema begins to resorb after about 
48 hours and, in the absence of complicating infection, recovery 
may take place with practically complete resolution of the lesion. 
Should this process be complicated by secondary bacterial infection 
of the lungs the clinical signs of a purulent bronchitis and broncho- 
pneumonia will be apparent at about 3 to 5 days. In some cases 
there may be focal intrabronchial and peribronchial fibrosis as a 
result of the initial damage to the bronchiolar walls. Investiga- 
tions have shown that in recovered individuals, the percentage of 
cases showing significant residual lesions is small. Such lesions as 
were found following gassing in the last war consisted chiefly of in- 
tances of chronic emphysema, chronic bronchitis or bronchiectasis, 
and pulmonary fibrosis. 
b. Symptoms. Immediately after exposure there is likely to be 
coughing, choking, a feeling of tightness in the chest, nausea and 
occasionally vomiting, headache and lacrimation. The presence or 
absence of these systems is of little value in immediate prognosis, 
as some patients with severe cough fail to develop serious lung in- 
jury, while others with no signs of early respiratory tract irrita- 
tion go on to fatal pulmonary edema. There may be slowing of 
the pulse initially, followed usually by an increase in rate. A period 
follows during which abnormal chest signs are absent and the pa- 
tient may be symptom-free. This interval commonly lasts 2 to 24 
hours, but occasionally is shorter. It is terminated by the signs 
and symptoms of pulmonary edema. These begin with rapid, shal- 
low breathing, painful cough and cyanosis. Nausea and vomiting 
may appear. As the edema progresses, discomfort, apprehension, 
and dyspnea increase and much frothy sputum is raised. Rales and 
rhonchi are audible over the chest, and breath sounds are dimin- 
ished. The patient may develop a shocklike state, with leaden, 
clammy skin, low blood pressure, and a feeble heart. 
c. Diagnosis. Irritation of the nose and throat by phosgene 
may be mistaken for an upper respiratory tract infection. Diffi- 
culty in breathing and complaint of tightness in the chest may sug- 
gest an acute asthmatic attack. The pulmonary edema is like that 
produced by many other gases and may be confused with the edema 
associated with heart failure. Diagnosis can be established with 
certainty only from a definite history of exposure to phosgene. 
d. Treatment. (1) Rest. Pending the appearance of definite 
symptoms, men may continue their duties. When symptoms of 
respiratory distress appear, the patient should be evacuated by 
litter. 5 
(2) Warmth. Phosgene casualties should be kept only comfort- 
ably warm. 
(3) Oxygen therapy. Anoxia should be treated with oxygen. 
The need for oxygen is indicated by cough, dyspnea, cyanosis and 
restlessness. Oxygen should be administered in as high a con- 
centration as possible, in any case high enough to eliminate cyano- 
sis. Oxygen decrease anoxia and quiets the patient. It is best ad- 
ministered by mask. Lower and less well controlled concentrations 
are obtainable in tents and with nasal catheters. Carbon dioxide- 
oxygen mixtures are not indicated in phosgene poisoning. 
(4) Venesection. There is at present no definite evidence that 
venesection is beneficial at any time; it is certainly harmful during 
the shock-like state. 
(5) Sedation. If cough is a prominent symptom, codeine in 
doses of 0.032 to 0.064 grams (grains 1/2 to 1) is effective. If 
oxygen fails to quiet the patient, morphine may be used subcutane- 
ously in a dose of 0.01 to 0.015 grams (grains 1/6 to 1/4). The 
physician must weigh the value of its sedative effect against its de- 
pression of respiration. Sedative doses of barbiturates are in- 
effective and large doses may be harmful. 
(6) Specific antibasterial therapy. (a) Specific antibacterial 
therapy should not be given during the latent period. Thereafter, 
it may be administered for the prevention of pulmonary infection 
as soon as the edema begins to subside, as evidenced by an im- 
provement in the patient’s general condition. Decision as to the 
prophylactic use of specific therapy following exposure to lung 
irritants will be dependent in part upon the estimated severity of 
the lung damage and in part upon the season of the year, the lo- 
cality, and the prevalence of respiratory infections. The drug of 
choice is penicillin which, when available in adequate amounts, will 
be used in all cases of this type in which specific therapy is con- 
sidered desirable. A suggested dosage schedule is 15,000 Oxford 
units intramuscularly every 3 hours for a minimum of 4 days, mak- 
ing a minimum total dose of 480,000 Oxford units. Prolongation 
of the treatment will be determined by clinical evaluation of the 
individual patient. 
(b) If penicillin is not available, sulfadiazine will be used when 
specific antibacterial therapy is deemed desirable. Like penicillin, 
sulfadiazine will be used only when the severity of the lung damage, 
or other considerations indicate the probability of development of 
pulmonary infection if specific therapy is withheld. When sulfa- 
diazine is used, it should be prescribed in adequate dosage. A sug- 6 
gested schedule is 4 grams (grains 60) as an initial dose, and 1 
gram (grains 15) every 4 hours therafter for a minimum of 4 
days, but longer when necessary. The usual precautions to pre- 
vent the complications of sulfonamide therapy must be observed. 
The daily urine output must be maintained above 1500 cc. and the 
urine should be kept alkaline by the administration of sodium bi- 
carbonate (4 grams with the initial dose of sulfadiazine and 2 
grams every 4 hours thereafter). Alertness must be maintained 
to detect any signs of drug toxicity through repeated blood counts, 
urinalyses, and inspections of the patient for signs of a skin rash. 
Evaluation of a low grade fever in these patients is difficult since 
the fever may be caused by absorption of the break-down products 
of necrotic tissue, infection, or drug reaction. 
(c) If pulmonary infection appears, as evidenced by an increase 
of the body temperature or change of chest signs, penicillin or 
sulfonamides must be used in the dosage outlined in (a) and (b) 
above. 
(7) Expectorants. Expectorants should not be used in the treat- 
ment of phosgene poisoning. 
(8) Other measures. Atropine does not diminish edema or im- 
prove breathing; its acceleratory action on the heart is undesirable. 
Plasma is of no value in the treatment of phosgene poisoning. In- 
fusions pass readily into the lungs and increase the edema. Con- 
centrated plasma is even more harmful. Surgery, except emer- 
gency measures to save life, is contraindicated in the active stage 
of edema. If anesthesia is required, local infiltration or nerve block 
is the method of choice. Cardiac and respiratory stimulants, such 
as adrenalin, ephedrine, benzedrine, coramine, and metrazol, do 
more harm than good. Alcohol is contraindicated. 
e. Convalescent Care. Absolute rest must be continued until 
the acute symptoms have disappeared. As recovery progresses, 
exercise should be resumed gradually. Sitting in bed should be 
permitted first, then for brief intervals in a chair. Bathroom privi- 
leges should follow and then short periods of alternate walking 
and resting. Later the convalescent should walk increasing dis- 
tances. 
. ./. Prognosis. Prognosis should be guarded because of the in- 
sidious nature of the poisoning. Most deaths occur within the first 
48 hours. The few which occur later are due largely to broncho- 
pneumonia. Casualties from phosgene which survive more than 
48 hours usually recover without sequelae. Rarely do chronic bron- 
chitis and bronchiectasis result. The incidence of tuberculosis is 7 
not greater in those poisoned by phosgene than in the general popu- 
lation. 
6. Chlorpicrin (PS) 
a. Pathology. As a rule, chlorpicrin has been used in warfare 
in combination with other agents. When used alone, its effects on 
the lung are quite similar to those of phosgene. Apart from the 
difference in toxicity, chlorpicrin may produce almost as severe 
pulmonary edema as phosgene. There may be even more severe 
necrosis of the bronchiolar epithelium than is produced by phos- 
gene, and, in addition, focal necrosis of the epithelium of the trachea 
and large bronchi, although in this respect the action of chlorpicrin 
is much less marked than that of chlorine. The course of events 
following the inhalation of chlorpicrin is essentially the same as 
that following phosgene. Chlorpicrin vapor irritates the conjunc- 
tiva, and severe exposures may result in corneal injury. It is also 
irritating to the skin, and contamination of the skin with liquid 
chlorpicrin may result in deep burns. 
h. Symptoms. Irritation of the eyes is the first symptom noted, 
as chlorpicrin is a strong lacrimator. This is frequently followed 
by pain in the chest, cough, nausea and vomiting. Severe exposure 
causes pulmonary edema, like that produced by phosgene, and 
generalized muscular weakness, with feeble heart action. Repeated 
small exposures increase susceptibility to asthmatic attacks from 
traces of this gas. 
c. Diagnosis. Diagnosis can be established by a history of ex- 
posure, a characteristic flypaper odor on clothing, and the symp- 
toms described in h above. 
d. Treatment. Irritation of the eyes and nose can be relieved 
by irrigation with water, followed by the instillation of eye and 
nose drops (Medical Department item No. 9109100). Inhalation of 
steam relieves the bronchial irritation. Codeine helps to allay the 
cough. If pulmonary edema develops, it is treated like that caused 
by phosgene. 
e. Prognosis. Most deaths occur in the first 24 hours and if 
later are usually due to bronchopneumonia. Casualties surviving 
this period generally recover without sequelae. 
7: Chlorine (CF) 
Chlorine is very irritating to the respiratory tract. It produces 
damage which may result in necrosis of the mucous membrane of 
the trachea, bronchi, and lungs. Pulmonary edema occurs, similar 8 
to that caused by phosgene. After exposure, the initial symptoms 
are: burning in the throat, violent coughing, a feeling of suffoca- 
tion, nausea and occasionally vomiting. Pulmonary edema follows 
sometimes within 20 minutes. The history and the intense irrita- 
tion of the nose and throat are aids to early diagnosis. The treat- 
ment of chlorine poisoning is the same as that outlined for chlorpi- 
crin. (See par. 6d.) SECTION III 
VESICANTS 
8. General 
a. The vesicants act primarily on the eyes and skin. In addition, 
they damage the respiratory tract when inhaled and, when ab- 
sorbed, they cause systemic poisoning. The nitrogen mustards and 
the arsenical vesicants are the most dangerous in this last respect. 
b. Vesicants poison food and water and render other supplies 
dangerous to handle. 
c. Casualties contaminated with vesicants endanger unprotected 
attendants. Those in contact with such patients should wear, at 
least, protective masks,' impermeable aprons and gloves, and other 
protective clothing if the area is contaminated. 
d. Special precautions must be taken in receiving contaminated 
casualties to prevent injury of others. These casualties should be 
undressed in the open to prevent vapor accumulation indoors. They 
should be kept separate from contaminated patients until decon- 
tamination is complete. Contaminated litters, blankets, and equip- 
ment should be left outdoors. It is necessary to decontaminate 
equipment and ambulances after transporting such casualties. 
(See par. 146d, FM 21-40.) 
e. Identification of the agent is important in order to apply 
specific treatment. 
/. Any service mask protects only the face, eyes and respiratory 
tract. The eyeshield protects the eyes from contamination by li- 
quid, but not from vapor. Permeable protective clothing and pro- 
tective ointment help to prevent the vesicant from reaching the 
skin. 
9. Mustard (H) 
a. Properties. Mustard is an oily liquid heavier than water. It 
ranges from colorless when pure to dark brown when plant-run. 
Its oder is like garlic or horseradish. It is only slightly soluble 
in water,’which gradually destroys it, but undissolved mustard may 
persist in water for long periods. It is more soluble in fats and 
oils, and freely soluble in gasoline, kerosene, acetone, carbon tetra- 
chloride, and alcohol. These solvents do not destroy mustard. From 
9 10 
contaminated ground or materials mustard disappears through 
evaporation or through hydrolysis. It can be destroyed rapidly by 
decontaminating chemicals or by boiling in water. It is slowly 
absorbed by rubber articles and so may contaminate their inner 
surfaces. The persistence of hazard from mustard vapor or liquid 
depends on the degree of contamination by the liquid, the type of 
mustard, the nature of the terrain and of the soil, the type of muni- 
tion used to disperse the mustard and the weather conditions. The 
persistence of mustard in wooded area may be much longer than in 
the open. In winter, mustard persists two to five times as long as 
in summer and the hazard from the vapor is many times greater 
under hot than under cool conditions. Concentrations of mustard 
vapor should be estimated in the field by gas detectors. (See par. 
127, FM 21-40, and pars. 85-90, TM 3-290.) 
h. Eye. (1) Pathology, symptoms, and prognosis, (a) The 
eye is more vulnerable to mustard than either the respiratory tract 
or the skin. Eye lesions follow an exposure of 2 hours to a concen- 
tration barely perceptible by odor (0.001 mg. per liter). This ex- 
posure does not significantly affect the respiratory tract or skin. 
(b) A latent period of 4 to 12 hours follows mild exposure, after 
which there is lacrimation and sensation of grit in the eyes. The 
conjunctivae and lids become red and edematous. Heavy exposure 
irritates the eye after a shorter latent period, and produces more 
severe lesions. Mustard burns of the eye may be divided into 
groups. 
1. Mild conjunctivitis (75 percent of cases in World War 
I). Recovery, 1 to 2 weeks. 
2. Severe conjunctivitis with minimal corneal involvement 
(15 percent of cases). Blepharospasm, and edema of 
lids and conjunctivae. Orange-peel roughening of the 
cornea. Recovery, 2 to 6 weeks. 
3. Mild corneal involvement (10 percent of cases). Areas 
of corneal erosion staining green with fluorescein. Su- 
perficial corneal scarring and vascularization. Iritis. 
Temporary relapses. Convalescence, 2 to 3 months. 
This group requires hospital care. 
4. Severe corneal involvement (approximately 0.1 percent 
of cases). Ischemic necrosis of conjunctivae. Dense 
corneal opacification with deep ulceration and vascu- 
larization. Convalescence, several months. Predispo- 
sition to late relapses. 
(2) Decontamination of the eyes, (a) Vapor. When the eyes 
are exposed to mustard vapor alone, no decontamination procedure 11 
is of any value. The gas mask should be put on immediately. 
(b) Liquid. 
1. All contaminations of the eyes by any liquid blister gas 
whether they be by mustard, nitrogen mustards, lewi- 
site or mixtures thereof are decontaminated by one 
standard procedure. The decontamination incorpo- 
rates the use of BAL Eye Ointment (or BAL Oint- 
ment) , massage and irrigation. Immediately after the 
eye has been contaminated by a liquid blister gas BAL 
Eye Ointment is squeezed directly into the lower con- 
junctival sac. In cases where the eye cannot be opened 
(for example, after contamination by lewisite) the 
ointment should be applied to the lids and rubbed well. 
This will work sufficient ointment between the lids to 
relieve pain and blepharospasm to such an extent as to 
make it possible for the soldier to open the eye thus 
permitting him to instil larger quantities of the oint- 
ment into the lower sac. The lids are then closed and 
massaged for 1 minute. This is followed by irrigation 
of the eye with water from the canteen or other avail- 
able uncontaminated source. To accomplish this the 
head is thrown back, the lids are forced open with one 
hand, while the water is poured into the eye from a 
container in the other hand. The water should be 
poured directly and slowly into the eye and should be 
continued for at least 30 seconds, or until the canteen 
is empty, and not longer than 2 minutes. If BAL Eye 
Ointment or BAL Ointment is not immediately avail- 
able, the eye should be irrigated as early as possible 
without waiting to obtain the ointment. The decon- 
tamination must be completed before the gas mask 
is put on, in spite of the presence of vapor. Therefore, 
the individual should hold his breath as much as pos- 
sible until the treatment is completed and the gas mask 
can be adjusted. In contaminations by liquid mustard 
the initiation of the first aid within the first few sec- 
onds is markedly effective and after 2 minutes is of 
very little value. (Note. The fact that the individual 
tubes of BAL Eye Ointment or BAL Ointment do not 
have printed on them directions for use against mus- 
tard, nitrogen mustards, and mixtures of these with 
lewisite is not to be considered a contraindication to its 
use against these agents.) 
2. Liquid mustard in the eye causes no immediate pain or 12 
discomfort. When BAL Eye Ointment is placed into 
an eye contaminated with this agent there will be im- 
mediate irritation and blepharospasm. This is to be 
expected and the first aid procedure should not be dis- 
continued because of it. The irritation from the oint- 
ment stops as soon as the irrigation is begun. How- 
ever, the irrigation should not be stopped as soon as 
the stinging disappears, but should be continued for 
the length of time outlined in paragraph (b) 1 above. 
3. BAL Eye Ointment or BAL Ointment placed in an un- 
contaminated eye is quite irritating and causes imme- 
diate stinging and blepharospasm which may interfere 
with the individual’s combat ability for a period up to 
15 minutes. Therefore, the ointments should be used 
in the eye only when the individual is fairly certain 
that his eye has been contaminated by liquid blister 
gas. The chance of liquid contamination is slight ex- 
cept when in the close vicinity of a shell or bomb burst, 
or in a direct airplane spray. 
U. Previous manuals have stated that irrigation alone should 
be used as first aid for liquid mustard contamination 
of the eye. Recent studies have shown that BAL Eye 
Ointment followed by irrigation is superior to irriga- 
tion alone. A further advantage of this new first aid 
procedure is that since it is used for all liquid blister 
gas contaminations of the eye, the soldier has to re- 
member only one first aid procedure. He is therefore 
not required to distinguish between different contami- 
nating agents at a time when this would be difficult. 
Therefore, previous directives are to be disregarded in 
favor of the method described above. 
(3) Decontamination of eyelashes and lids. The lids, lashes, and 
skin areas close to the eyes are best decontaminated by washing 
with soap and water. Protective ointment is irritating to the eyes. 
If water is not available, liquid vesicants may be removed from the 
lids by dabbing carefully with a cloth or other absorbent. 
(4) Treatment of mustard conjunctivitis. (a) Mild lesions re- 
quire little treatment. Although they seldom become infected, 3 
percent sodium sulamyd solution, two drops instilled every 4 to 8 
hours, (Medical Department item No. 9120300) has an analgesic 
action and aids in preventing sepsis. Two drops of eye and nose 
drops (Medical Department item No. 9109100) may be instilled for 
added comfort. If the lids tend to stick together during sleep, 13 
petrolatum (Medical Department item No. 9116500) may be ap- 
plied to the lid margins. 
(b) More severe injuries will cause enough edema of the lids, 
photophobia, and blepharospasm to obstruct vision. This is very 
alarming to the patient; consequently, the lids should be gently 
forced open to assure the patient that he is not blind. Pain may be 
allayed temporarily by eye and nose drops (Med. Dept, item No. 
9109100), but these drops, or other local anesthetics, should not be 
used persistently. It is best to control the pain by morphine and 
other systemic sedation. All patients having severe photophobia 
and blepharospasm should have 1 drop atropine solution 1 percent 
instilled or an atropine ophthalmic disc (Med. Dept, item No. 
9116300) inserted into the eye three times a day. To prevent in- 
fection, a few drops of 3 percent to 10 percent solution of sodium 
sulamyd should be instilled every 4 hours. Penicillin sodium solu- 
tion 1000 units per cc. or sulfathiazol ophthalmic ointment (Med. 
Dept, item No. 1464000) may be substituted for sodium sulamyd. 
The eye must not be bandaged or the lids allowed to stick together. 
Sealing of the lids may be prevented by the application of petro- 
latum to the lid margins. The accumulation of secretions in the 
conjunctival sac, or pressure on the eye, predisposes to corneal 
ulceration. Irrigations should be gentle and must be held to the 
minimum necessary to remove secretions. Copious irrigation 
should be avoided as it tends to loosen and remove injured corneal 
epithelium. Isotonic or slightly hypertonic sterile solutions must 
be used, never hypotonic solutions; 1 percent saline is satisfactory. 
When the lids can be opened sufficiently for an ophthalmic examina- 
tion, the cornea should be stained with fluorescein, one drop of 2 
percent solution in saline, or by insertion of fluorescein ophthalmic 
disc (Med. Dept, item No. 9116300) into the lower conjunctival 
sac. /The eyes should then be rinsed with a few drops of sterile 
saline and examined for yellowish-green staining of the cornea. 
Staining indicates damage to, or loss of, epithelium. If the cornea 
stains, or if severe photophobia persists, the patient should be 
transferred to the care of the ophthalmologist. When possible the 
patient should be kept in a darkened room. Dark glasses or an 
eyeshade may be worn for photophobia, but should be discarded 
as soon as possible to prevent psychologic sequellae. 
(5) Treatment of infected mustard hums of eye. Secondary in- 
fection is a serious complication and increases the amount of perma- 
nent scarring of the cornea. If infection develops, the eye should 
be treated with several drops of a 10 percent solution of sodium 
sulamyd every 2 hours, or penicillin sodium, 1000 units per cc., 
every 4 hours, or sulfathiazol ophthalmic ointment every 4 hours. 14 
Irrigation should ge gentle and employed only to remove accumu- 
lated exudate (4) (5) above. Pain is controlled as described in 
(4) (6) above. Patients with secondary infection or other com- 
plications should be referred to the ophthalmologist. 
c. Skin. (1) Pathology. The severity of the lesions and the 
rapidity with which they develop are greatly influenced by weather 
conditions as well as by the degree of the exposure. Hot, humid 
weather strikingly increases the action of mustard. Even under 
temperate conditions, the warm, moist skin of the perineum, ex- 
ternal genitalia, axillae, antecubital fossae, and neck are particu- 
larly susceptible. 
(a) Latent 'period. After exposure, there is a latent period 
which varies with the degree of exposure. It may be as short as an 
hour with liquid contamination when the weather is hot and humid, 
or as long as several days with mild vapor exposures. With most 
vapor exposures in temperate weather, the latent period usually 
lasts 6 to 12 hours. 
(5) Erythema. Erythema gradually appears and becomes 
brighter, resembling sunburn. Microscopically, there is capillary 
hyperemia in the corium, accompanied by a variable degree of 
dermal edema. If severe burns the latter may be considerable, and 
limit motion of a limb. 
(c) Vesication. Except with mild vapor burns, erythema is fol- 
lowed by vesication. This is caused by progressive development 
of liquefaction necrosis of cells in the lower layers of the epidermis. 
Exudation of tissue fluid into the spaces so formed results in an 
intraepidermal vesicle. Clinically, multiple pinpoint lesions may be 
seen to arise within the erythematous skin; these* enlarge and 
coalesce to form the typical blister which is usually large, domed, 
thin-walled, superficial, translucent, yellowish, and surrounded bv 
erythema. The blister fluid is clear, at first thin and straw-colored, 
later yellowish and tending to coagulate. It is completely non- 
irritating. Liquid contamination of the skin usually results in a 
ring of vesicles surrounding a gray-white area of skin which, 
though necrotic, does not vesicate. 
(d) Resorption. If the blister does not rupture, resorption takes 
place in about a week. The roof forms a crust, beneath which re- 
epidermization takes place. However, because of their thinness 
and tenseness, the blisters are fragile and usually break. If the 
roof becomes ragged, the burn may be considered an open wound. 
Such lesions may become secondarily infected. 
(e) Healing. Since the damage to the corium is relatively super- 
ficial except in severe burns, healing takes place with little or no 
scare tissue formation except in very severe or infected burns. 
(/) Pigmentation. Mustard burns usually are followed by a 15 
persistent brown pigmentation, except as the site of actual vesica- 
tion, where there may be a temporary depigmentation. 
(g) Hypersensitivity. Repeated burns may lead to hypersensi- 
tivity of the skin to mustard. 
(2) Symptoms and prognosis, (a) An outstanding character- 
istic of the action of mustard is its insidiousness. Exposures to 
mustard are accompanied by no symptoms, nor do any local mani- 
festations occur until the development of erythema when there may 
be itching and mild burning. This pruritus may last for a number 
of days and even after healing. The blisters may be painful. 
(6) Very mild mustard burns heal within a few days. Burns of 
moderate severity heal usually within 2 to 4 weeks. Severe or in- 
fected burns may require 6 to 8 weeks or even longei to heal. 
(3) Diagnosis of skin lesions due to mustard. Similar skin 
burns are produced by mustard and the nitrogen mustards. Mus- 
tard burns are also similar in appearance to those due to lewisite 
and other arsenical vesicants. Differentiation of mustard lesions 
from those produced by lewisite is based upon: history of exposure 
to mustard; absence of pain or discomfort at time of contamination 
(lewisite is irritating or painful immediately) ; and wide zone 
of erythema surrounding blisters (lewisite, not prominent). It 
should be remembered that vesicular lesions, much like mild mus- 
tard burns, may be produced in sensitive individuals by a variety 
of substances, notably plant poisons such as poison ivy or poison 
oak. 
(4) Treatment of mustard erythema. Mustard erythema in 
mild cases requires no treatment. If annoying itching is present, 
considerable relief cai. be obtained with calamine lotion (contain- 
ing 1 percent each of phenol and methol, Medical Department item 
No. 9104800). Severe erythema is often accompanied by edema, 
stiffness and pain. Painful erythema of the genitalia may be 
treated with calamine lotion and a suspensory bandage. Alterna- 
tively petrolatum, a light protective dressing and suspensory may 
be used. 
(5) Treatment of mustard blister.. (a) Blisters should be 
treated by application of sterile petrolatum (or boric acid oint- 
ment) dressings. Frequent changes of dressing are undesirable. 
The dressing should be left in place as long as possible (up to 2 
weeks). Small blisters of the face are best left alone. Large 
blisters may be covered with a sterile perolatum dressing. Burns 
of the genitalia may be treated with a sterile petrolatum dressing 
and suspensory, using a minimum of petrolatum to avoid undue 
moisture with resulting excoriation. 
(b) If the dressing sticks to the wound, care will be necessary 
to avoid pulling off the blister top. It is good practice to trim the 16 
edges of the adherent gauze, leave it in place, and put a fresh dress- 
ing over it. If necessary to examine the wound, the dressing can be 
soaked off. 
(6) Treatment of denuded areas, (a) The same sterile tech- 
nique as for thermal burns, including face masks, should be em- 
ployed. Frequent change of dressing is to be avoided. 
(b) Blistered areas which have become denuded may be treated 
with sterile petrolatum or boric acid ointment as for thermal burns 
(app. V). . 
(c) Strong antiseptics and escharotics of all kinds are contra- 
indicated. 
(d) Other phases of the late treatment are similar to those of 
the treatment of thermal burns. Thus, occasional extensive granu- 
lating surfaces may require skin grafting. Multiple pinch grafts 
have proved successful. 
(7) Treatment of infected mustard, burns, (a) Contamination 
of mustard burns with saprophytic bacteria is common, but not 
serious. If there is no inflammatory reaction, the treatment is the 
same as for uncontaminated burns (5) and (6) above. 
(b) Infected burns showing inflammatory reaction should be 
considered infected wounds. They may be treated locally by the 
use of sterile petrolatum or boric acid ointment with proper cleans- 
ing and drainage, or hot sterile saline dressings. 
(8) Specific anti-bacterial therapy. When indicated, specific 
antibacterial therapy should be instituted. Penicillin is the drug 
of choice and should be given intramuscularly in doses of 25,000 
units every 3 hours as long as indicated. For cases in which sulfa- 
diazine is used, it should be given orally with an initial dose of 4 
grams (grains 60), and 1 gram (grains 15) every 4 hours there- 
after. Sufficient fluids should be given to maintain the output of 
urine over 1500 cc. qts.) daily. Four grams (grains 60) 
of sodium bicarbonate should be given with the initial dose of 
sulfadiazine and 2 grams (grains 30) every 4 hours thereafter 
to keep the urine alkaline. 
(c) Strong local antiseptics and escharotics are contraindicated. 
(9) Decontamination of skin, (a) Personal decontamination 
is an individual responsibility of all ranks in all branches. Only 
casualties who are unable to decontaminate themselves are cared 
for by the Medical Service. 
(b) Personal decontamination is the removal of liquid mustard 
at the earliest possible instant. The importance of prompt action 
cannot be overstressed. Proper skin decontamination during the 
first minute is always successful. After 3 minutes on the hot 
sweaty skin, or 5 minutes on the cool dry skin, no method of decon- 
tamination will prevent blistering. Decontamination should be per- 17 
formed, however, no matter how late, as long as liquid mustard is 
still present. Decontamination is of no value after vapor exposure. 
(c) Ointment, Protective, M5 will protect against liquid blister 
gas for a short time. Areas of skin contaminated with liquid blister 
gas, whether protected by the ointment, or unprotected must be de- 
contaminated as soon as possible. The free liquid blister gas is 
blotted from the skin with the absorbent cloth wrapped around 
each tube of ointment or by using any absorbent material at hand. 
Discard the used absorbent. Ointment is then applied freely to the 
area, the excess removed, more ointment reapplied and allowed to 
remain. If contamination with blister gas is light, no blotting is 
necessary but generous application of Ointment, Protective, M5, 
with thorough rubbing will be sufficient. 
(d) If reddening of the skin has appeared, cleanse the area 
with soap and water. Protective ointment is irritating to the red- 
dened skin and should be used only when liquid mustard is still 
present and soap and water are not available for thorough wash- 
ing. Solvents should not be used if soap and water are available. 
(e) Should the supply of protective ointment run short, the fol- 
lowing alternatives may be employed: 
1. Bleach 'paste. Prepared by mixing one part bleach and 
two part of water. Because of its irritant properties, 
it must be washed off the skin within 3 minutes. 
2. Solvents. Any nonirritant organic solvent may be used 
in an emergency to dissolve and dilute the liquid mus- 
tard. Since solvents do not neutralize the vesicant, the 
mustard solution formed must be completely and 
rapidly removed from the skin by flooding with a large 
excess of the solvent. Alternatively, the area may be 
sponged repeatedly with cotton or gauze dampened 
with solvent, with care to avoid the spread of mustard 
from contaminated skin. Gasoline, kerosene, alcohol, 
carbon tetrachloride (from automobile fire extinguish- 
ers) are most commonly available. (Caution: Pre- 
cautions against fire and explosion must be observed 
when employing inflammable solvents.) 
(/) The decontaminated skin areas should be thoroughly washed 
with soap and water as soon as practicable after decontamination. 
(g) Wounded cases, with liquid mustard contamination of the 
skin, will seldom be received at field installations in time to pre- 
vent subsequent blistering. Nevertheless, if erythema has not ap- 
peared, known or likely areas of contamination should be decon- 
taminated as outlined above. 
(10) Decontamination of hair. The contaminated hair may be 
clipped off, or decontaminated with bleach paste. The scalp should 18 
then be washed with soap and water. Protective ointment may be 
used, but is difficult to apply and to remove. 
d. Respiratory tract. (1) Pathology, (a) Inhalation of mus- 
tard vapor causes damage primarily to the laryngeal and tracheo- 
bronchial mucosa, which develops slowly after the exposure. Mini- 
mal amounts of vapor may be inhaled without significant damage. 
More severe exposures result in hyperemia or the respiratory mu- 
cous membrane, and necrosis of the lining epithelium. With severe 
exposures, the necrotizing action is accompanied by exudation 
which results in a diphtheritic-like pseudomembrane which may 
form a cast of the tracheobronchial tree. 
(b) In the more severe cases, the pulmonary parenchyma shows 
congestion, mild patchy edema, moderate acute emphysema, and 
focal atelectasis. Altogether, these changes are insufficient to cause 
anoxia, but they are frequently complicated by bacterial infection 
of the lung which results in suppurative bronchitis and broncho- 
pneumonia. The latter is responsible for almost all deaths follow- 
ing vapor exposures. The mortality from mustard in the American 
Expeditionary Force, slightly more than 2 percent, was almost en- 
tirely from such complication following inhalation of vapor. 
(2) Symptoms and prognosis. Respiratory tract lesions, like 
skin injuries, develop slowly and do not reach maximal severity 
for several days. Symptoms begin with hoarseness, which may 
progress to aphonia. A cough appears early and becomes produc- 
tive. Fever, dyspnea, and moist rales may develop. The incidence 
of bronchopneumonia is high. Convalescence is slow, and cough 
may persist a month or longer. Milder symptoms, like hoarseness, 
last only a week or two. 
(3) Treatment of respiratory tract injury due to mustard. Mild 
respiratory tract injury, with hoarseness and sore throat only, 
usually requires no treatment. Cough may be relieved by codeine, 
and pharyngitis with alkaline gargles. Relief from nasal irritation 
may be obtained with the eye and nose drops (Medical Department 
item No. 9109100). Since severe respiratory tract injuries predis- 
pose to bronchopneumonia, when clinical exidence of such injury 
becomes manifest, the prophylactic intramuscular administration 
of penicillin or oral administration of sulfadiazine is indicated (par, 
5d(6)). Laryngitis and tracheitis should be treated with steam 
inhalations. Morphine or the barbiturates can be used to quiet the 
patient. Secondary bronchopneumonia should be treated like any 
other bronchopneumonia. 
e. Systemic and Gastrointestinal. (1) Symptoms, (a) In- 
gestion of food or water contaminated by liquid mustard produces 
nausea and vomiting, pain, diarrhea and prostration. Mustard va- 
por does not significantly contaminate food or water. 19 
(b) Exposure of the skin alone to mustard may cause systemic 
symptoms such as malaise, nausea, vomiting and feverishness, com- 
ing on at about the time of onset of the erythema. With severe 
exposures, particularly extensive liquid contamination of the skin, 
these symptoms may be so marked as to result in prostration. Ex- 
ceptional cases of severe systemic mustard poisoning may also 
present central nervous symptoms such as cerebral depression, and 
paraympathomimetic effects such as bradycardia and cardiac ir- 
regularities. Cerebral excitation and salivation have been ob- 
served in animals, as well as bloody diarrhea and excessive loss of 
fluid and electrolytes. Hemoconcentration and shock may occur. 
It must be emphasized that such severe systemic effects do not oc- 
cur with ordinary mustard exposures. 
(2) Pathology. With ordinary skin or respiratory exposures to 
mustard, no apparent systemic lesions develop. With amounts ap- 
proaching a lethal dose, injury to the hematopoietic tissues (bone 
marrow, lymph nodes and spleen) may result. Such hematopoietic 
damage is reflected in the peripheral blood by leucopenia and 
thrombocytopenia. 
(3) Treatment, {a) In the treatment of the systemic symp- 
toms, atropine (Medical Department item No. 1086000) subcu- 
taneously (0.6 mg. (grains 1/100)) may prove useful in reducing 
the gastro-intestinal activity. The general discomfort and rest- 
lessness may require large doses of sedatives, for which the barbi- 
turates and morphine may be indicated. In the exceptional cases 
of severe systemic poisoning with vomiting and diarrhea, leuco- 
penia, hemoconcentration, and shock, every effort should be made 
to maintain an adequate nutritional status and replace the loss of 
fluid and electrolytes by transfusions of whole blood or plasma, 
and infusions of glucose and saline. Paregoric and bismuth sub- 
carbonate can be used for relief of diarrhea. 
(6) Injury due to the ingestion of liquid mustard in food or 
water may require morphine and atrophine for relief of pain, and 
shock therapy for collapse. 
(4) Prognosis, (a) With ordinary field exposures of mustard 
vapor, it is not anticipated that deaths will occur from the systemic 
effects of the absorbed mustard. Such deaths may occur from pro- 
longed exposures to high concentrations of vapor, or in instances 
of extensive liquid contamination of the skin in which decontami- 
nation is neglected or unduly delayed. The occurrence of shock or 
pronounced leucopenia in such cases may be regarded as bad prog- 
nostic signs. 
(b) Severe injury from ingestion of mustard is rare. 20 
10. Nitrogen Mustards (HN) 
a. General. The nitrogen mustards are oily, colorless, or pale 
yellow liquids, sparingly soluble in water but freely soluble in or- 
ganic solvents. Some possess a faint, fishy odor, while others are 
odorless. Their volatility varies with the particular compound. All 
are persistent, though not equally so. They are less readily hydro- 
lyzed than mustard or lewisite. All their hydrolytic products, ex- 
cept the final ones, are toxic. 
b. Eyes. (1) Symptoms and pathology. Nitrogen mustards 
irritate the eye in doses which do not significantly damage the skin 
or respiratory tract. The irritation (caused by the nitrogen mus- 
tards) appears in a shorter time than that from mustard but not 
so early as that from lewisite. Mild or moderate exposure causes 
mild smarting and lacrimation within 20 minutes. Thereafter sym- 
toms may wax and wane until they become persistent about 
hours later and reach their maximum in 8 to 10 hours. After more 
severe exposure, symptoms may begin immediately and progress 
for 24 hours or longer. Mild exposure produces erythema and 
edema of the palpebral and bulbar conjunctivae and superficial 
steamy haziness of the cornea. Irritation, lacrimation, deep eye 
pain, miosis, and photophobia are usually present. After more se- 
vere exposure the symptoms described above are followed by spotty 
hemorrhagiv discolorations of the iris. The corneal epithelium be- 
gins to show a roughened, lusterless surface, with areas of punctate 
staining demonstrable by the instillation of fluorescein (Medical 
Department item No, 9116300). Severe exposure may cause the 
corneal epithelium to exfoliate. Slit lamp examinations will re- 
veal clouding and edema of the corneal substance extending deep 
below Bowman’s membrane. Local necrosis of the cornea may rup- 
ture the globe. 
(2) Decontamination and treatment. These are the same as for 
mustard (par. 9b). In general the symptoms and lesions are more 
severe, requiring intensive and early treatment with atropine 
(Medical Department item No. 9116300). 
(3) Prognosis. The prognosis in contamination with any liquid 
nitrogen mustard is serious, unless the agent is removed by immedi- 
ate decontamination. Mild injury progresses to complete recovery 
in about 2 weeks. Severe injury heals more slowly, requiring 9 to 
12 weeks or longer. The cornea heals by vascularization, and the 
iris with discoloration and atrophy. Scarring may be expected. 
c. Skin. (1) Symptoms and pathology. In mild exposures 
there may be no skin lesions. After severe exposure, erythema 
may appear earlier than in mustard contamination. There may be 
irritation and itching as with mustard. Later, blisters may appear 
in the erythematous areas. Liquid nitrogen mustards are also 21 
vesicant. The skin lesions are similar to those caused by mustard. 
(2) Decontamination and treatment. The absorption of liquid 
nitrogen mustards through the skin is slower and more complete 
than that of mustard. Therefore, for the prevention of systemic 
toxicity, decontamination should be carried out as late as 2 to 3 
hours after exposure, even at the expense of increasing somewhat 
the severity of the local reaction. Early decontamination proce- 
dures are the same as for mustard. (See par. 9c (9.)). If early 
decontamination has been neglected late decontamination should be 
performed even if erythema is already present and there is no evi- 
dence of liquid nitrogen mustard on the skin. Protective ointment 
should be liberally applied, thoroughly rubbed into the affected area 
for about 1 minute and wiped off as completely as possible. Further 
cleansing may then be performed with soap and water. 
(3) Prognosis. Most blistered areas will heal in 2 to 4 weeks if 
infection is prevented. Occasionally, deeper burns require a longer 
time. 
d. Respiratory Tract. (1) Pathology. .The lesions caused by 
nitrogen mustards are similar to those caused by mustard. They 
decrease in severity down the respiratory tract from the point of 
entry. In the nose, larynx, and trachea, there may be swelling, 
erythema, and necrosis of the mucosa, followed by sloughing, and 
fibrinous exudation. Laryngeal edema and necrosis may lead to 
respiratory obstruction. In severe cases the damage may extend 
to the bronchioles and alveoli. Although pulmonary edema usually 
is not massive, secondary pulmonary infection is common. 
(2) Symptoms. The symptoms are much the same as those due 
to mustard, namely, delay in appearance, irritation of the nose and 
throat, hoarseness progressing to aphonia, and a persistent cough. 
Fever, dyspnea, and moist rales may develop. Bronchopneumonia 
may appear after the first 24 hours. 
(3) Treatment. The treatment of casualties with respiratory 
tract involvement is the same as for mustard. (See par. 9d (3).) 
(4) Prognosis. Mild tracheitis is likely to result in a persistent 
cough. Low grade fever may persist a week or longer. The prog- 
nosis is grave if there is a severe respiratory tract involvement. 
Late deaths due to pneumonia may occur. 
e. Gastrointestinal Tract. Following oral administration or 
systemic absorption, the nitrogen mustards cause injury to the 
intestinal tract. In animals severe diarrhea, which may be 
hemorrhagic, occurs. Lesions are most marked in the small in- 
testine and consist of degenerative changes and necrosis in the 
mucosa. In man, the ingestion of 2 to 6 milligrams causes nausea 
and vomiting. 
/. Systematic Effects. (1) Pathology. The most specific ef- 22 
fects of the nitrogen mustards are on the hematopoietic and lym- 
phoid tissue. These follow absorption from the intact skin, 
respiratory or gastro-intestinal tract. In bone marrow the de- 
generative changes can be detected within 12 hours and may 
progress to severe aplasia. The thymus, spleen, and lymph nodes 
involute rapidly with necrosis and phagocytosis of their Impho- 
cytes. This injury is demonstrable in the blood through a transient 
leucocytosis of a few hours’ duration, followed by severe lympho- 
penia, granulocytopenia, thrombocytopenia, and a moderate ane- 
mia. The blood picture may show little change other than lym- 
phopenia for 5 to 10 days after exposure, at which time the white 
count may fall to 500 cells/mm.3 or lower. The various nitrogen 
mustards differ in their abilities to produce these changes. 
(2) Treatment. The blood should be studied carefully and 
transfusions of whole blood given for thrombocytopenia or anemia. 
Vomiting or severe diarrhea may call for the replacement of fluid 
and electrolytes in addition to symptomatic treatment with seda- 
tives, atropine, and opiates. If these symptoms are prolonged, 
every attempt should be made to maintain an adequate nutritional 
status by the intravenous route if necessary. 
(3) Prognosis. Severe leucopenia, thrombocytopenia, and a loss 
in weight are grave manifestations. 
(4) Diagnosis. Diagnosis is based upon a history of exposure, 
a faint, fishy odor on the skin and clothing, and the signs and sym- 
toms described above. 
11. Lewisite (L) 
a. General. (1) Lewisite is an oily, colorless to light amber 
liquid, with a faint odor of geraniums. It is more volatile and less 
persistent than mustard. Lewisite is readily soluble in gasoline, 
kerosene, and alcohol. Although poorly soluble in water, it is 
rapidly hydrolyzed in contact with moisture. Lewisite oxide, one of 
the hydrolysis products, is vesicant and toxic and may contaminate 
ground for long periods. Lewisite, like mustard, penetrates fabrics 
and rubber, making it dangerous to wear clothing or rubber gloves 
previously contaminated. 
(2) Lewisite, like mustard, injures the eyes, skin, and respira- 
tory tract but the systemic effects are more likely to be serious than 
those following mustard contaminations. In contrast to liquid 
mustard, lewisite causes stinging pain in 10 to 30 seconds which 
increases in severity. Burns from field concentrations of vapor 
are unlikely and no decontamination or treatment is necessary fol- 
lowing exposure unless pain is experienced. In such a case the 
procedures to be followed are those described in the following 
subparagraphs. 23 
h. Eye.. (1) Symptoms, pathology and. prognosis. Liquid 
lewisite causes severe damage to the eye. On contact, pain and 
blepharospasm occur instantly. Edema of the conjunctiva and lids 
follows rapidly and closes the eye in an hour. Inflammation of the 
iris usually is evident by this time. After a few hours the edema 
of the lids begins to subside, while haziness of the cornea develops 
and iritis increases. The corneal injury, which varies with the 
severity of the exposure, may heal without residua, may develop 
pannus formation, or progress to massive necrosis. The iritis may 
subside without permanent impairment of vision, if the exposure 
was mild, or after heavy exposure hypopyon may ensue, terminat- 
ing in necrosis, depigmentation of the iris, and synechia formation. 
Liquid lewisite instantaneously produces a gray searing of the 
cornea like an acid burn at the point of contact. Necrosis and 
sloughing of both bulbar and palpebral conjunctivae may follow 
very heavy exposure. All injured eyes are susceptible to secondary 
infection. Mild lewisite conjunctivitis in man heals in a few days 
without specific treatment. Severe exposure may cause perma- 
nent injury or blindness. 
(2) Decontamination of eyes, (a) Liquid. Eyes contaminated 
with liquid lewisite are decontaminated by the same procedure as 
those contaminated with liquid mustard (par9£»). Immediate de- 
contamination is essential. When liquid lewisite is the contaminat- 
ing agent the immediate pain and blepharospasm caused by the 
agent is rapidly relieved by the instillation of BAL Eye Ointment. 
(6) Effectiveness of BAL. BAL is effective agaihst lewisite 
for a longer period of time after contamination than it is against 
mustard. If BAL is used within the first minute following con- 
tamination, the eye usually recovers in a few days. When used 
10 minutes after contamination the eye requires several weeks to 
heal and usually suffers permanent damage. After 30 minutes, 
BAL has practically no effect. (Caution: Hydrogen peroxide 
solutions furnished in some of the older chests is of value in treat- 
ment of skin contamination by lewisite, but must NOT be used 
in the eyes; they are worthless to treat eye contamination due to 
lewisite and are damaging to the cornea.) 
c. Skin. (1) Symptoms. Stinging is felt in 10 to 30 seconds 
after contact with liquid lewisite. This increases in severity as the 
lewisite penetrates and in a few minutes becomes a deep aching 
pain. Pain on contact with liquid lewisite usually gives sufficient 
warning so that decontamination may be begun promptly and deep 
burns will therefore occur rarely in conscious victims. After about 
5 minutes contact, a gray area of dead epithelium is noted which 
resembles that seen in corrosive burns. Erythema and edema of 
the skin appear in about 30 minutes. The erythema is like that 24 
caused by mustard but is accompanied by more pain. Itching and 
irritation persist only about 24 hours whether or not a blister de- 
velops. Blisters are often well developed in 12 hours and are pain- 
ful at first, in contrast to the relatively painless mustard blister. 
After 48 to 72 hours the pain lessens. 
(2) Pathology. Liquid lewisite produces more severe lesions 
of the skin than does liquid mustard. Contamination of the skin 
with liquid lewisite is followed after a short time by erythema. 
Vesication follows, and tends to cover the entire area of erythema, 
so that the surrounding halo of erythema is less conspicuous than 
with mustard blisters, although the two are often indistinguishable. 
Microscopically, the lewisite blister roof is slightly thicker than the 
mustard blister roof, consisting of almost the complete thickness of 
the epidermis which shows more complete coagulation necrosis and 
less disintegrative necrosis than that of mustard blister. The 
yellowish blister fluid is slightly more opaque than that of the 
mustard blister, and, microscopically, contains a greater number 
of inflammatory cells. It contains a trace of arsenic an analysis, 
but is nontoxic and nonvesicant. Within the corium and subcutane- 
ous tissue there is deeper injury to the connective tissue and muscle, 
greater vascular damage, and more severe inflammatory reaction 
than is exhibited in mustard burns. In large, deep, lewisite burns, 
there may be considerable necrosis of tissue, gangrene, and slough. 
(3) Prognosis. Lewisite erythema usually recedes more rapidly 
than mustard erythema and with less pigmentation. Small lewisite 
blisters heal in about the same time as those due to mustard. Larger 
lewisite lesions may involve deep injuries which heal slowly and 
require skin grafts. Sensitization to lewisite after repeated burns 
occurs as with mustard. 
(4) Decontamination of Skin, (a) Vapor. The risk of skin 
burns from field concentrations of lewisite vapor is small and de- 
contamination of the skin for such exposure should seldom be re- 
quired. When drops of liquid lewisite contaminate the clothing, 
concentrated vapor from these drops penetrates the cloth and dam- 
age the underlying skin. Such clothing must be removed promptly. 
Decontamination of skin may be accomplished if specific measures 
are taken within a few minutes after contact. (See (5) below.) 
(h) Liquid. The removal of liquid lewisite from the skin is the 
individual responsibility of all ranks in all branches. If the skin 
is wet with lewisite, the excess liquid is quickly removed by blotting 
with cotton or other absorbent. Protective ointment M-5 or BAL 
ointment (Med. Dept, item No. 9102800) for skin decontamination 
is then immediately applied as described in (5) below. 
(5) Decontaminants. The individual issue of M-5 protective 
ointment is highly effective in decontaminating lewisite on the skin 25 
and should be applied as described for mustard (par. 9c (9)). It 
will decontaminate only such lewisite as remains on the skin. BAL 
ointment or BAL Solution (Med. Dept, item No. 9109525) are 
effective against all arsenical blister gases on the skin and pene- 
trate through the skin, neutralizing the agent which has been ab- 
sorbed. For this reason they are more desirable than protective 
ointment M-5 and should be used if available. The individual issue 
of eye ointment BAL (not a Med. Dept, item) in the 3-gram 
ophthalmic tube is to be reserved for eye contaminations only. The 
BAL ointment or solution is spread on the skin in a thin film, 
rubbed in with the fingers and allowed to remain at least 5 minutes. 
The film may be washed off when circumstances permit. The 
strong “rotten-egg” odor of BAL preparation must be considered 
in close night fighting. BAL preparation sometimes cause tem- 
porary stinging and itching urticarial wheals when applied to the 
skin. These lesions usually last only an hour or so and should not 
cause alarm. Mild dermatitis is fairly frequent if repeated appli- 
cations are made to the same skin area. This prevents the use of 
BAL ointment as a protective film. If protective ointment, or a 
BAL preparation, is not available wash immediately with soap and 
water. Organic solvents are moderately effective in preventing 
blisters and then only when used in the first few seconds after ex- 
posure. Care must be taken to avoid spreading the solution of the 
agent to adjacent areas. 
(6) Treatment for wounded. Wounded men, contaminated with 
liquid lewisite, will seldom be received at field installations in time 
to prevent blistering. However, their burns may be lessened and 
significant systemic protection obtained if the procedures outlined 
in e(3) below are carried out promptly. 
(7) Decontamination of hair. Contaminated hair may be 
clipped off or decontaminated with BAL solution or ointment and 
then washed with soap and water. 
(8) Treatment of lewisite erythema. The treatment of lewisite 
erythema is the same as that for mustard erythema, except that 
treatment seldom is required for longer than 24 hours (par. 9c 
(4)). BAL ointment may be tried in the early stages. 
(9) Treatment of leivisite blister. Lewisite and mustard blis- 
ters are treated alike. (See par. 9c (5).) 
(10) Treatment of denuded areas and infected lewisite burns. 
The treatment of these lesions is the same as that for similar lesions 
due to mustard. (See par. 9c (6) and (7).) 
(11) Treatment of deep leivisite burns. Large burns may be 
accompanied by serious systemic poisoning and shock demanding 
general measures as well as local treatment. Morphine and splint- 
ing of the affected parts may be necessary for the relief of pain. 26 
When the burned tissue becomes gangrenous, it should be treated 
in accordance with appendix V as for thermal burns. 
d. Respiratory Tract. (1) Symptoms. Lewisite vapor is 
highly irritating to the respiratory tract and quickly induces sneez- 
ing and coughing. This property, together with the strong odor of 
geraniums, so effectively warns of the presence of the gas that no 
severe respiratory injuries are likely to occur. Inhaled lewisite 
vapor produces lesions of the respiratory mucosa essentially similar 
to those produced by mustard. Edema of the lung often is more 
marked, and is frequently accompanied by pleural fluid. 
(2) Treatment of respi7utory tract injury due to lewisite. Since 
there have been no human respiratory tract injuries from lewisite, 
treatment is recommended solely from the results of animal ex- 
perimentation. In general, the treatment is a combination of that 
for the systemic effects of lewisite (see e(3) below) plus that for 
mustard respiratory tract injuries. (See par. 9d (3).) 
(3) Prognosis. The prognosis in respiratory tract injuries from 
lewisite is unknown but probably is similar to that for an equiva- 
lent mustard injury, with the added danger of systemic arsenical 
poisoning unless treatment with BAL preparations is instituted. 
e. Systemic. (1) Pathology and symptoms. Liquid lewisite on 
the skin, as well as inhaled vapor, is absorbed and may cause sys- 
temic poisoning. A manifestation of this is a change in capillary 
permeability which permits loss of sufficient fluid from the blood 
stream to cause hemoconcentration, shock and death. In nonfatal 
cases hemolysis of erythrocytes has occurred with a resultant 
hemolytic anemia. The excretion of oxidized lewisite into the bile by 
the liver produces focal necrosis of that organ, necrosis of the 
mucosa of the biliary passages with peribiliary hemorrhages, and 
some injury to the intestinal mucosa. Acute systemic poisoning 
from large skin burns causes pulmonary edema, diarrhea, restless- 
ness, weakness, subnormal temperature and low blood pressure in 
animals. 
(2) Prognosis. Burns severe enough to cause shock and sys- 
temic poisoning are dangerous to life. Even though the patient sur- 
vives the acute effects, the prognosis must be guarded for several 
weeks. 
(3) Treatment. There has been no experience in treating sys- 
temic lewisite poisoning in man, but the following measures may 
be of value: 
(a) Indications for treatment. The indications for systemic 
treatment following exposure to arsenical blister gases by any 
route are: 
1. Cough with dyspnea and frothy sputum, which may be 
blood-tinged and other signs of pulmonary edema. 27 
2. A skin burn the size of the palm of the hand, or larger, 
caused by a liquid arsenical blister gas, which was not decontami- 
nated within the first 15 minutes. 
3. A skin contamination covering 5 percent (about one 
square foot) or more of the body surface caused by a liquid 
arsenical vesicant, in which evidence of immediate skin damage 
(gray or dead-white blanching of the skin) or erythema devel- 
ops over the area within 30 minutes. 
4. In cases seen late where there is blistering of skin areas 
the size of the palm of the hand or larger. 
(b) Two types ot treatment are required. 
1. Intramuscular injection of 10 percent BAL in oil. (Med. 
Dept, item No. 1088500). (See (c) below.) 
2. Local neutralization on and within the skin by a liberal 
inunction of BAL ointment (Med. Dept, item No. 9102810). The 
affected skin is to be left covered with a layer of the ointment. 
Any protective ointment must first be removed from the area to 
be treated by BAL. 
(c) Dosage of BAL in Oil. 
1. An immediate intramuscular injection of 10 per cent 
BAL in Oil (Med. Dept, item No. 1088500) is given deep into 
the muscles of the buttocks. Take every precaution against in- 
jecting into a blood vessel. Dosage must be adjusted to the esti- 
mated weight of the patient as follows: 
125 pounds 2.5 c.c. 175 pounds 3.5 c.c. 
150 pounds 3.0 c.c. 200 pounds 4.0 c.c. 
2. The intramuscular injection of 10 per cent BAL in Oil 
should be repeated at different sites in the buttocks at 4, 8 and 12 
hours after the initial injection, making a total of four equal 
doses. 
3. If pulmonary symptoms or other evidence of severe ar- 
senical poisoning are present, the interval between the first and 
second dose may be shortened to 2 hours. In severe cases subse- 
quent daily half doses should be given at the rate of one injection 
per day for 3 or 4 days. 
U. In toxic or shocked patients, the usual measures such 
as plasma, high vitamin, high protein, high carbohydrate diets; 
liberal fluids by mouth or intraveneously if necessary are to be 
employed as indicated. 
(d) Symptoms caused by BAL in Oil. These may include a feel- 
ing of constriction in the throat, sense of oppression in the chest, 
burning sensation of the lips, mild lacrimation, slight reddening of 
the eyes, dryness of mouth and throat, generalized muscular ach- 
ing, abdominal pain, mild to moderate tenderness and increased 28 
muscle tonus at injection site, mild restlessness and nervousness 
with sweating of the hands, apprehension, mild nausea and vomit- 
ing on eating, and a transient rise in blood pressure. Symptoms 
appear 15 to 30 minutes after injection and last 30 minutes. Unless 
unduly severe or prolonged, they do not contraindicate the full 
course of treatment. 
12. Ethyldichlorarsine (ED) 
a. Properties. Ethyldichlorarsine is a colorless or brown liquid 
which is more volatile than lewisite and possesses a faint fruity 
odor. 
5. Pathology. The lesions are the same as those caused by 
lewisite. (See par. Ho- and b (1).) 
c. Symptoms. Low concentrations of vapor produce no symptoms 
for the first minute. Stinging pain in the nose, a burning sensation 
in the throat, headache, nausea and vomiting then begin. Even 
though the gas mask is put on at once. Symptoms may increase for 
several minutes before they regress. High concentrations are in- 
stantly so irritating to the eyes and respiratory tract that they 
compel wearing of the gas mask. A stinging and burning sensation 
is felt on the skin within 1 or 2 minutes. In very hot weather, this 
may progress to redness in 10 minutes, and to shallow blistering 
in a few hours. Pain persists only about 24 hours, and the blisters 
crust over in a few days and heal rapidly. Liquid ethyldichlorar- 
sine, like lewisite, is immediately painful on the skin and causes 
severe blistering. It produces eye injuries similar to but less severe 
than those due to lewisite. 
d. Diagnosis. The following factors should be considered in 
making the diagnosis: 
(1) History of exposure. 
(2) Fruity odor of skin and clothing. 
(3) Intense sternutatory irritant, and early vesicant effect. 
e. Decontamination. Decontaminating procedures are identi- 
cal with those for lewisite. (See'par. 115 (2),c (4), (5),and (6).) 
/. Treatment. Treatment of mild respiratory tract irritation 
is the same as that for DM (par. lid). After decontamination, 
eye.and skin lesions are treated as those due to mustard. (See par. 
95(4) and (5), c(4), (5), (6), (7), and (8).) BAL preparations 
may be used if indicated as prescribed for lewisite (par. 11c (4) 
e(3).) 
g. Prognosis. Respiratory tract irritation from low vapor con- 
centrations subsides within an hour. Skin burns in general, heal 
more rapidly than similar mustard burns. Liquid ethyldichlorar- 
sine contamination in the eye causes serious injury, possibly blind- 29 
ness, unless a BAL preparation is promptly administered. See 
par. 116(2).) 
13. Phenyldichlomrsine (PD) 
a. Properties. This agent, a clear viscid liquid, is less volatile 
than lewisite or ethyldichlorasine. It is readily hydrolyzed in 
water. 
6. Action. Phenyldichlorarsine, when inhaled, is a strong 
sternutator and lung irritant. Eye injury produced is similar to 
that caused by lewisite. (See par. 116(1).) On the skin the vapor 
or liquid is only slightly less vesicant than mustard or lewisite. If 
absorbed, phenyldichlorarsine may produce systemic poisoning. 
c. Pathology. The lesions and the systemic effects produced by 
phenyldichlorarsine are essentially those of lewisite. 
d. Symptoms. Irritation of the eyes, nose, and throat is promi- 
nent. Symptoms referable to the lungs and skin are like those pro- 
duced by lewisite. (See par. 11c(1) and cZ(1).) 
. . e. Treatment. Treatment in general is the same as that de- 
cribed for lewisite. (See par. 11c(4) and e(3).) 
14. Mixed Blister Gases 
a. General. Arsenical vesicants, such as lewisite (L) or phen- 
yldichlorarsine (PD) are often mixed with mustard. Such mix- 
tures do not produce more severe lesions than either agent alone, 
but they tend to confuse and make diagnosis difficult. 
6. Decontamination. (1) Eyes. Eyes contaminated by a mix- 
ture of liquid blister gases are treated in the same fashion as in 
the case of mustard (par. 96). The arsenical vesicant portion of 
the agent will produce pain and blepharospasm which will prob- 
ably necessitate working the ointment between the lids, as for 
lewisite, before the soldier is able to open his eyes. 
(2) Skin. Any excess of the liquid mixture is blotted from the 
skin at once. Protective ointment is then applied as described 
under mustard (par. 9c(9)). The ointment is thoroughly re- 
moved and a BAL preparation, if available, is rubbed on as for 
lewisite (par. 11c(4) and (5)). This should be removed immedi- 
ately and applied again. 
c. Treatment. (1) Eyes. Definitive treatment of eye injuries 
due to mixtures is like that for mustard injury of the eye. (See 
par. 96(4) and (5).) 
(2) Skin. Definitive treatment of skin lesions produced by 
mixtures is like that described for lewisite burns. (See par. 11c 
(8), (9), (10).) SECTION IV 
LACRIMATORS 
15. Symptoms and Treatment 
a. The more important lacrimators are chloracetophenone 
(CN), chloracetophenone solutions (CNS and CNB), and brom- 
benzyl cyanide (BBC). 
b. General symptoms produced by the lacrimators include lac- 
rimation, photophobia, blepharospasm and some irritation of the 
nose and of the freshly shaven face. In hot weather moist skin 
will not be irritated. In addition, chloracetophenone solutions 
CNS and CNB may cause some mild papulovesicular dermatitis, 
especially in warm weather, and occasional vomiting. Lacrimator 
casualties ordinarily do not require medical attention. 
c. First Aid and Treatment. (1) First aid. The mask should 
be put on and rapid breathing maintained to aid circulation of 
air in the mask. The eyes are kept open as much as possible. 
They should not be rubbed. If a liquid or solid agent has entered 
the eye, it should be promptly washed out with water from the 
canteen. 
(2) Treatment. (a) Eyes. Lacrimators produce a marked but 
self-limited irritation of the conjunctiva. When liquid lacrimators 
are splashed into the eye, the action is corrosive and resembles the 
burns of a strong acid. The eye should be flushed immediately 
with water from the canteen. This may be followed by the in- 
stillation into the eye of a solution of sodium sulfite (*4 percent), 
if available, which dissolves and neutralizes the irritating agent. 
Eye pain may be treated by instilling eye and nose drops (Med. 
Dept, item No. 9109100). The further treatment is as for other 
burns of the eye. 
(b) Skin. Superficial skin burns may be treated by calamine 
lotion for symptomatic relief. Deep burns should be treated as 
other skin burns. 
30 SECTION V 
VOMITING GASES (NOSE GASES, IRRITANT SMOKES, 
STERNUTATORS) 
16. General 
a. The vomiting gases, diphenylaminechlorarsine (DM, adam- 
site), diphenylchlorarsine (DA), and diphenylcyanarsine (DC) 
are crystalline solids which are dispersed by heat as fine particu- 
late smokes, DM smoke is canary yellow near the point of emis- 
sion, while those of DA and DC are white; all are colorless when 
diluted with air. Low concentrations are effective and smell like 
burning fireworks. 
b. These agents produce strong pepperlike irritation in the 
respiratory tract, most pronounced in the trachea and large 
bronchi. The onset of symptoms may be delayed for several min- 
utes, especially with DM, and effective exposure therefore may 
occur before the presence of the smoke is suspected. If the gas 
mask is then put on, symptoms will increase for several minutes, 
in spite of adequate protection. The soldier may believe his mask 
is ineffective, remove it, and be further exposed. This is dis- 
astrous if the smoke is immediately followed by a lethal gas. 
c. Both the service gas mask and the collective protector offer 
adequate protection against these agents. 
17. Diphenylaminechlorarsine (DM) (Adamsite) 
a. Pathology. DM produces local inflammation of the nose, 
nasal accessory sinuses, throat and eyes. 
b. Symptoms. These consist of pain and a sense of fullness 
in the nose and sinuses, accompanied by a severe headache, in- 
tense burning in the throat, and tightness and pain in the chest. 
Irritation of the eyes and lacrimation are produced. Coughing is 
uncontrollable and sneezing is violent and persistent. The nasal 
secretion is greately increased and quantities of ropy saliva flow 
from the mouth. Nausea and vomiting are prominent. Mental 
depression may occur. 
c. Diagnosis. This is made from the history of exposure and 
the relatively rapid spontaneous improvement which occurs de- 
spite the original miserable appearance and condition of the 
individual. 
31 32 
d. Treatment. The mask must be worn in spite of nausea and 
salivation, but it should be lifted from the face during actual 
vomiting. Frequent inhalations of chloroform (Medical Depart- 
ment item No. 9105800) administered early, give relief. Aspirin 
may be given to relieve the headache and general discomfort. 
Few cases should reach the medical service for treatment, since 
recovery is prompt and the soldier can carry out his battle mission 
in spite of sternutators. 
e. Prognosis. Ordinarily all symptoms disappear in about 1 to 
2 hours. Permanent injury is unlikely following exposure to field 
concentrations. Exposure in confined spaces may produce pulmo- 
nary injury and death. 
18. Diphenylchlorarsine (DA), Dlphenylcyanarsine (DC) 
The pathology, symptoms, diagnosis, treatment, and prognosis are 
similar to those diphenylaminechlorarsine (DM). (See par. 17.) SECTION VI 
SCREENING SMOKES 
19. General 
The most important of these agents are HC mixture (HC), sulfur 
trioxide-chlorsulfonic acid (FS), and titanium tetrachloride 
(FM). These smokes are not toxic in field concentrations, but 
may be dangerous in the heavy concentrations formed at the site 
of dispersion. 
20. White Phosphorus (WP) 
See paragraph 27. 
21. Titanium Tetrachloride (FM) 
a. Pathology. The liquid produces acid burns. 
h. Symptoms. Smoke generated by liquid FM is unpleasant to 
breathe as it irritates the nose and throat, but it is not dangerous 
in field concentrations. Exposure of the eyes to spray will cause 
conjunctivitis, with lacrimation and photophobia. Skin burns like 
those from acids are produced by contact with the liquid. 
c. Treatment. The burned eyes or skin should be thoroughly 
washed with water and then treated like any other burn. 
d. Prognosis. Good. 
22. Sulfur Trioxide-chlorsulfonic Acid Solution (FS) 
a. Pathology. Acid burns are produced by contact with the 
liquid. 
b. Symptoms. These are usually limited to a prickling sensa- 
tion of the skin, but exposure to heavy concentrations may result 
in severe irritation of the eyes, skin, and respiratory tract. 
c. Treatment. The eye is irrigated with water at once. Fluro- 
rescein (Medical Department item No. 9116300) will reveal cor- 
neal ulceration. For pain, eye and nose drops (Medical Depart- 
ment item No. 9109100) may be instilled. The eye is then covered 
with a light pad. Skin burns should be washed with water and 
then with sodium bicarbonate solution. Later treatment should be 
that employed for other burns. 
33 34 
d. Prognosis. The prognosis depends on the degree of corneal 
ulceration. The prognosis of skin burns and respiratory irrita- 
tion is good. 
23. HC Mixture (HC) 
a. Toxicity. Field concentrations of this smoke are harmless, 
but dangerous to fatal levels may be encountered in poorly venti- 
lated spaces or near the point of smoke production. 
b. Pathology. HC smoke, if inhaled, damages the respiratory 
tract by the action of the contained zinc chloride. Following 
severe exposure a chemical pneumonia with pulmonary edema 
may develop as in phosgene poisoning. 
c. Symptoms. When HC is breathed in high concentrations 
there is a feeling of suffocation and some irritation of the nose 
and throat with coughing and choking. This may be followed by 
bronchial constriction with symptoms similar to those of asthma; 
severe exposures produce nausea and vomiting, and later, signs 
and symptoms of pulmonary edema may appear. 
d.. Treatment. The early symptoms due to bronchial constric- 
tion may be relieved by the intramuscular injection of 0.5 mg. 
(0.5 cc. of a 1:1000 solution) of epinephrine hydrochloride. This 
dose may be repeated in 20 to 30 minutes if necessary. If the 
exposure has been heavy, treatment with intramuscular BAL in 
oil should be instituted. The dose and procedure are the same as 
for systemic L poisoning (par. lie(3) (c)) except that injections 
are continued for 48 hours at 4-hour intervals. Should pulmonary 
edema develop, treatment is like that for phosgene poisoning 
(par. 5d). 
e. Prognosis. The prognosis depends on the severity of expo- 
sure and the extent of pulmonary damage. SECTION VII 
INCENDIARY AGENTS 
24. General 
The principal agents in this group are thermite (TH), magne- 
sium and its alloys, white phosphorus (WP), and combustible 
oils. All generate tremendous heat and can inflict severe burns. 
Chemical fire extinguishers containing carbon tetrachloride 
(pyrene) or liberating carbon dioxide should not be used in 
confined spaces to extinguish thermite and magnesium incendiary 
bombs. When carbon tetrachloride comes in contact with flame 
or a highly heated metal, a mixture of phosgene, chlorine, carbon 
monoxide, and hydrochloric acid is liberated. The service mask 
does not offer protection against carbon monoxide. 
25. Thermite (TH) 
Thermite incendiaries burn at a temperature of about 4330° F. 
and scatter molten iron. Frequently explosive charges are added 
and make control hazardous. The particles of iron that lodge in 
the skin usually produce multiple small but deep burns. The par- 
ticles should be cooled immediately with water and removed. 
Thereafter the treatment is that used for other thermal burns. 
26. Magnesium and Its Alloys 
Magnesium burns at a temperature of about 3630° F. with a 
scattering effect similar to that of thermite. Deep burns are 
caused by its particles, which, unless removed promptly, result 
in slow healing. Removal is usually possible under local anes- 
thesia. When explosive charges have been added to a magnesium 
bomb, the fragments may be embedded deep in the tissues, caus- 
ing the localized formation of hydrogen gas and tissue necrosis. 
27. White Phosphorus (WP) 
Extensive burns may be produced by incandescent particles of 
white phosphorus. The burns are usually multiple, deep, and 
variable in size. The smoke is nontoxic in field concentrations. 
White phosphorus continues to burn unless deprived of oxygen. 
35 36 
The burned areas should be immersed immediately in water or 
covered with dressings soaked in water, urine, or any nonirritant 
aqueous solution. Immersion should be continued until a 5 percent 
solution of copper sulfate (Medical Department item No. 
9107500) is applied. A 2 percent solution of copper sulfate may 
be used in the eye. Copper sulfate forms a noninflammable coat- 
ing of black copper phosphide on the phosphorus particles. All 
particles should be removed under water, unless the copper sul- 
fate solution has been applied. They may be located by their 
phosphorescence in the dark. Burning particles are recognizable 
by the evolution of smoke. It is well to debride the burn promptly, 
if the patients condition will permit, in order to remove bits of 
phosphorus which might be absorbed and produce systemic poi- 
soning. Following the removal of the particles the lesions are 
treated as thermal burns. Salves with an oily base should not be 
used until it is certain that all phosphorus has been removed. 
28. Oil Incendiaries 
a. Burns may be produced by flame throwers and by oil incen- 
diary bombs which may also contain phosphorus and sodium. 
Lung damage from heat and irritating gases may be a complica- 
tion added to the injuries from incendiaries, especially in confined 
spaces. Morphine should be given guardedly to patients with pul- 
monary complications. The treatment of burns caused by oil in- 
cendiaries is like that for other heat burns. 
b. Flame Thrower Attack. (1) General. As flame from 
burning fuel fills an inclosed fortification the oxygen content of 
the air is reduced and hot fumes and smoke are produced. The 
coolest and purest air is found at floor level. 
(2) Casualties. Deaths may occur during or shortly after flame 
attack. Survivors may have thermal burns of the skin and upper 
respiratory tract as well as pulmonary damage from fumes. 
Laryngeal and glottic edema may cause suffocation. 
(3) Protection. The floor level is the safest area during flame 
attack. Any kind of cover affords some protection from heat. A 
wool blanket is excellent. The gas mask should be worn for the 
protection it affords against smoke and for its slight cooling effect 
on the inspired air. 
(4) Treatment. Casualties should be removed to fresh air as 
soon as possible. Artificial respiration (with the inhalation of 
100 percent oxygen if possible) should be instituted if breathing 
has ceased. Burns of the skin are treated as any thermal burns 
(app. V). If there are burns about the face, the possibility of 
laryngeal burning with subsequent edema producing respiratory 
obstruction should be borne in mind so that tracheotomy can be 37 
performed in an emergency. The general treatment of the 
casualty burned by flame attack does not differ from that given 
for any extensive thermal burns. Plasma is given for the preven- 
tion of shock and other procedures outlined in app. V are followed. SECTION VIII 
SYSTEMIC POISONS 
Systemic poisons produce their effects after absorption into the 
body. Hydrocyanic acid, cyanogen chloride and arsine are in- 
cluded in this group. 
29. General 
30. Hydrocyanic Acid (AC) 
a. Physical Properties, Hydrocyanic acid is a colorless, high- 
ly volatile liquid which boils at 26° C. Its vapor is nonpersistent 
and its odor is faint, like peach kernals or bitter almonds, but 
undetectable to some. 
b. Pathology. Hydrocyanic acid acts by combination with an 
enzyme essential for oxidative processes of the tissue. The central 
nervous system, particularly the respiratory center, is especially 
susceptible to this interference, and respiratory failure is the 
usual cause of death. In high concentrations of hydracyanic acid 
(10 mg per liter or more) the amount inhaled in a few breaths 
may be sufficient to cause immediate death without anatomical 
changes. After exposure to lower concentrations, death may be 
delayed for hours to days. Small areas of hemorrhage and soft- 
ening, the more pronounced the longer the course, may be found 
in the brain in fatal cases. 
c. Symptoms. The symptoms depend upon the concentration of 
the gas and the duration of the exposure. In high concentrations 
there is increased depth of respiration within a few seconds; vio- 
lent convulsions after 20 to 30 seconds; cessation of regular respi- 
ration in 1 minute; occasional shallow gasps, and finally, cessation 
of heart action several minutes after initial exposure. Following 
moderate exposures, vertigo, nausea, and headache appear very 
early and are followed by coma and convulsions. These may per- 
sist for several hours or days and be followed by death or re- 
covery. If the patient recovers after a prolonged course during 
which coma and convulsions were present, there may be evidence 
of damage to the central nervous system, such as irrationality, 
altered reflexes and unsteady gait, which may last weeks or 
38 39 
longer. Mild exposure may produce headaches, vertigo, and 
nausea, but recovery is complete. 
d. Diagnosis. The diagnosis may be made from the history, 
the odor, and the rapid onset of symptoms. 
e. Treatment. (1) Adequate protection against field concen- 
trations of AC is provided by all army gas masks of M9A2 or 
later model of canister. The most practicable therapeutic mea- 
sure at present available is the inhalation of amyl nitrite. In the 
event that use of hydrocyanic acid by the enemy is anticipated in 
a specific combat zone, ampouls of amyl nitrite (Medical Depart- 
ment item No. 1069000) should be distributed to each soldier. 
When hydrocyanic acid is detected, the soldier must attempt to 
hold his breath and adjust his gas mask. If he is capable of doing 
this, the hydrocyanic acid already absorbed will usually be de- 
toxified. However, if the soldier is incapacitated (disorientation, 
coma, or convulsions) emergency treatment must be given im- 
mediately by the nearest individual. If hydrocyanic acid is still 
present in the atmosphere and the stricken soldier has not been 
able to put on his gas mask, this must be done for him. The 
soldier should be placed on the ground in a horizontal position. 
Two ampouls of amyl nitrite are crushed and inserted under the 
facepiece. Since the patient will usually not be breathing, or 
breathing feebly or irregularly, manual artificial respiration must 
be instituted to facilitate the inhalation of the amyl nitrite. The 
insertion of two crushed ampouls of amyl nitrite is repeated three 
times at 3- to 4-minute intervals until a total of eight ampouls is 
given. If hydrocyanic acid is gone from the surrounding atmos- 
phere within a few seconds after the soldier is stricken and the 
gas mask has not been put on, time should not be taken to adjust 
the mask. Two ampouls of amyl nitrite may be crushed in the 
hollow of the hand and held close to the patient’s nose. As above, 
administration is repeated every 3 or 4 minutes until a total of 
eight ampouls is given. Artificial respiration should be continued 
until spontaneous regular respiration returns. Treatment should 
be continued for at least 10 minutes after the last sign of cardiac 
activity. 
(2) Where available, sodium nitrite and sodium thiosulfate 
should be administered intravenously. Then cc. of a 1 percent 
solution of sodium nitrite should be injected intravenously over 
a period of 1 minute every 10 minutes until a total of 50 cc. is 
given. Between the nitrite injections, 10 cc. of a 10 percent solu- 
tion of sodium thiosulfate (Medical Department item No. 
1449500) should be given intravenously over a period of 1 minute. 
(3) Amyl nitrite administration may lead to a marked but 
temporary and not dangerous fall in blood pressure. The decrease 40 
in blood pressure following sodium nitrite injections is negligible 
unless the patient is allowed to get into an upright position. The 
development of a slight degree of cyanosis is evidence of a desir- 
able degree of methemoblobinemia. It is not anticipated that, at 
the above dosages, an extreme or injurious degree of methemo- 
globinemia will develop. If it does, however, it should be treated 
by 100 percent oxygen inhalation. 
31. Cyanogen Chloride (CK) 
a. Properties. Cyanogen chloride is a colorless liquid which 
boils at 15°C. yielding a volatile irritant vapor. Although only 
slightly soluble in water, it dissolves readily in organic solvents. 
b. Pathology. The acute toxicity of cyanogen chloride is simi- 
lar to that of hydrocyanic acid. The respiratory center is at first 
stimulated and then rapidly paralyzed. Cyanogen chloride, like 
phosgene damages the respiratory tract resulting in mild inflam- 
matory changes in the bronchioles, and congestion and edema of 
the lungs. The edema may form much more rapidly than in phos- 
gene poisoning. 
c. Symptoms. The signs and symptoms combine those pro- 
duced by a lung irritant and hydrocyanic acid. Very low concen- 
trations produce lacrimation. Following exposure there is an 
immediate intense irritation of the nose, throat and eyes, with 
coughing, choking, tightness in the chest, and lacrimation. There- 
after the exposed person may become dizzy and increasingly dys- 
pneic. Unconsciousness is followed by failing respiration and 
death within a few minutes. Convulsions, retching, involuntary 
urination and defecation may occur. If these effects, typical of 
cyanide poisoning, are not fatal, the signs and symptoms of pul- 
monary edema may develop. There may be persistent cough with 
much frothy sputum, rales in the chest, severe dyspnea and 
marked cyanosis. 
d. Treatment. Adequate protection against field concentra- 
tions of CK is provided by all army gas masks of later model than 
the one with carister M1XA1. On detection of the gas, the breath 
should be held and the gas mask should be adjusted. Treatment 
is a combination of those for hydrocyanic acid and for phosgene 
poisoning. (See pars. 5d and 30e.) The predominant signs and 
symptoms determine therapy. 
e. Prognosis. If death does not occur promptly from cyanide, 
the outlook is determined by the severity of the manifastations of 
lung irritation. 41 
32. Arsine (SA) 
a. Properties. Arsine is a colorless, odorless gas, but when im- 
pure it may have a garliclike odor in high concentrations. 
b. Pathology. The gas is absorbed from the respiratory tract 
into the blood and gives rise to intravascular hemolysis. This 
results in anemia, hemoglobinemia, methemoglobinemia and 
hemoglobinuria. Through the action of circulating arsine and its 
oxidation products there is serious disturbance of the tissue 
metabolism of kidney and liver. The kidneys show marked tubu- 
lar change and numerous blood pigment casts. Anatomical 
changes in the liver are less constant, but hepatitis and focal 
necrosis may be present. Jaundice is due to hemolysis or to liver 
damage or both. Death results from renal or hepatic failure, 
anemia, or a combination of these. 
c. Treatment. Therapy is both symptomatic and specific. The 
symptomatic treatment consists in: the daily administration of 
about 3000 cc. fluid, either orally or parenterally as isotonic saline 
and glucose; blood transfusions of 500 cc. each, repeated so as to 
maintain the hemoglobin above 50 percent and the r.b.c. count 
above two million per cu. mm.; the daily administration of 20 gm. 
sodium bicarbonate in divided doses. The specific treatment is 
the same as that for lewisite poisoning and consists in the intra- 
muscular injection of BAL (par. lie(3) (a), (c), and (d)). SECTION IX 
INCIDENTAL GASES 
33. General 
a. This group includes carbon monoxide, nitrous fumes, hydro- 
gen sulfide and ammonia. These may be encountered in dangerous 
concentrations in confined or poorly ventilated spaces. 
b. Protection against incidental gases. The service mask and 
collective protectors are not efficient against carbon monoxide or 
ammonia. Special canisters are available. 
34. Carbon Monoxide 
a. Physical Properties. Carbon monoxide is a colorless, odor- 
less gas, which is lighter than air, into which it diffuses rapidly. 
6.. Occurence in Military Operations. Carbon monoxide is 
formed by gun blasts, bursting shells, internal combustion en- 
gines, and in the incomplete combustion of fuels. Dangerous con- 
centrations are apt to occur in confined spaces such as tank land- 
ing craft, garages, poorly ventilated gun turrents or emplace- 
ments, and in mining operations. 
c. Pathology. Asphyxiation is produced by the inactivation of 
hemoglobin through combination with carbon monoxide. The re- 
sultant anoxia produces nervous system changes. Post mortem 
examinations reveal little beyond the characteristic cherry red 
color of the blood and hemorrhages in the brain. The dissociation 
of carbon monoxide from hemoglobin may be hastened by oxygen. 
d. Symptoms. The symptoms progress from throbbing head- 
ache, vertigo, yawning, and poor visual acuity, to the development 
of cherry red mucous membranes, weakness and coma, subnormal 
temperature, feeble pulse and perhaps death. 
e. Diagnosis. The diagnosis is made from circumstances of ex- 
posure and the appearance of cherry red color of the skin and 
mucous membranes. 
/. Protection. Adequate ventilation should be provided for all 
inclosed space where carbon monoxide may be produced. The 
safety of the air in the space may be tested by introducing a cage 
containing a mouse or canary. The air will be safe for man to 
breath as long as these remain unaffected. Caution: This test can 
42 43 
only be relied upon at atmospheric or higher pressures. At high 
altitudes it is not reliable. 
g. Treatment. Remove to pure air, give oxygen and artificial 
respiration if necessary. Rest, blankets, and warm drinks are also 
indicated. 
h. PROGNOSIS. The longer the period of coma the less the 
chance for recovery. Most mildly exposed individuals recover 
with early treatment. Tachycardia and dyspnea may continue for 
months and there may be central nervous system disturbances 
ranging from simple neuritis to mental deterioration. 
35. Nitrous Fumes 
a. General. The term “Nitrous fumes” applies to the mixture 
of oxides of nitrogen which is liberated when high explosives are 
burned or detonated. Nitrous oxide has anesthetic properties in 
high concentrations. It possesses no irritating action. Nitric 
oxide combines rapidly with oxygen to form nitrogen dioxide 
which is a dark brown gas. Nitrogen dioxide reforms nitric oxide 
when it passes through the gas mask. Nitrogen dioxide also 
forms N2Oi. The latter compound reacts with water to form ni- 
trous and nitric acid. 
h. Occurrence of Poisoning. The danger of nitrous fume 
poisining is great if high explosives, such as smokeless powder or 
cordite, are burned or detonated in the absence of sufficient ven- 
tilation. This may occur in gun pits, armored vehicles, ship maga- 
zine and turrets, as well as in mining and tunneling operations. 
c. Pathology. Nitric oxide, NO, combines with hemoglobin to 
form NO-hemoglobin. It is doubtful, however, whether this latter 
compound exists in the body during life. Inhalation of nitric oxide 
causes the formation of methemoglobin but does not appear to 
lead to any tissue lesions. Inhalation of nitrogen dioxide results 
in the formation of nitrite and hence leads to a fall in blood pres- 
sure and to the production of methemoglobin. Inhalation of high 
concentrations of nitrogen dioxide (above 0.5 mg. per liter) 
causes rapid death without the formation of pulmonary edema. 
Somewhat lower concentrations result in death with the produc- 
tion of yellow frothy fluid in the nasal passages, mouth and 
trachea and marked pulmonary edema. The findings in other 
tissues are negligible. 
d. Symptoms. The symptoms following inhalation of “nitrous 
fumes” are due chiefly to nitrogen dioxide. The symptoms depend 
upon the concentration of the gas. At exposures to concentrations 
less than 0.005 mg. per liter over long periods of time, inflamma- 
tion of the gums, emphysema of the lungs, hypotonia and brady- 
cardia have been observed. At exposure to higher concentrations, 44 
there is severe local irritation with burning and choking in the 
chest, violent cough, expectoration of yellow colored sputum, head- 
ache and vomiting. A latent period of 2 to 24 hours then follows. 
The late symptoms start with coughing, nausea, vomiting, frothy 
sputum, dyspnea, cyanosis, convulsions and symptoms of lung- 
edema. This train of symptoms may result in death. At exposures 
to very high concentrations for short periods of time, the onset of 
symptoms is very sudden and marked. Convulsions, unconscious- 
ness and respiratory arrest occur within a short time and death 
may follow. 
e. Diagnosis. The diagnosis is made from the history, the 
symptoms described, and sometimes from the pungent odor of the 
gas or the yellow discoloration of the exposed mucous membranes. 
/. Treatment. Treatment of casualties with symptoms of pul- 
monary irritation is the same as that outlined for phosgene poi- 
soning (par. 5d). The few cases with symptoms referable to the 
central nervous system either die quickly or, on removal to fresh 
air, recover spontaneously. 
g. Prognosis. Fatal cases usually die within 48 hours. Bron- 
chopneumonia and varying degrees of pulmonary fibrosis and 
emphysema often follow recovery from the acute stage. 
36. Hydrogen Sulfide 
a. This colorless gas in low concentrations has the odor of 
rotten eggs. In high concentrations it may dull the sense of smell 
and be difficult to recognize. Hydrogen sulfide is nearly as toxic 
as hydrocyanic acid. 
b. Pathology. In low concentrations, less than about 0.5 mg. 
per liter, hydrogen sulfide may produce inflammation of the eyes, 
nose and throat if breathed for periods of V2 to 1 hour or longer. 
Somewhat higher concentrations may produce edema of the lungs. 
Still higher concentrations, 2 mg. per liter or greater, are rapidly 
fatal, presumably by combination of the hydrogen sulfide with 
the tissue respiratory pigments and the subsequent paralysis of 
the respiratory center. 
c. Symptoms. The symptoms depend upon the concentration of 
the gas. At the lowest concentrations, the effects are chiefly on 
the eyes: conjunctivitis, swollen eye-lids, itchiness, smarting, 
pain, photophobia, and blurring of vision. At somewhat higher 
concentrations, respiratory tract symptoms are more pronounced. 
Rhinitis, pharyngitis, laryngitis, and bronchitis may occur. Pul- 
monary edema may also result. At very high concentrations, un- 
consciousness, convulsions and cessation of respiration develop 
rapidly. 
d. Treatment. The patient should be removed immediately 45 
from the contaminated atmosphere. Aritficial respiration and, if 
possible, inhalation of oxygen should be instituted immediately. 
Treatment of pulmonary edema is the same as of that caused by 
phosgene (par. 5d). 
e. Prognosis. Mortality from severe exposure is high. When 
there are symptoms of lung damage the prognosis is like that in 
phophosgene poisoning (par. 5/). 
37. Ammonia 
a. Physical Properties. Ammonia is a colorless gas which is 
soluble in water and has a pungent, characteristic odor. 
b. Occurrence in Military Operations. This gas has not 
been used in warfare but may be encountered in industrial acci- 
dents and bombings involving refrigeration plants. 
c. Pathology. Exposure to high concentrations of ammonia 
produces prompt and violent irritation of the eye and respiratory 
tract. There may be spasm and edema of the glottis of even 
necrosis of the laryngeal mucous membranes. Pulmonary edema 
may develop as in phosgene poisoning and may be complicated by 
bronchopneumonia. 
d. Symptoms. Inhalation of high concentrations produces vio- 
lent, burning pain in the eyes and nose, lacrimation, sneezing, pain 
in the chest, cough, spasm of the glottis, and pulmonary edema. 
Often there is a temporary reflex cessation of respiration with 
spasm of the glottis. Edema of the glottis at a later period may 
seriously interfere with breathing. Concentrations of 0.1 percent 
are intolerable to man. Liquid ammonia is vesicant. 
e. Treatment. First-aid treatment consists of prompt removal 
to pure air, and artificial respiration. Later measures are directed 
toward the treatment of pulmonary edema, bronchitis and pneu- 
monia. (See par. 5d). 
/. Prognosis. The mortality is high following severe exposure 
with lower concentrations, recovery is usually rapid, although 
bronchitis may persist. SECTION X 
OXYGEN DEFICIENCY 
38. General 
a. General. (1) The proportion of oxygen in the atmosphere 
may be reduced to a dangerous degree in closed or poorly venti- 
lated spaces such as shelters, compartments, or underground 
tunnels, by human consumption, combustion by fire, or dilution 
with other gases. The absolute reduction of oxygen at high alti- 
tudes while mainly of concern to aviation, may also deserve con- 
sideration in land operations in mountains. 
(2) A normal 70 Kg. man while resting in bed requires 0.240 
1/min, of oxygen. Consumption is increased with activity to 1.2 
1/min, while walking at a rate of 4 miles per hour and to 3 or 4 
1/min. at maximum exertion. 
b. Symptoms. (1) When the oxygen of the inspired air is di- 
minished to values between 16 and 12 percent (a candle is extin- 
guished at 17 percent), the volume of breathing is increased and 
the pulse rate is accelerated. The ability to think clearly is dimi- 
nished. Finer skilled movements are disturbed. 
(2) When the oxygen of the inspired air is diminshed to 14 to 
10 percent judgment becomes faulty, injuries may cause no pain, 
emotions are volatile, and muscular effort causes easy fatigue. 
(3) When the oxygen is diminshed to 10 to 6 percent nausea 
and vomiting may appear. Bewilderment and loss of conscious- 
ness follow. Muscular movements may be impossible. The sub- 
ject may be wholly unaware that anything is wrong. 
(4) When the oxygen is diminshed to below 6 percent, respira- 
tion consists of gasps separated by periods of apnea. Convulsive 
movements may occur. Respiration ceases and the heart continues 
to beat for a few minutes. Death follows rapidly. 
c. Acclimatization. Initial exposure to anoxia at high altitudes 
may give rise to the above symptoms. After several days at high 
altitudes, acclimatization takes place. There is an increase in the 
volume of breathing and of the red cells in the blood with a de- 
crease of the alkali in the blood and of carbon dioxide in the 
alveolar air. This enables the individual to increase his activity 
toward normal. 
46 47 
d. Treatment. (1) The individual should be removed from 
the atmosphere to pure air if possible. At high altitudes and 
where removal to air is impossible, oxygen must be administered. 
If respirations have ceased, artificial respiration should be given 
until at least 10 minutes after signs of cardiac action have dis- 
appeared. Oxygen 95 percent and carbon dioxide 5 percent should 
be administered by inhalation. 
(2) (The individual exposed to low oxygen concentrations 
should remain recumbent and move as little as possible in order 
to diminish his metabolic needs for oxygen. 
(3) It is obvious that no gas mask will protect against oxygen 
deficiency. 
e. Prognosis. (1) If the anoxia is corrected before conscious- 
ness is lost or shortly thereafter, most of the symptoms disappear 
within a few hours. Headache, nausea, and malaise may continue 
for 24 to 48 hours. 
(2) If anoxia has continued for a long period, degenerative 
changes may occur in the nervous system with paralysis or am- 
nesia. Death occurs rapidly when the oxygen content of the in- 
spire air drops below 6 percent. SECTION XI 
ANIMAL CASUALTIES 
a. The material on human casualties from chemical warfare 
agents is generally applicable to animals. Hence only facts im- 
portant in the handling of gassed horses, mules and dogs will be 
stressed. 
39. General 
b. The prevention of gas casualties in Army animals is import- 
ant to eliminate lost working days. Animal gas masks and leg 
covers offer the best individual protection. Animals, especially 
horses, may, if masked, withstand exposure to vesicant vapors 
without developing incapacitating injuries. Protection by covers 
against airplane spray may be required. The dog gas mask pro- 
vides protection for the eyes and respiratory tract. His working 
efficiency is so reduced when masked that he should not be ex- 
pected to work in it. The feet and legs of dogs are particularly 
vulnerable to liquid vesicants. Animals should be prevented from 
drinking from water holes, trenches, or shell craters and from 
pasturing in areas which have recently been contaminated, until 
the water and forage are known to be suitable for consumption. 
Water in deep wells or large streams and lakes is usually safe. 
40. Lung Irritants 
a. General. The effects of lung irritants in animals are like 
those in men. 
b. Phosgene. (1) Symptoms. Cyanosis, so prominent in hu- 
mans, is masked in animals. 
(2) Treatment. Heavy work is dangerous, especially after pul- 
monary edema develops. Animals in shock should be kept com- 
fortably warm. Oxygen therapy for animals is not practicable 
under field conditions. Venesection has not proved beneficial and 
is certainly harmful during the shocklike stage. Contraindica- 
tions in treatment are the same as those for man. If the animal 
survives 4 days, recovery may be expected, unless bronchopneu- 
monia supervenes. 
c. Chlorpicrin. Chlorpicrin irritates the upper bronchi and 
48 trachea as well as the alveoli. Pulmonary edema may appear. The 
clinical picture and treatment are as described for phosgene. 
49 
d. Chlorine. Chlorine causes bronchospasm and a choking 
cough. If death is not immediate from intense bronchial spasm, 
the later symptoms and the treatment are those described for 
phosgene. 
41. Vesicants 
a. General. (1) The terms “blister” and “vesicant” agents 
are misnomers for animals since vesication does not occur. The 
vesicants, especially the arsenicals, contaminate forage, water, 
grain, and other supplies. 
(2) Before treating vesicant casualties, veterinary personnel 
must be protected. 
b. Mustard, (1) Injury caused by mustard, (a) Incapacitat- 
ing injury to animals may result from liquid mustard sprayed 
from aircraft or splashed from shell bursts, or from contact with 
recently contaminated ground. Mustard vapor produces less in- 
jury to animals than to man. A long coat of hair does not prevent 
injury but does impede penetration of liquid and cause lateral 
spreading. This results in a shallow lesion with a short healing 
time. Usually 10 to 20 minutes after the application of a liquid 
vesicant to the hair there is an erection of the hair coat in the 
vicinity of the drop. This phenomenon persists for 1 hour or 
longer and may be important in diagnosis. Two or more hours 
after contamination, edema of the underlying tissue appears and 
may increase for 24 hours. These signs appear more slowly in 
cold weather. As the edema subsides, particularly on the body 
skin, superficial layers may exfoliate. Where contamination has 
been heavy an eschar forms and later sloughs leaving an area of 
ulceration. The majority of such burns heal in 6 to 8 weeks, but 
some may require 14 weeks or longer. When horses and mules 
traverse ground where droplets of mustard remain, they frequent- 
ly develop filling edma around their pasterns and fetlock joints. 
The animal becomes lame. Edema fluid oozes through the skin 
and accumulates in the hair coat. The skin becomes pulpy and 
soft. Fissuring and ulceration may occur and be aggravated by 
motion of the limb. The fine skin of the hollow of the heel is 
particularly susceptible and infection may be expected. The horny 
hoof including the frog is sufficiently resistant to mustard as to 
require no protection. If a horse, mule or dog must pass through 
a freshly contaminated area its legs should be protected by im- 
permeable leggings, or by a suitable protective ointment.* Pro- 
* Protective ointment, M-4, is irritant to an animal’s skin. 50 
tective ointment M-5 may be used for this purpose but when 
used on the dog it should be removed by washing with gasoline 
followed immediately with soap and water since it may produce 
skin irritation. It should be borne in mind that shell holes may 
contain liquid vesicants for weeks after contamination. 
(b) The eyes of animals, especially the horse, are more resist- 
ant than mans to injury from mustard vapor. Injury is not pro- 
duced with short exposures to field concentrations. However, 
serious eye injury may follow severe exposure. Droplets in the 
eye cause conjunctivitis, keratitis, and temporary blindness or 
necrosis of the cornea with permanent opacity. Eye shields which 
need not be airtight give horses sufficient protection against liquid 
vesicants. The dog’s eye is less resistant than the horse’s to mus- 
tard vapor. The dog gas mask protects the eyes. 
(c) Under ordinary field conditions severe exposure to mus- 
tard vapor is necessary to cause respiratory tract injury in horses. 
Here again the dog is more susceptible. Edema, necrosis, and ul- 
ceration of the mucous membranes of the respiratory tract follow 
inhalation of fine mists of mustard in the immediate vicinity of 
an H shell burst. Signs may appear as early as 10 minutes after 
exposure. The edema of the air passages often causes an obstruc- 
tive dyspnea. A bacterial bronchopneumonia may follow. 
(d) Contaminated fodder and water, or licking contaminated 
parts, may produce ulceration and edema of the buccal mem- 
branes. When the gastro-intestinal tract is involved, abdominal 
pain and diarrhea may result. 
(e) Vapor injury may be severe from the evaporation of liquid 
mustard on equipment close to the skin. 
(2) Decontamination and treatment. Because the hair coat of 
animals impedes penetration, effective prophylactic measures may 
be instituted later in animals than in man. The healing time is 
shortened in proportion to the speed with which decontamination 
is employed and some mitigation of the injury may be expected 
even after 1 hour. Bleach paste (1 part chlorinated lime in 3 
parts of cold water) or calcium hypochlorite (in 8 parts of cold 
water) should be used to neutralize mustard. This must be 
worked into the skin carefully avoiding the eyes. Decontami- 
nants are irritant to the animal’s skin and should be washed off 
within 2 to 5 minutes. Decontamination may be accomplished also 
by vigorous scrubbing of the contaminated area with a 5 percent 
solution of potassium permanganate. Swabbing with soap and 
water or with solvents like gasoline and kerosene usually spreads 
the agent, causing a shallow but larger lesion. When other agents 
are not available protective ointment M-5, if rubbed into the 
part, may be used to decontaminate the skin of dogs. Treatment 51 
of vesicant burns will depend upon the severity of the injury 
and the site oif the lesion. Frequently, sprayed droplets of vesi- 
cants remain on the surface of the hair and cause slight super- 
ficial skin injury from vaporization. In such instances the drop- 
lets should be first wiped away with absorbents to prevent the 
treatment agents from carrying the liquid into the skin. Since 
liquid vasicants may remain in the hair for days, decontamina- 
tion procedures should always be carried out before attempting to 
treat lesions that have already developed. In treating developed 
burns, the objectives are cleanliness of the wound and reduction 
of infection, thereby promoting healing. Cod liver oil ointment, 
tannic acid, gentian violet (Medical Department item No. 
1213500), potassium permanganate (Medical Department item 
No. 1372200), or other preparations may be of value. Slight in- 
jury to skin not exposed to friction of harness and saddlery sel- 
dom needs treatment. Eyes contaminated with liquid mustard 
should be irrigated immediately with water. If the conjunctivae 
and lids become edematous, bathing with boric acid solution may 
be of benefit. Pain may be allayed by local anesthetics (1 percent 
butyn, Medical Department item No. 1108500). Treatment of 
injuries to the alimentary and respiratory tracts is symptomatic. 
Prevention of secondary pneumonia should be attempted with one 
of the sulfonamide drugs. Steam inhalations may provide respi- 
ratory relief. Fresh air, warmth, and nursing are essential. 
Food should be offered from the floor to promote drainage of nasal 
secretions. Appetizing foods should be given. 
c. Lewisite. (1) Injury caused by lewisite. Although the 
sensitivity of animals is nearly the same to lewisite as to mustard 
vapor, the lesion produced by liquid lewisite appears earlier and 
is more severe than that produced by liquid mustard. Lewisite 
burns resemble those caused by mustard, but are immediately 
painful and cause restlessness. There may be systemic effects. 
(2) Decontamination and treatment. Decontamination for the 
destruction or removal of lewisite must be initiated at the first 
opportunity. Scrubbing the contaminated skin with a 5 percent 
solution of potassium permanganate or with bleach as advised for 
mustard will reduce the injury and lessen the danger of arsenical 
poisoning. Treatment of the eye, including the use of BAL, is 
similar to that for man. Late treatment is symptomatic. 
d. Ethyldichlorarsine. Injury to the skin by ethyldichlorar- 
sine is less than with lewisite or mustard. Treatment is similar 
to that for lewisite. 
e. Nitrogen Mustards. (1) These agents are less damaging 
to the skin of animals than equal concentrations of mustard or 
lewisite. On the respiratory tract their action produces injury of 52 
severity equal to that of mustard. The eyes of the dog and horse 
may be more susceptible to these vapors than to those of mus- 
tard. Injury to the eyes from liquid nitrogen mustards is more 
severe than from mustard. The treatment of animal casualties 
should proceed along the general lines advised for mustard. In 
cases of eye injury, where there is miosis, atropine sulfate (1 
percent) should be instilled until mydriasis is induced. The 
prognosis in contamination of the eye with these agents in the 
liquid form is serious unless the agent is removed by irrigation 
with water within 1 or 2 minutes. 
(2) Severe exposures, in laboratory animals, result in lesions 
of the nervous and hemopoisetic systems and in the gastrointesti- 
nal tract. (See par. 10/.) 
(3) Protective devices, especially to guard the eye against li- 
quid spray, are important in prevention of animal casualties from 
nitrogen mustards. The horse and dog gas masks are effective. 
42. Lacrimators and Irritant Smokes 
While these agents are intolerable to man in even very low con- 
centrations, under ordinary field conditions they have little effect 
upon animals, especially horses. Severe irritation may result 
when a liquid lacrimator gets in the eyes. The treatment is im- 
mediate irrigation with water or sodium bicarbonate solution. 
43. Screening Smokes 
a. White Phosphorus. (1) Effects. Burning particles of 
white phosphorus produce deep burns on contact with the skin. 
The smoke is nontoxic. 
(2) Treatment. Smother the burn immediately with water or 
mud. Keep the burn under water until a 2 to 10 percent copper 
sulfate solution can be applied. This excludes air by forming a 
protective metallic coating on the phosphorous particles. The 
particles can then be removed with forceps or a hemostat. Fur- 
ther treatment is that for ordinary burns. 
b. Sulfur Trioxide-chlorsulfonic Acid Solutions (FS). It 
is believed that this smoke in field concentrations will not affect 
an animal’s skin. Eye burns may follow exposure to irritating 
concentrations. Water or sodium bicarbonate solution may be 
used for eye irrigations. 
c. Titanium Tetrachloride (FM). The liquid may produce 
burns on the skin and in the eyes, but it is not so irritant as FS. 
Treatment is the same as for burns caused by FS. 
d. HC Mixture. Usual field concentrations are not irritating 53 
to animals, but higher concentrations may produce respiratory 
tract damage like that caused by the lung-irritant gases. 
44. Incendiary Agents 
Treatment of burns from incendiary agents is that used for 
any heat burn. 
45. Systemic Poisons 
a. General. . These are agents which produce their effects after 
absorption. The most important are hydrocyanic acid, cyanogen 
chloride, and arsine. Protection requires an efficient type of ani- 
mal gas mask or collective protector 
b. Hydrocyanic Acid and Cyanogen Chloride. Hydrocyanic 
acid produces asphyxia of the tissues, especially the central nerv- 
ous system, and paralyzes the respiratory center. Cyanogen 
chloride, in addition to producing cyanide effects, irritates mu- 
cous membranes and may cause lung edema. Procedure advised 
in treating human casualties may be used with animal casualties 
when practical. Dosage of drugs should be adjusted according 
to weight. 
c. Arsine. For effects of arsine see paragraph 32. Treatment 
is symptomatic. The animal gas mask gives adequate protection. 
46. Incidental Gases 
Exposure to incidental gases such as carbon monoxide, nitrous 
fumes, and ammonia is not expected in the field. APPENDIX I 
A GUIDE FOR THE DISPOSITION OF PERSONNEL WITH 
BLISTER GAS BURNS 
1. Introduction 
a. This material will serve as a guide for the use of medical 
officers in the field in the event they should be confronted with 
casualties due to blister gases. Its chief purpose is to bring to 
their attention the current views concerning the casualty-produc- 
ing powers of blister gases. It will assist the medical officer in 
the forward area in deciding which type of blister gas case he 
should evacuate as a casualty, and which type he may retain in 
the lines without appreciable interference with the fighting effec- 
tiveness of the individual. Management and treatment of blister 
gas injuries have been specifically omitted since they are con- 
sidered in other sections of this manual. 
b. In the years 1917-18 large numbers of allied troops with 
mustard gas burns were needlessly evacuated from the front lines 
before the medical officers came to realize the true significance of 
the lesions and the limitations of their casualty-producing power. 
Casualties of World War I 
Analysis of 6980 mustard gas cases from World War I 
showing location of burns) 
Percentage 
Eyes 86 
Respiratory Tract 75 
Scrotum 42 
Face 27 
Anus 24 
Percentage 
Legs 11 
Buttocks 10 
Hands 4 
Feet 1.5 
c. During the course of World War II, investigations have been 
made of the influence of blister gas burns on the ability of troops 
to carry out common types of military duties. In several experi- 
mental installations in the U.S.A., Canada, Great Britain and 
Australia, volunteer soldiers with varying degrees of military serv- 
ice, ranging from recruits with a few months’ elementary train- 
ing to fully trained troops with combat experience, have been 
burned with blister gas. The degree of disability produced was 
carefully evaluated on assault courses, route marches, or by simu- 
54 55 
lated combat exercises in the field lasting over a number of days. 
The observations which were made served to demonstrate the 
limits of the casualty-producing powers of blister gas and, fur- 
thermore, indicated the types of lesions which may or may not 
cause disability, and have been the basis for this guide, which, 
however, is not intended to be an adequate substitute for clinical 
demonstrations of blister gas cases as a means of orientating 
medical officers in this subject. 
d. There are two broad groups of blister gas cases, the dispo- 
sition of which will offer no problem to the medical officer. In 
the first group are those who are totally disabled, and who are 
incapable of either offensive or defensive operations regardless of 
the seriousness of the military situation. These will be classi- 
fied as casualties and evacuated as such. Examples of injuries 
causing total disability are blindness, or vesication of extensive 
areas of the body, such as an entire limb or the front or back of 
the trunk. In the second group are those men who have been 
burned, but whose lesions are trivial and affect their military 
effectiveness slightly or not at all. They will be classified as 
noncasualties and returned to the line accordingly, with or with- 
out treatment. 
e. Between these two groups lies the indeterminate group of 
the partially disabled men who would be able to carry out certain 
types of military duties, but would be unable to attempt more 
strenuous tasks. The disposal of such cases is most likely to 
present the greatest problem to the medical officer in the field. 
This guide will draw his attention to typical casualty and non- 
casualty injuries within this group. In disposing of such cases 
the medical officer will be influenced by a number of factors, in 
addition to the severity of the burns, such as the urgency and 
nature of the military situation, and the physical and mental 
make-up of the individual under consideration. 
/.No effort has been made to differentiate between the in- 
juries produced by the several blister gases which may be used by 
the enemy. This omission has been made purposely in the in- 
terests of simplicity. While there are several points of difference 
between the typical mustard and arsenical vesicant lesions, it is 
not recommended that the medical officer, seeing these cases in 
the field, attempt to dispose of them differently. The diagnostic 
features of the various blister gases and treatments peculiar to 
each are described in section III. 
2. Eye Injuries 
a. The correct disposition of personnel with eye lesions caused 
by blister gas is less of a problem to the medical officer than when 56 
the skin of the trunk and limbs is involved. A very accurate 
estimate of the degree of impairment of vision resulting from eye 
lesions can be made by simple inspection. 
5. The eye is more sensitive and more vulnerable to the action 
of mustard than any other part of the human anatomy. Approxi- 
mately 85 percent of the mustard casualties in World War I had 
eye lesions of some degree. Exposure for 2 hours to a concentra- 
tion of mustard vapor just barely perceptible by odor will pro- 
duce eye lesions, but may not affect the respiratory tract or skin. 
There is no immediate symptomatic or local reaction to the ab- 
sorbed agent; a latent period that varies with the degree of 
exposure precedes the onset of symptoms. The latent period 
varies from 4 to 12 hours in the case of mild exposures, and may 
be reduced to 1 to 3 hours after severe exposures. 
c. The lesions have been divided into mild, moderate and severe. 
(See par. 95 (1) (5)5 and 4.) 
(1) Mild {75 percent cases in World War I.) The first symp- 
toms include itching, lacrimation, a sensation of grit in the eye, 
followed by burning and sometimes photophobia. There is hy- 
peremia of both the palpebral and bulbar conjunctivae, the re- 
action in the latter usually beginning as a band-shaped area run- 
ning transversely across the eye, with normal white bulbar con- 
junctiva above and below it. Edema of the lids may also be 
present. Hospitalization is seldom required, and recovery takes 
place in 1 to 2 weeks without classifying the soldier as a casualty. 
(2) Moderate. In this group there is complete closure of the 
eyes resulting from a combination of spasm and swelling of the 
lids. There is a latent period of 3 to 6 hours following exposure. 
Burning, itching, lacrimation, grittiness, pain and photophobia 
are more severe than after mild exposures, and blepharospasm 
and blurring of vision are present. There are marked hyperemia 
and edema of the conjunctiva with a prominent interpalpebral 
band, edema of the lids, mild iritis, edema of the epithelium of 
the cornea, producing a roughened appearance like orange peel, 
although the stroma may be normal. The blepharospasm and 
edema of the lids may be so severe that the patient cannot open 
his eyes, and may even believe himself blind. Miosis is present 
early. A muco-serous discharge is usually present, and although 
sterile in the early stages, it may cause the lids to stick together, 
causing accumulation of secretions in the conjunctival sac and 
predispose to infection. Since cases presenting this picture are 
temporarily blind they will be evacuated as casualties. Early 
and prolonged hospitalization is required with transfer to the 
care of an ophthalmologist if possible. Recovery from these le- 
sions occurs in 1 to 6 weeks, and there is usually no visual loss. 57 
Return to duty has to be determined by the extent of corneal 
injury, photophobia and blepharospasm. 
(3) Severe. The latent period is short, lasting from 1 to 3 
hours. There is deep ocular pain and headache, both of which 
may be severe, in addition to severe blepharospasm and blurred 
or dimmed vision. There is marked hyperemia and edema of the 
conjunctiva with a blanched area of ischemic necrosis in the 
interpalpebral portion, chemosis, and edema of the lids, which the 
patient cannot open. The epithelium and stroma of the cornea 
are damaged. Early surface epithelium is hazy, and will stain ex- 
tensively or in a punctuate manner with flurescein within 24 
hours. After 24 to 48 hours there is also edema of the stroma 
of the cornea and a deeper haze becomes apparent. Iritis and a 
mucoserous discharge are also present. If progressive, there may 
be dense corneal opacification, with deep ulceration and vascu- 
Figure 1. Casualty. 
Twelve hours previously this man was exposed to mustard gas vapor without 
a gas mask. At the time of photographing, his eyes were closed completely, but 
he made an effort to open the lids as shown by the contracted skin on the fore- 
head. Photophobia was marked. Lacrination was profuse; tears can be seen 
between the lids. The conjunctivae were injected and the eyelids slightly swol- 
len and congested. 
Ehinitis was also present, the man complaining of symptoms of a “cold in 
the head.” 
A few days later cough became troublesome and he developed aphonia. 
Within 10 days the eye condition had subsided. The cough lasted for a week 
longer. 
This man was classified as a casualty because of the marked interference 
with vision caused by blepharospasm and photophobia. 58 
Twelve hours previously this man was exposed to mustard gas vapor. 
At the time of photographing, blepharospasm was marked and he was 
experiencing considerable discomfort on moving the eyes. For a period of 
4 days he was unable to separate the lids voluntarily. On forcing the lids apart 
with the fingers the conjunctivae were seen to be injected and the corneas were 
slightly hazy. 
Neither lacrimation nor swelling of the lids was a prominent feature of 
this cake. 
Figure 2. Casualty. 
larization from the limbus. The cases with corneal ulcers heal 
slowly and may have relapses. Some may have perforations into 
the anterior chamber. These cases require hospital care, and 
should be evacuated at the earliest possible moment. 
d. Droplets of liquid blister gas entering the eye may produce 
similar effects except that one eye alone may be involved or one 
eye may be affected more severely than the other. Droplets of 
lewisite in the eyes, in contrast to droplets of mustard, cause im- 
mediate and painful spasm of the lids. 
e. In deciding the disposition of eye patients, the medical officer 
must assure himself that mild symptoms are not merely the early 
evidence of what will develop to severe inflammation, with tem- 
porary blindness within a few hours or a day. Reference to the 
time of exposure to the gas and rate of development of symptoms 
will guide him as to the course he should take. If the exposure 
occured within the previous few hours, and the effects are in- 
creasing rapidly in severity, it is advisable to evacuate the case as 
a casualty in anticipation of the development of disabling effects 59 
within the next few hours. As a general rule it can be stated 
that the symptoms will reach a maximum within 6 to 12 hours. 
3. Respiratory Effects 
a. The local action produced by mustard, vapor, on the skin 
and eyes is matched by a similar necrotising action on the mucous 
membranes of the respiratory tract. Most of the inhaled vapor is 
absorbed or removed in the large respiratory passages and bron- 
chi and very little injury to the lung parenchyma results. 
h. The most common respiratory lesions are due to prolonged ex- 
posure to relatively low concentrations of the vapor. In addition, 
severe casualties may result from men unknowingly exposing them- 
selves to strong concentrations of mustard vapor, because of the fa- 
tiguing effect of even low vapor concentrations on the olfactory 
organs, which may follow after only a few minutes exposure. 
More severe lesions can be expected, however, in those unable 
to mask, for example, unconscious casualties, or those with severe 
injuries to the face and both hands. 
c. Lesions of the respiratory tract are characterized by a re- 
latively long latent period before the onset of symptoms; usually 
18 to 36 hours intervene between exposure and symptoms. Since 
the eye is much more sensitive to the agent, and is exposed simul- 
taneously with the nares, respiratory tract lesions should be ex- 
pected to follow all definite eye lesions, as well as vapor burns 
of the face in unmasked personnel. Regard vapor burns of the 
face and eyes as precursors of lesions in the respiratory tract. 
d. In the nose, the first visible effect is hyperemia of the mu- 
cosa, and congestion of the submucosal blood vessels. This is 
followed by degenerative changes in the epithelium, varying with 
the degree of exposure, from small focal ulcerations to large 
sloughing ulcerated areas. Nasal symptoms consist of an early 
and profuse thin mucopurulent discharge. Epistaxis is rare. 
Nasal injury seldom occurs alone, and if it does, it is not usually 
a cause for hospitalization. 
e. In the pharynx acute inflammation usually appears 1 to 3 
days after exposure to mustard vapor although there may be a 
delay of a week in moderate and mild cases. There is mild 
dryness and soreness of the throat, aggravated by swallowing, 
and rarely accompanied by regional lymphatic enlargement, un- 
less secondary infection develops. Pharyngeal and laryngeal le- 
sions may develop without significant nasal involvement, es- 
pecially in mouth breathers. Upon inspection, the palate, uvula, 
tonsils and pharynx, are engorged. Multiple white ulcerations 
may follow. They vary in size depending on the severity of the 60 
exposure. Pharyngeal injury, like nasal involvement, is unlikely 
to occur alone; if it does, casualty status is not warranted. 
/. Laryngeal involvement is especially common as a result of 
inhaling mustard vapor, the lesions resembling those of the 
pharynx. Hoarseness, sometimes progressing to aphonia, may 
last 3 weeks, rarely even longer. This lesion although not likely 
to require hospitalization, is almost invariably associated with 
other injuries to the respiratory tract. 
g. In the trachea and bronchi, depending on the dosage, a si- 
milar ulcerative and necrotizing inflammatory process in the mu- 
cosa follows contact with mustard vapor. The exudative results 
in the formation of a pseudo-diphtheritic membrane in the larynx, 
trachea, and large bronchi, which is fairly thick and tenacious. 
It may form a more or less complete cast of the lumen of the 
structures involved. This lesion may prove fatal, and requires 
early and prolonged hospitalization. In mild cases, however, small 
focal ulcerations occur, with hyperemia of the lining epithelium, 
submucosal edema and congestion, and an outpouring of mucus. 
Respiratory symptoms and signs suggestive of these lesions, for 
example, respiratory embarrassment, cough, tachypnea or cyano- 
sis warrant prompt hospitalization. 
h. The action of mustard on the lung parenchyna itself is 
usually insignificant. Secondary infection in the bronchi or alveoli 
may lead to lobular, or lobar consolidation, and the course, symp- 
toms, signs, and pathologic findings may then be dominated by the 
characteristics of the type of pneumonia. The initial injury due 
to mustard in no way affects the choice of standard antibacterial 
preparations to combat organisms that may be the cause of the 
secondary infection. 
4. Cutaneous injury 
a. Introduction. (1) Many attempts have been made to formu- 
late clear-cut criteria which will enable medical officers to dispose 
correctly of personnel reporting with blister gas burns. Experi- 
ence in field trials at experimental installations has shown that 
no rigid rules or criteria can be defined which can act as a casualty 
yard-stick. The most that can be done is to note the types and 
sites of lesions which have most frequently led to disablement in 
troops who were exposed to blister gas in field trials, and who 
subsequently took part in simulated combat exercises, obstacle 
courses, marches or the like. From these observations the follow- 
ing facts have emerged and are summarized in (2) below. 
(2) Results of observation.. (a) Widespread vesication of the 
trunk makes a man a casualty. 
(b) Localized vesication makes a man a casualty, if it is situ- 61 
A single discrete lesion such as that shown in this photograph is of non- 
casualty significance because it does not interfere with locomotion; a protective 
dressing, which will remain in position during exercise, can be applied to a 
lesion of this size. 
Figure 3. Noncasualty. 
Large areas of intense erythema involving the buttocks require the applica- 
tion of a protective dressing. Friction of the clothing can easily break down 
the injured skin leaving raw excoriated areas of tissue exposed. 
The subject of this photograph had additional severe lesions on the trunk 
which warranted a classification of casualty (fig. 11). This single lesion of 
itself is not of casualty significance and if it existed alone, the man could con- 
tinue with his duties. 
ated in certain vulnerable areas of the body. Localized vesication 
in nonvulnerable areas is not of casualty significance, if the le- 
sions can be satisfactory protected to allow the man to continue 
with his duties. 
(c) Burns, when produced by high dosages of vapor on masked 
troops and especially in tropical climates are of casualty severity 
partly on account of changes brought about in the skin (edema 
and vesication), and partly the result of constitutional reactions 
which accompany the skin changes such as nausea, vomiting, col- 
lapse and prostration. 
(d) Burns produced by low dosages of vapor, while sufficient 
to bring about skin reactions such as edema and subjective symp- 62 
toms (burning and itching) are not usually of casualty severity. 
(e) When classifying a case as a casualty or non-casualty, the 
stage of development of the lesion must be taken into considera- 
tion. 
b. Trunk and Neck. (1) Extensive vesication of trunk. All 
the cases considered under this heading should be evacuated 
promptly as casualties. 
(a) By extensive vesication is meant numbers of vesicles dis- 
tributed over the greater portion of one aspect, anterior or pos- 
terior, of the trunk. Under such circumstances the intervening 
area of skin will be involved by more or less severe erythema and 
pinpoint vesication (figs. 10, 12, and 13). Vesication of this type 
is likely to occur more frequently on the back of the trunk than 
on the front, (Possible reasons for this distribution are the pro- 
Figure 4- Noncasualty. 
This photograph shows mustard blisters localized to a comparatively con- 
fined area. 
Cases of this type are classified as noncasualties (figs. 5 and 6). With the 
application of a protective dressing full duties can be resumed. Figure 5. Noncasualty. 
Blisters in this location can be treated and a dressing applied which will 
allow the man to continue with his duties. 
Two days before this photograph was taken this man was contaminated by 
mustard gas. Twenty-four hours after contamination, the small of the back 
was covered by erythema, which progressed to vesication by the following day. 
After that time, the lesions began to subside. 
tection afforded to the front of the trunk by webbing, ammuni- 
tion pouches, etc., and the fact that the front of the uniform does 
not cling tightly to the body). 
(b) Extensive vesication may be associated with constitutional 
effects such as fever, nausea and vomiting. These effects tend to 
occur more readily in tropical than in temperate climates. 
(c) Secondary bacterial infection may complicate the course of 
the lesion at any stage. The medical officer in a forward position 64 
is not likely to see infection of large vesicated areas since such 
cases will have been evacuated to the rear medical services within 
the first day or two after contamination, that is before secondary 
infection is likely to have developed. 
(2) Localized vesication of trunk, (a) Vesication occurring 
within or adjacent to the natal cleft (between the buttocks) 
usually calls for evacuation to the base medical services. Walking 
becomes increasingly difficult. Defecation is painful, and dress- 
ings require frequent changing. The lesion is usually most in- 
tense at the upper end of the natal cleft and may extend outwards 
over the buttocks and downwards along the walls of the cleft (figs. 
7 and 8). Severe vesication of the buttocks involving the natal 
cleft is usually due to sitting on heavily contaminated ground, 
or for prolonged periods on contaminated trousers (fig. 8). Un- 
der these circumstances the vesicated area is frequently seen to 
Figure 6. (T) Noncasualty. 
These men were exposed to a low concentration of mustard vapor. They 
had previously been exposed on a number of occasions to low dosages which 
produced no visible effects. Close inspection of the photographs will reveal the 
morbilliform rash characteristic of reactions of sensitized individuals. 65 
Figure 6. (2) Noncasualty 
extend forwards across the perineum to involve the scrotum and 
the penis. 
(b) Trivial burns such as mild erythema affecting the natal 
cleft are not of casualty severity, but require careful attention 
since walking or running easily aggravates these lesions, may 
break down injured skin, and leave excoriated areas and small 
intractable ulcers. Small discrete blisters may also be considered 
in this light but, when the blister gas encountered is mustard, 
vesication occurs as only part of more extensive lesions consisting 
of intense erythema and edema of the tissues, and such cases 
should be classified as casualties. 
(c) Single discrete blisters on the buttocks avoiding the natal 
cleft can be classified as noncasualties (fig. 3). 
(d) The majority of blisters on the trunk will require some 
form of protective dressing. Otherwise the blister roof will be 
torn off exposing the raw, sensitive floor to the friction of the 66 
clothing. The secretions tend to cause the clothing to stick to the 
blister floor, predisposing towards infection. In disposing of 
blister gas burns, the medical officer must decide whether or not 
it will be possible to apply protective dressings which will remain 
in position during active exercises. 
(e) Examples of vesication on areas where permanent dress- 
ings are difficult to apply are shown in figures 9 and 11. 
(/) Blister gas burns of the trunk which may be considered 
as noncasualty severity are illustrated in figures 4, 5, and 6. 
(3) Burns caused by exposure to high dosages of blister gas 
vapor. Aftef exposure to a high dosage of mustard gas vapor, 
The case shown in this photograph was contaminated by liquid mustard on 
the previous day. There is an old scar on the loin not related to the present 
condition. 
Figure 7. Casualty. 67 
This photograph shows extremely severe vesication of the entire surface of 
the buttocks. The upper half of the natal cleft was occupied by large coalesing 
blisters. The vesicated area extended across the perineum to the penis and 
scrotum which were severely affected. 
Figure 8. Casualty. 
This man was contaminated heavily by liquid mustard on the trousers. 
After contamination he sat down for a number of hours, thereby pressing the 
contaminated clothing into the skin and allowing the vapor to pass upwards 
towards the perineum. 
The photograph was taken 24 hours after exposure. The lesions continued 
to develop for 2 to 3 days. This man had a high fever for 4 days. He had 
nausea, anorexia, and suffered considerable mental distress through pain, 
insomnia, and the fear that the genital region had been permanently injured. 
He was detained in the hospital for 4 weeks. 
especially under tropical conditions, nausea, vomiting, and early 
symptoms of collapse, are usually evident before the erythema on 
the skin is completely developed. It is important to note that 
these effects occur even amongst troops who wear masks during 
the period of exposure to the gas. Since these constitutional 
symptoms may persist on and off for several days, during which the skin burns will be increasing in intensity, cases of this type 
should be classified as casualties. Severe vapor burns of the 
trunk appear as generalized vivid erythema (fig. 14) with pale 
gray areas indicating sites which will eventually vesicate or be- 
come necrotic. It is common to see patches of skin where ery- 
thema is absent or mild. These represent areas where the cloth- 
ing was pressed in close apposition to the skin, for instance by a 
gas mask carrier. 
68 
(4) Burns caused by exposure to low dosages of blister gas) 
vapor, (a) Mild vapor burns, while causing erythema, itching, 
and irritation, are not casualty producing. 
(b) It is to be noted again that the medical officer should al- 
ways consider the interval after exposure in relation to the se- 
verity of the burns, since a case which presents itself with appar- 
Figure 9. Casualty 
An area of vasication extended around one side of the neck from back to 
front. This condition was caused by a splash of liquid mustard which con- 
taminated the blouse. 
It was found difficult to apply a protective dressing which would allow the 
man to carry on with his duties, including the wearing of his equipment. 
Without a dressing, the blister roof would be easily torn off, the blister floor 
repeatedly irritated by the friction of the clothing and healing would be 
delayed. Such a lesion would bring about a state of partial incapacitation, 
Qn these grounds cases of this type should be classified as casualties. 69 
Vesication of this extent is of casualty severity. Frequently a rise in tem- 
perature occurs. Nausea and vomiting may be present and add to the in- 
capacitation caused by the burns. 
Figure 10. Casualty. 
These blisters were produced as a result of heavy liquid mustard which 
contaminated the uniform over the back. No decontamination measures were 
applied. The uniform was worn for 4 hours after exposure to the agent. 
ently mild burns may in fact be showing the early effects of a 
severe exposure to a vesicant vapor. It will not always be possi- 
ble to determine the period which has elapsed since exposure to 
the gas, but an effort should be made to do so. Factors that will 70 
This case was classified as a casualty. Extensive areas of sharp erythema 
with poinpoint vesication were present within 24 hours of exposure to the 
agent. The photograph shows the extent of these areas 48 hours after con- 
tamination. 
Figure 11. Casualty. 
Vesicated areas over the scapular region and the buttock require protection 
from the friction of the clothes and the pressure of equipment. Erythema with 
beginning vesication should also be protected by a dressing, otherwise the 
affected skin tends to break down and the vesicated area to spread. It is 
difficult to apply, and retain in position, dressings which would protect areas 
of the extent shown here. Figure 12. Casualty. 
The greater portion of the back was vesicated. This man had a temperature 
of 100° to 101°F. for a few days. He was apathetic, depressed, nauseated, and 
lost his appetite for 5 to 6 days. 
These lesions were produced by mustard sprayed from an airplane 2 days 
prior to this photograph. After contamination he wore his uniform for 4 hours. 
At the end of that time, patches of diffuse erythema had appeared on the 
shoulders. Twenty-four hours after exposure to the agent, the erythema was 
associated with swelling of the skin and pinpoint vesication. 
In deciding the disposition of a case of this type, special note should be made 
of the rapid increase in severity of the lesion over the first 24-hour period after 
contamination. 72 
help the medical officer to substantiate his decisions are the 
rapidity of development of effects and the presence of constitu- 
tional effects. 
(5) Sensitization due to multiple exposures to mustard gas. 
(a) Attention should be paid to the characteristic appearance of 
‘re-exposure” mustard gas burns, occurring in individuals who 
have been exposed to mustard gas 1 to 3 weeks (or more) pre- 
viously. A small percentage of men who have been exposed more 
than once will become sensitized to the agent. Such individuals 
react differently both qualitatively and quantitatively. 
(b) A sensitized man will usually show the effects of re-ex- 
Figure 13. Casualty. 
Widespread vesication caused by mustard extended from the shoulders to 
the buttocks. The skin between the vesicles was erythematous and edematous, 
and in many parts showed pinpoint vesication. 
Severe discomfort, caused by stretching of the skin, accompanies lesions of 
this type. In addition, increase in temperature, nausea and vomiting are com- 
mon, especially in tropical climates. 
Burns of this severity, uncomplicated by secondary infection, require treat- 
ment in hospital for at least 3 to 4 weeks followed by a period of convalescence. 73 
Figure Ik. Casualty. 
Twenty-four hours before this photograph was taken this man, wearing a 
gas mask and protective shorts was exposed to a high dosage of mustard vapor 
in a warm climate. 
Within 6 hours he became a casualty on account of nausea and vomiting, as 
well as generalized erythema involving the upper part of the trunk and upper 
limbs. The gastric symptoms persisted on and off for 2 days. 
During the ensuing 2 days the erythema continued to increase in severity, 
deepen in color and break out in pin-point vesication at scattered areas. The 
axillae and flexures of the elbows were especially affected. 
Such cases are classified as casualties soon after exposure. 74 
posure by a rapid onset of symptoms. Erythema, with or without 
edema and pronounced itching and burning, usually appears 
within one hour of exposure. Furthermore, less mustard vapor is 
required to produce effects in a sensitized individual than would 
be the case in a non-sensitized man. If the erythema and edema 
are the result of exposure to a low dosage of mustard vapor, they 
will generally develop rapidly, and subside within 2 to 3 days. If 
vesication occurs, however, the time required for healing is no 
less than that in non-sensitized men. 
(c) One of the most frequent occurrences in sensitized men who 
have been re-exposed is the development of a morbilliform rash. 
Such a case is illustrated in figure 6 0 and 6 @. Another character- 
istic reaction is an eczematoid dermatitis, surrounding any old 
burns, whether or not they have healed completely. Such a derma- 
titis may last for several days; it can best be compared with 
dematitis venenata (poison ivy). Usually this type of reaction 
subsides within 48 to 72 hours after the individual is removed 
from the source of mustard vapor. Similar sensitization pheno- 
mena have been known to occur with lewisite and with the nitro- 
gen mustards. 
c. Arms. (1) In a large proportion of the cases of blister gas 
injuries on the arm, the use of the limbs is not materially impaired, 
and when suitably treated, the individual is able to continue with all 
his duties. Vesication, when localized (figs. 15 and 16) will produce 
little or no disability. 
(2) Extensive vesication involving the axillae or the volar or 
dorsal aspects of the elbow frequently results in partial disable- 
ment, by impairing the movement of the limb at these points. Se- 
vere burns are most frequently associated with edema of the 
surrounding tissues which tends to immobilize further the move- 
ments of the limbs. The dorsal aspect of the elbow and forearm are 
common sites of severe burns since these areas, together with the 
knees, are points of pressure supporting the body when the indi- 
vidual drops prone on the contaminated ground and fires his shoul- 
der arms from this position. The clothing covering these sites is 
thereby pressed into the ground, and tends to pick up contamina- 
tion in these areas. Typical lesions produced in this manner are 
shown in figures 17 and 19. In each case severe edema was present 
together with widespread areas of vesication. Although the limb 
could be bent, such movements were painful. Cases of this type 
should be evaluated as casualties when the lines of communication 
are normal. 
(3) Widespread vesication of the arms is usually associated with 75 
intense local reaction, both factors combining to produce a state 
of partial disability. Unless the urgency of the military situation 
will not permit, cases of this type should be evacuated as casualties. 
d. The Hands. (1) Medical officers may expect to encounter 
frequently blister gas burns of the hands. In general, burns affect- 
ing the hands tend to cause a degree of incapacitation out of pro- 
portion to the size of the lesions. Considerable care and judgment 
is called for in the correct disposition of such cases. 
(2) Experience in tropical experimental installations indicates 
that, while adequate protection against high dosages of vapor can 
be provided by impregnated gloves and anti-gas ointment, it is diffi- 
Figure 15. Noncasualty. 
These blisters were produced by liquid mustard gas through clothing. Con- 
tamination occurred 1 day previously. 
The blisters were discrete and surrounded by an area of erythema with 
slight swelling of the tissues. When a protective dressing was applied, the man 
was able to continue with all his duties. 
As a rule blisters involving the bends of the limb tend to incapacitate more 
easily than similarly sized lesions elsewhere on the limb, because of aggrava- 
tion and retardation of healing resulting from the constant movements of the 
joints. Blisters of the size shown here are of themselves not casualty pro- 
ducing. More extensive vesication in this area would have interfered seriously 
with the use of the limb and necessitated the individual’s being classified as a 
casualty. 76 
These blisters were produced by liquid mustard gas which contaminated the 
uniform worn by the man 2 days previously. He discarded his contaminated 
clothing after 4 hours’ wear. 
Figure 16. Noncasualty. 
A lesion of this size is associated with edema of the tissues in the neighbor- 
hood of the blister. In some cases the edema involves the entire circumference 
of the limb, and may spread upward toward the elbow or downward toward 
the hands. A severe local reaction of that type would make a limb virtually 
unusable, and warrant a classification of casualty. 
Under tropical conditions lesions produced through clothing by liquid 
musturd gas may be expected to increase in severity for 2 to 3 days after 
contamination. Under temperate weather conditions the lesions are later in 
appearing, and slower in developing to full maturity. 
cult to avoid burns of the hands due to liquid blister gas, especially 
in heavily contaminated jungle. 
(3) The palms of the hands are resistant to vesication. How- 
ever, if sufficient amounts of liquid agent come in contact with the 
palms, directly or through gloves or ointment, vesication can oc- 
cur (fig. 20). Blisters affecting the palms are characteristically 
painful and slow to heal. When the integument is removed a raw 
tender surface is exposed and epithelialization is slow. 
(4) If the lesion is single and of limited extent (fig. 20), with 
suitable treatment and the application of a protective dressing, 
little or no disablement may result. 
(5) Burns produced by a liquid agent on the dorsum of the hand 
result in a severe local reaction characterized by intense edema of 
the tissues of the back of the hands and of the fingers. Pain is a 77 
Figure 17. Casualty. 
The left forearm shows the effects of wearing for 4 hours a Herringbone 
twill jacket- Contaminated with liquid mustard gas. This man fell prone onto 
contaminated ground in the jungle, crawled a few yards, and fired a rifle from 
this position. 
Exposure occurred 2 days prior to photographing the lesions. The elbow and 
upper third of the dorsal aspect of the left forearm were involved by a deep 
burn which was pale with incipient necrosis in the center and vesicated at the 
periphery. Edema involved the circumference of the elbow and the upper two- 
thirds of the forearm. The limb could be moved at the elbow but movements 
were painful and resisted by the soldier. Lesions of this type and severity are 
of casualty significance for 2 or 3 weeks’ duration. 
characteristic feature of such lesions, and is intensified by any 
movement of the fingers or wrist. In this way a state of partial 
disablement is brought about. Burns of this type impair the ability 
of the individual to carry out any but the crudest actions of the 
fingers and hands (figs. 21 and 22). Such cases should be regarded 
as casualties. 
(6) In deciding the disposition of blister gas cases, the medical 
officer should remember that the lesions continue to increase in 
severity until the second or third day after exposure. Consequently 
when seeing cases exposed within the previous 24 hours, he should 
try to anticipate the condition of the lesion within the following 
day or two. In the case of the hands an individual exposed within 
the previous 24 hours and reporting for treatment with appar- 
ently trivial blisters on the hands may be totally incapacitated the 
following day (fig. 21). As a working rule, it may be stated that 78 
when an individual exposed to a vesicant, liquid or vapor, within 
the previous 12 to 24 hours shows sharp erythema of the dorsum of 
the hand with commencing vesication, it may be assumed that the 
lesion will progress within the next day or two to the extent that 
all the erythematous area will become vesicated. If this is exten- 
sive, (for example, involving half the hand or more) edema of the 
tissues will be also present. Under such circumstances, the indi- 
vidual should be evacuated as a casualty when first seen. If the 
Figure 18. Casualty. 
This photograph was taken 24 hours after the man was contaminated by 
liquid mustard while going through freshly contaminated undergrowth. He 
was wearing impregnated clothing, which was removed 4 hours after he became 
contaminated. The “doughnut” or ring-shaped area of blisters which surround 
a gray necrotic area at the elbow is a clear example of a severe burn which 
will require from 2 to 4 weeks to heal satisfactorily. 79 
Figure 19. Casualty. 
This photograph was taken 2 days after exposure to mustard. The soldier 
fired a rifle while lying on mustard contaminated jungle floor. As in the cases 
shown in figures 17 and 18, he wore his contaminated clothing for four hours. 
The pale center of the annular vesicle involving the right elbow indicates a 
deep burn, the center portion of which will eventually become necrotic leaving 
a slowly healing wound. Severe edema involves the forearm. 
Blister gas burns of this type and position make a man a casualty for about 
3 to 4 weeks. If secondary bacterial infection occurs, the healing time will be 
considerably lengthened. 
After 2 weeks the limb was still swollen and the lesions had not yet healed. 
examination is made 48 hours or more after the exposure the lesion 
may be considered to be maximal in size. 
(7) More frequently the lesions will consist of a number of scat- 
tered small vesicles and limited areas of erythema. These cases 
can be treated satisfactorily, and the individual returned to his 
duties, the main requirement being protection of the tender area 
by means of a suitable covering. 
(8) Exposure to vesicant vapor produces diffuse erythema in- 
volving the dorsum of the hand and wrist. With low dosages of 
vapor the condition does not proceed beyond erythema. High dos- 
ages cause generalized sharp erythema, edema of the tissues and 
vesication of the dorsum of the hand and fingers. In severe cases 
of this type, pinpoint vesication involves the entire dorsum of the 
hand and fingers, thereby totally disabling the hands. These cases 
will be evacuated as casualties. 
e. Lower Extremities. (1) The most common sites of develop- 
ment of liquid blister gas burns on the lower extremities are the 
knees. This site, together with the ankles, frequently contains le- 80 
sions which result in incapacitation of the individual by interfering 
with locomotion. Movements of the limb at the joints tend to aggra- 
vate existing lesions by increasing local edema. A further inca- 
pacitating factor is introduced by the discomfort attending the ap- 
plication and wearing of firm dressings to the points of maximum 
movement of the lower limb. 
(2) It has been mentioned under “Arms” that when an indi- 
The palm of the hand is resistant to vesication. Prolonged contact with 
liquid vesicant agent is necessary to produce blisters on this area. The photo- 
graph shows a hand on which a glove contaminated with liquid mustard gas 
was worn for 4 hours. Exposure occurred 2 days prior to the photograph. 
The blister was treated, a protective dressing applied, and the soldier continued 
with his duties. 
Figure 20. Noncasualty. 
Blisters on the palm of the hand are painful. If denuded, a raw tender area 
is exposed which is slow to heal; consequently, a protective dressing is neces- 
sary. 
In the present case the soldier experienced discomfort for several days in 
handling objects, but discomfort alone is not usually regarded as a casualty 
producing factor. 81 
Figure 21. Casualty. 
The dorsum and fingers of each hand were vesicated. The remainder of the 
skin was erythematous, and the tissues markedly edmatous especially on the 
left hand. The hands were virtually useless and the individual was classified 
a casualty. 
Pain of a burning and throbbing nature sufficient to prevent sleep for a few 
days is a prominent feature of severe blister gas burns of the hands. 
Two days previously this man crossed an area of jungle contaminated with 
liquid mustard gas. Even though his hands were covered by impregnated 
gloves worn over antigas ointment, he picked up sufficient mustard on his 
gloves to cause burns like these. 
vidual is compelled to fall prone onto the ground in a contaminated 
area, the elbows and knees become points of pressure, and lesions 
tend to develop on these sites with greater frequency than else- 
where. Vesication frequently spreads over the kneecaps, upward 
on the thighs, and downward on the legs. These burns tend to be 
extensive and deep, and are frequently associated with edema. 
Edema involves not only the immediate site of the burns, but often 
extends as high as half way up on the thigh and half way down the 
leg (fig. 28). In view of the interference with locomotion, the pain 
caused by movements of the limbs and the tendency of such lesions 
toward delayed healing, it will be advisable for medical officers 
to evacuate as casualties all cases presenting these appearances. 
(3) In general, burns of the leg are more incapacitating than 
burns of the thigh. This is especially true of the calf of the leg, the 
pretibial area, and the ankle. 
(4) It has been shown in simulated combat exercises in experi- 
mental installations that in many cases the presence of numbers 
of superficial blisters on the legs and thighs alone are not sufficient Blister gas burns of this severity are always of casualty significance. 
Figure 22. Casualty. 
This photograph was taken 48 hours after the exposure, the lesions having 
reached full maturity by that time. The dorsum of the hand was grossly 
erythematous and the ulnar half was occupied by a large blister. The dorsum 
of each finger was vesicated and the skin stretched tight with edema. 
In addition there were six discrete blisters on the palm of the hand, an area 
which is resistant to vesication except by prolonged contact with liquid 
mustard gas. 
The hand was tender to touch, pain was severe and was of a throbbing 
nature accentuated by holding the hand in the dependent position. This soldier 
required 4 weeks’ hospital treatment before the lesions were sufficiently healed 
to allow him to return to his duties. 83 
to render a man incapable of carrying out normal military duties. 
The type of case referred to is illustrated in figures 23, 24, 25, and 
26. With suitable dressings, troops with lesions such as these were 
able to take part in daily marches, gun drill, or similar activities. 
In disposing of cases with lesions of this type and extent, in addi- 
tion to the clinical findings, the medical officer will take into con- 
sideration additional factors which should influence his decision, 
such as the mental and physical make-up of the individual, his will- 
ingness to continue with his duties, and the military situation ex- 
isting at the time. Such cases will fall into the category of par- 
tially disabled personnel. After suitable protective dressings have 
been applied, men with good morale and robust physiques may be 
returned to duty as noncasualties. 
(5) Reference has already been made to the influence of the site 
of the lesion on the degree of incapacitation. A relatively small 
blister or group of blisters situated in the popliteal area may re- 
duce significantly the efficiency of a man to the extent that he should 
be evacuated as a casualty (fig. 29). This is due largely to the 
interference with locomotion and the aggravation of the lesions by 
moving the limbs. At the same time it does not follow that any 
blisters affecting these areas are necessarily casualty producing 
(fig. 27). Effects, such as local inflammation and edema, the pres- 
ence of infection, and extent of the lesions on other parts of the 
body should be borne in mind when deciding the disposition of the 
individual. In this respect, the available evidence from trials in the 
field with mustard gas and lewisite indicates that the mustard gas 
blister, size for size, is potentially more incapacitating than the 
lewisite blister. The main reason for this is the tendency of the 
mustard blister to be surrounded by a diffuse area of erythema 
and edema, while the lewisite blister is usually circumscribed with 
little local reaction in the neighboring tissues. 
(6) A not uncommon site for the development of vesicant le- 
sions is in the vicinity of the ankle at the level of the top of the 
shoes. A vesicant area frequently circumscribes the limb at the 
point of least protection between the shoes and the leggings. Such 
a lesion is associated with severe pain due to circulatory impair- 
ment and tense edema of the entire lower limb. Cases of this type 
should be evacuated as casualties on the grounds that movements 
of the limb tend to aggravate the severity of the condition, and, in 
addition to interfering with locomotion, they seriously retard heal- 
ing. 
(7) Vapor burns of legs tend to be aggravated in the popliteal 
spaces. Pin-point vesication is frequently found in these areas as- 
sociated with local edema. After exposure to higher dosages in- 
tense erythema with scattered area of vesication may be seen over 84 
This plate shows a number of blister gas burns on the legs of a man sprayed 
with mustard gas from an aircraft 2 days previously. He wore his con- 
taminated clothing for 4 hours. When suitably protected by dressings, which 
may be expected to remain in position during active exercises, the individual 
may return to full duty. 
Figure 23. Noncasualty. 
the entire surface of the leg. While such lesions are invariably of 
casualty-producing significance, they are in addition always accom- 
panied by severe burns in other parts of the body and frequently 
with severe systemic effects. 
(8) Mild vapor burns of the legs produce the characteristic irri- 
tation and itching common to all widespread vapor burns. While 
such effects are troublesome, they are not of casualty-producing 
significance, and men so affected should be returned to their duties. 
(9) Extensive vesication of the feet is not common. The thick 
skin of the soles is resistant to vesication. Furthermore it is 
protected by the sole of the shoe unless this is in bad state of repair. 
Blister gas burns on the dorsal aspect of the foot are often asso- 
ciated with a sharp local reaction similar to that seen on the backs 
of the hands. Cases with burns of this type, especially if wide- 85 
A man with vesication of this extent is on the border line of the casualty 
state. The individual blisters escaped the bends of the knees; therefore, they 
were not constantly aggravated by the movements of walking or running. Fur- 
thermore, the vesicant agent was lewisite, which tends to produce discrete 
blisters with a narrow zone of erythema in contrast with mustard and which 
causes a more severe reaction over a wider area around the blister. 
Figure 2U- Noncasualty. 
This man claimed that he was able to continue with his duties. After the 
application of a protective dressing he took part in daily route marches or mild 
duties such as gun drill. The blisters continued to make satisfactory progress 
during the ensuing 10 days. 86 
spread over the foot, find it difficult or impossible to wear shoes and 
will require evcuation to the rear medical services. Small discrete 
blisters may be of noncasualty significance. They may be effec- 
tively protected to allow wearing of the shoes and walking with 
little discomfort. 
/. Genitalia. (1) The genital region is, after the eyes and the 
respiratory tract, the most sensitive area of the body for blister 
gas burns. In World War I, many casualties were produced by 
mustard gas burns of the genitalia. The majority of these burns 
were caused by mustard vapor. While the present methods of 
protection against blister gas include special impregnated gar- 
ments designed to protect the genitalia, when blister gases are 
employed in chemical warfare, medical officers (especially in tropi- 
Figure 25. Non-casualty. 
A single vesicle is not necessarily of casualty significance. 
The individual whose knee is shown in this photograph sustained a severe 
lesion just above the knee cap. The local reaction did not seriously interfere 
with locomotion and after a firm dressing had been applied he was able to 
continue with his duties. 
The importance of the site of a lesion in relation to its incapacitating effects 
has been referred to previously. A lesion of the type shown in this photograph 
would be of casualty severity if it were situated in the bend of the knee. 87 
Figure 26. Noncasualty. 
This shows erythema and pigmentation of the legs 72 hours after exposure 
to mustard vapor. There had been superficial vesication of the knees. This 
man was able to perform all of his duties and to complete an obstacle course 
without difficulty. The erythema is demarcated at the upper thigh because of 
impregnated undershorts that were worn during the exposure. 
cal theaters of war) may be confronted with a large number of 
blister gas burns affecting this area. 
(2) The most common type of burn affecting the male genitalia 
is a diffuse vapor burn. Erythema is not conspicuous on account 
of the normal pigmentation of the penis and scrotum. The most 
prominent objective feature of the burn is edema which involves 
the penis and scrotum. Edema fluid accumulates most readily at 
the prepuce, which becomes markedly distended in its entire cir- 
cumference, and forms a characteristic semitranslucent ring 88 
around the corona (figs. 30 and 31). In more severe cases the skin 
covering the entire body of the penis becomes grossly edematous, 
the external aperture being constricted to pin-point size (fig. 32). 
(3) Lesions of this type give rise to greater mental apprehen- 
sion than physical discomfort although the latter can be consider- 
able. Occasionally, vesication is superimposed on the edematous 
skin of the penis. Small blisters or ulcers due to break down of 
the skin are not infrequent at the tip of the prepuce, where they 
are likely to become secondarily infected and retard healing. With 
the severe cases associated with marked edema, retention of urine, 
partly mechanical and partly reflex, may occur. 
Figure 27. Noncasualty. 
Small, discrete and superficial blisters do not necessarily make a man a 
casualty even though they affect the skin in close proximity to the bend of a 
limb. 
This photograph shows blisters which affected the left leg within a feyr 
inches of the bend of the left knee. Each blister was surrounded by a diffuse 
area of erythema. With a suitable protective dressing this man was able to 
continue with his duties without impairment of efficiency. 
With blisters of this size and distribution, even though treatment were not 
available, it is not likely that the man would be incapacitated, but he might 
experience considerable discomfort. 
(4) In mild cases objective changes on the scrotum are liable to 
pass undetected because of the normal pigmentation and the elas- 
ticity and looseness of the skin. Edema may be present before 
sufficient fluid accumulates to reveal its presence. In severe cases 
the scrotum may become grossly enlarged as a result of edema, 
to which the tissues in this region are predisposed by the amount 
of subcutaneous tissue, laxity of the skin, and the dependent posi- 
tion of the organs. The rugae may be partially or completely 
obliterated (fig. 32). Pin-point vesication may be present. Usually 
a delay of a few days occurs before it appears. The skin of the 89 
scrotum tends to break down easily leaving small painful ulcers 
and fissures. 
(5) Burning is the most prominent subjective symptom of le- 
This picture demonstrates the severe reaction produced by a mustard blister 
on the lower third of the left thigh. An annular vesicle with a pale parchment- 
like center is seen to occupy the lower third of the ventral surface of the thigh. 
This is surrounded by a wide area of erythema which extends downward over 
the knee and around the circumference of the limb. 
Figure 28. Casualty. 
This burn was associated with a continuous throbbing pain made worse by 
walking or any other movement of the limb. 
Cases showing this combination of extensive vesication and swelling of the 
tissues should be regarded as a casualty significance even though only one limb 
is involved. 
This photograph was taken 24 hours after contamination. A reaction as 
severe as that depicted shows that the individual had been exposed to a 
severe liquid contamination for a prolonged period. The severity of the burn 
may be expected to increase during the following day or two. 90 
Figure 29. Casualty. 
This photograph was taken 48 hours after the man had been sprayed with 
mustard gas from an aircraft. He discarded his contaminated clothing after 
4 hours wear. Mustard blisters of this type situated in the bends of the limbs 
are usually of casualty significance, since locomotion is impaired by the pain 
and discomfort brought about by movements of the joints. Furthermore, pro- 
longed marching or running tends to aggravate the local reaction in the tissues, 
which is usually an accompaniment of mustard gas burns. This is in contrast 
with the findings of lewisite burns which are usually circumscribed and accom- 
panied by a more localized reaction in the surrounding tissues. 
sions of the genitalia. It increases in intensity as the condition 
develops. Mental apprehension, anxiety and distress prevail while 
the objective changes described above are present. As the appear- 
ances subside, itching commences and may persist long after the 
active effects have subsided. Sometimes itching is intolerable. For 
a considerable period after the lesions have healed, the skin of the 
scrotum tends to break down, with raw cracks and ulcers which 
are painful and irritating. 
(6) A characteristic feature of the genital region occurring 
after exposure to low dosages of blister gas is the delay in the de- 
velopment of the effects, frequently 4 to 10 days elapsing before the 
earliest evidence appears. 
(7) Mild cases without edema or vesication, complaining only 
of subjective irritation and burning may be safely returned to the 
lines. Some form of anti-irritant lotion is advisable. In disposing 
of mild cases of blister gas burns of the genitalia, the medical 
officer must assure himself as best he can that the symptoms are 91 
not in an early stage of development that will mature within a day 
or so to a severe degree of vesication and edema. He may do so by 
noting the circumstances of the exposure, the interval since expo- 
sure, and the severity of the associated lesions. Severe cases as 
Cases presenting this appearance within 24 to 48 hours of the exposure to 
mustard vapor should be evacuated as casualties. In all cases the edema is 
likely to increase in amount and in some cases within the following few days 
will assume massive proportions (fig. 32). 
Figure 30. Casualty. 
Because of the normal pigmentation of the skin in these areas erythema is 
rarely conspicuous on the scrotum or penis except after exposure to high 
dosages. Deepening of the normal pigmentation may be evident after 1 or 2 
weeks. 
Edema fluid accumulates most readily at the prepuce. 92 
Figure 31. Casualty. 
The appearances of the penis 48 hours after exposure to a moderate dosage 
of mustard vapor are shown in this photograph. Edema had distended the 
prepuce which formed a translucent ring around the corona. 
In addition, edema was present in and beneath the skin of the scrotum. 
Burning and itching of the parts were troublesome. 
Cases presenting these appearances should be evacuated as casualties. 
described above should be evacuated as casualties, not only on ac- 
count of the physical discomfort involved, but also because of the 
marked mental apprehension from which the individual suffers. 
5. Systemic Effects 
a. In general it may be considered as probable that severe sys- 
temic effects due to the blister gases will be encountered only in the 
presence of, or antecedent to, disabling skin burns. The medical 
officer should be familiar with these effects which include anorexia, 
nausea, vomiting, depression, and fever and are far more likely to 
be encountered in hot than in cool climates. Malaise and nausea 
generally initiate the reaction which may then progress to either 
mild and transient vomiting or to severe and persistent vomiting 
and retching. In mild reactions anorexia may be the only com- 
plaint. The usual time of onset for such symptoms is from 4 to 
12 hours after exposure and often occurs before skin injury is mani- 
fest. No rule can be given from the duration of these symptoms, 
although men have usually recovered for the severe gastric dis- 93 
turbances (vomiting) within 24 to 36 hours. Anorexia and nausea 
may persist over a longer period of time. 
b. The temperature may remain elevated for several days. Men- 
tal depression may follow mustard burns and persist for several 
days after exposure. 
c. Since men with systemic reactions will probably be casualties, 
not only because of these symptoms, but also because of extensive 
skin burns, such cases should be evacuated without hesitation as 
soon as facilities permit. 
6. Secondary Bacterial Infection in Blister Gas Injuries 
a. This section deals with secondary bacterial infection of blis- 
ter gas injuries, so far as it influences the disposition of the affected 
personnel by the medical officer in forward positions. For the man- 
agement and treatment of such cases, see section III. 
b. Secondary bacterial infection has frequently been cited as a 
common complication of mustard injuries of the skin. While these 
injuries sustained in the field are exposed to the same risk of de- 
Figure 32. Casualty. 
This photograph shows the effects of exposure to high dosages of mustard 
vapor. 
There was massive edema of the entire penis sufficient to interfere mechani- 
cally with micturition. Vesication was present at the end of the penis. The 
scrotum was generally edematous with pin-point vesication. The rugae were 
partially obliterated. 
Lesions of this type call for evacuation to the hospital where treatment for 
4 to 6 weeks is usually required. 94 
veloping sepsis as are thermal and traumatic injuries, observations 
made at experimental installations in both temperate and tropical 
climates indicated that the incidence of sepsis in mustard lesions 
has been remarkably low. 
c. When it occurs, secondary infection manifests itself some days 
after the injury first develops. It is unlikely that forward medical 
officers will see gross secondary infection of extensive blister gas 
injuries since these more severe cases will probably have been 
evacuated as casualties prior to the development of infection. In- 
fected lesions of this type will more probably come to the notice of 
medical officers in rear medical units. 
d. When secondary infection develops in blister gas injuries of 
noncasualty severity, each case should be judged individually. In- 
fection in small lesions does not compel a man to be evacuated. 
Infection in multiple lesions which previously allowed a man to 
continue with his duties is usually an indication for his evacuation 
as a casualty, particularly if constitutional effects are associated 
with the local effects of sepsis. 
e. Sites in which sepsis tends to be particularly disabling are 
the feet and hands, the genitals and the flexures of the limbs. 
/. In injuries to the respiratory tract caused by blister gas va- 
por, secondary infection, as in cutaneous lesions, is more likely 
to occur in severe rather than in mild cases. It is unlikely that the 
medical officer in forward areas will ever encounter such cases. 
Severe respiratory tract effects will invariably be associated with 
eye effects of casualty severity. Such respiratory lesions which 
may develop will not appear for several days by which time the 
case will have been evacuated as an eye casualty to a rear medical 
unit. 
g. Secondary infection is uncommon in mild cases of mustard 
conjunctivitis wdiich ordinarily would allow an individual to con- 
tinue in the line. 
h. With eye effects short of casualty significance, respiratory 
tract effects, (pharyngitis, laryngitis and tracheitis) may continue 
to increase in severity for several days. Cases of this type may 
rarely develop secondary infection (bronchitis and broncho-pneu- 
monia) . APPENDIX II 
GENERAL PRINCIPLES IN THE HANDLING OF CASUALTIES 
CONTAMINATED BY CHEMICAL WARFARE AGENTS 
1. General 
All medical installations will be well prepared in advance to re- 
ceive casualties contaminated with blister gases. Other chemi- 
cal casualties do not present the problems which arise with the 
handling of blister gas contaminated casualties, and may therefore 
move with the regular flow of casualties, but there should he sepa- 
rate arrangements for the reception and handling of the blister gas 
contaminated casualties. 
2. Responsibility of Medical Facilities 
a. It is the responsibility of each officer and. man to carry out 
personal decontamination for himself or his buddy at the earliest 
possible moment. Medical personnel will attempt the decontamina- 
tion of casualties who are unable to carry out personal decontami- 
nation but are not to decontaminate personnel who are not casual- 
ties. 
b. Medical installations are concerned only with casualties, that 
is, personnel no longer able to carry out their military duties. No 
other men should be sent to the medical services. 
3. Objectives of Medical Facilities 
In handling blister gas contaminated casualties, the general ob- 
jectives desired are: 
a. The casualty should be handled in such a manner as to mini- 
mize the injury which may result from his chemical exposure, with- 
out at the same time significantly aggravating the clinical condi- 
tions arising from the associated injury. 
b. Litter bearers should be protected from unwarranted chemi- 
cal injuries as a result of working in contaminated areas and of 
handling the contaminated wounded. 
c. The spread of contamination to other personnel and to the 
interior of ambulances and inclosed spaces, such as operating rooms 
and hospital wards should be avoided. 
d. Medical facilities must be protected so that normal services, 
unrelated to chemical casualties, can be carried out. 
e. A single method should be instituted for collecting all casual- 
95 96 
ties which is as simple and streamlined as the complicated situation 
will allow. 
4. Decontamination of Wounded 
a. If the situation permits and life is not endangered by the de- 
lay, personal decontamination of wounded men should be carried 
out on the spot by the litter bearers, or as soon thereafter as possi- 
ble. This is desirable since the longer the contamination remains 
on the body, the more severe are the subsequnt burns, the greater 
is the danger of the spread of contamination to equipment, blankets 
and other personnel, and the greater the vapor hazard from casual- 
ties in inclosed spaces and ambulances. 
b. To complete personal decontamination, which requires time, 
will prolong exposure and may increase shock. The tactical situ- 
ation may be such that complete personal decontamination may be 
impossible. In severe injuries, decontamination will rarely be pos- 
sible until the immediate surgical condition is attended to, and even 
then the extent to which it can be done will vary greatly. General 
guides as to the probable action required are essential to success- 
ful training of litter bearers and company aid men. Litter casual- 
ties will, as a rule, receive little personal decontamination as their 
injuries will usually be severe. Most walking casualties will be less 
severe and shoud have had personal decontamination. The general 
principle “better the blistered living than the decontaminated 
dead” should be followed. 
c. In general, the following are considered advisable in the order 
named: 
(1) Essential first aid for wounds. 
(2) Care of contaminated eyes. 
(3) If casualty is required to stay in the contaminated area 
or to wear contaminated clothing for any time, mask to protect 
lungs just as soon as rendering of essential first aid permits. 
(4) Decontamination of contaminated skin just as soon as es- 
sential first aid and protection for lungs (if required) are provided. 
5. Reception of Contaminated Casualties (fig. 33) 
a. The reception and handling of blister gas contaminated casual- 
ties will vary with the type of medical installation receiving them 
and with the tactical situation. For the reception of such casualties 
a “dirty” area is required. In that area contaminated casualties 
will be decontaminated, and thereafter be passed along with the 
“clean” (uncontaminated) cases. A general principle for the sort- 
ing and reception of all casualties including chemical, is indicated 
in the diagram. 97 
CONTAMINATED A’B’ DIRTY 
EMERGENCY 
Extemporized area or specially des- 
ignated facility for operating on 
emergency contaminated wounded, * 
Medical personnel from O come here 
and return later to D. 
CLEAN 
E 
Awaiting evacuation. 
CLEAN C CLEAN 
WOUNDED 
Reception all cases. 
Records. 
D CLEAN 
Treatment 
Additional medical aid. 
Figure 33. Basic plan for sorting. 
Direction Sign 
Sentry 
* Who are decontaminated when the situation points. 
CONTAMINATED DIRTY 
WOUNDED A 
Free ventilation; some cover. Re- 
move contaminated outer clothing, 
gear and blankets. Speed in un- 
dressing desirable. Change to clean 
litter, blankets. Skin pencil areas of 
contamination. Undressers, bearers. 
B DIRTY 
May be warmed. Underclothes re- 
moved and passed forward or placed 
in sacks or bins frequently removed. 
Ointment or soap and water to skin 
areas believed exposed. BAL oint- 
ment if lewisite. Washing facilities. 
Attendants masked, protected. 
Clean 
Contaminated 
— — . — .— Contaminated 
emergency 98 
b. Uncontaminated casualties will be admitted directly to the 
“clean” area (C) to be treated as ordinary medical casualties. Con- 
taminated casualties will be received into “dirty” area (A), there 
to be decontaminated before being passed into the normal flow of 
casualties. If requiring special medical aid before personal decon- 
tamination, they are received directly into the “dirty” area (A’ B’) 
for contaminated emergencies, thus by-passing A, B, C and D. 
Once emergency is cared for in A’ B’ the function of A and B, which 
are not yet completed, are carried out before passing the patient 
into the flow of clean casualties for evacuation (Area E). 
c. Within the “dirty” area, the following will apply: 
(1) The arrangements to be made will vary with the location 
of the unit and the facilities available. 
(2) Areas A, B and C need not be adjoining rooms or facilities. 
(3) In certain permanent establishments, special provisions may 
be made. If “cleansing or decontamination centers” have been 
previously constructed, they should be so employed as to conform 
to this basic plan. 
(4) In temporary camps an existing hut, tent or open shelter 
may be utilized. 
(5) In the field the “dirty” area may be only an area marked 
out and situated not adjoining, but yet not to far removed from the 
medical installation. Simple arrangements only are required. 
(6) Personnel manning the “dirty” area must be trained in the 
decontamination of casualties and should be provided with pro- 
tective aprons, protective gloves and M-5 protective ointment. 
(See TM 3-220.) (The U. S. Army Cover, Protective, Individual 
can be employed to advantage. 
(7) Free ventilation is required, and, if possible, some cover 
overhead. 
d. Detailed Procedure. (1) Area A. Here all contaminated 
outer clothing, equipment, and blankets are removed. They must 
not be taken beyond this point. Speed in undressing casualties 
requires practice. The casualty is then changed from a contami- 
nated blanket to a clean litter and a clean blanket. If available, a 
skin pencil can be used to indicate the area of contamination. 
(2) Area B. This area may be warmed. Here underclothing 
is removed and placed in bins, sacks or piles, which are frequently 
removed from the area on the assumption that they are contami- 
nated material. In this area the skin is treated with appropriate 
ointment, solvent or soap and water. Ointment is preferable if no 
erythema has appeared. If erythema or blisters are present, use 
soap and water, except with lewisite cases, who at this point re- 
ceive BAL ointment if possible. It is desirable to provide washing 99 
facilities so that when expedient a soap and water bath can be 
given here. Indications for this will vary. 
(3) Area C. In this area all cases are received. Clean cases 
are admitted directly; contaminated cases only after going through 
A and B. Note exception A’ B’ above, “Contaminated Emergen- 
cies.” 
(4) Area D. Special treatments are given in this area, including 
facilities for soaping and washing off with water. 
(5) Area A’ B’. Here medical personnel come to care for casual- 
ties requiring immediate medical and surgical aid more urgently 
than personal decontamination. Once emergency service is ren- 
dered the casualty, personal contamination is completed here. 
Medical personnel wear gas masks, protective aprons (U. S. Army 
Cover, Protective, Individual is excellent), and apply M-5 oint- 
ment to their hands and carry out personal decontamination before 
returning to the clean medical facility. It may be an extemporized 
facility or a designated room set aside for the purpose. It cannot 
be used later for clean cases, but can be used for similar emergen- 
cies. It must be recognized as a contaminated area and respected 
accordingly. 
(6) AreaE. The casualties are held in this area to await evacu- 
ation. 
(a) A most important need is effcient sorting of casualties in 
Area A by an officer or a noncommissioned officer. Of nearly as 
great importance is the supervision of the admittance of casualties 
to Area C. 
(b) The personnel employed in Area A, in addition to a well 
trained soldier for sorting, should be the litter bearers who bring 
in the casualties. It may be possible to detail extra medical aid 
men to assist in the activities of this area. 
(c) In Area B the undressers will be medical department soldiers 
detailed and trained for the special activity required in this area. 
(d) A problem of considerable importance is the handling of 
valuables and personal effects of contaminated casualties. Experi- 
ence has already shown that what would appear to be a small mat- 
ter may cause a great deal of trouble. Clothing and equipment 
removed from the casualty must be searched and small valuables, 
letters, etc. cared for by suitable means. If contaminated, and then 
carried with the casualty into an inclosed space, they may create 
a serious vapor hazard there. 
(e) Reclothing will be a problem which must be planned for. 
Fatigue clothing, pajamas or underwear may be available for litter 
cases. Some clothing and shoes may be obtained from litter cases 
which have not been contaminated. At hospitals, ordinary hospital 
clothing is available. 100 
6. Reception of Contaminated Casualties at Rear Zone 
a. Reception and handling of chemical casualties at fixed installa- 
tions in zones well to the rear require certain modifications of the 
above plan. Two of contaminated casualties must be ex- 
pected : those incurred in the vicinity of the installation and prob- 
ably grossly contaminated, such as would occur with a high explo- 
sive bombing followed by chemical attack; and those incurred in a 
forward area some time earlier, and evacuated after personal de- 
contamination to the hospital for treatment. The latter, are clean 
cases and present no problem as to reception. The former present 
a considerable problem. 
Installation 
b. The present problem with regard to reception and handling 
of chemical casualties at fixed medical establishments is one of 
decentralization, as opposed to the former idea of a single decon- 
tamination center for all chemical casualties. Any plan which per- 
mits a line of individuals to await decontamination at a centralized 
point will result in increasing the degree of injury. 
c. It is essential that contaminated clothing be removed at the 
earliest opportunity and that there be available multiple decentral- 
ized reception points, that is, “dirty” areas A and B, and “clean” 
area C, and that, employing this principle, all blister gas contami- 
nated casualties be segregated from clean casualties, until the 
former have been properly decontaminated. 
d. Blister gas contaminated wounded can, if the plan is properly 
prepared in advance, be taken from the place of sorting to ward 
entrances, just forward of which (Area A or Area A-B) clothing 
will be removed by litter bearers and placed in bins, sacks or piles 
to await periodical collection by decontamination squad personnel 
or sentries posted to this duty. Here also valuables will be properly 
cared for until decontamination can be carried out. If no special 
entrances facility has been provided, the casualty will be decon- 
taminated just forward of the entrances to the ward, as in Area 
A-B, and changed to new litter and blanket, then passed just inside 
the entrance as in Area C. At times it may be necessary to carry 
out Area B activities just inside ward entrance (in very cold 
weather). It may be possible to plan for reception of such con- 
taminated casualties via an entrance or facility which is set aside 
to provide for the procedures normally carried out in Area B of 
basic plan. 
e. At times it may appear to be necessary for certain emergency 
cases to by-pass all of these various points and go directly to an 
operating room. If this is done, it must be remembered that the 
room and equipment will become contaminated and this must be 101 
taken care of before subsequent casualties may be cared for therein. 
From the military standpoint it is undesirable, because of interior 
contamination, to lose the use of such a*! important operating fa- 
cility. IT IS NECESSARY TO HAVE ALTERNATIVE PLANS 
WHERE THE OPERATING TEAM CAN GO TO AN IMPRO- 
VISED OPERATING ROOM TO CARE FOR SUCH EMERGEN- 
CIES (AREA A’ B’). All personnel handling emergjncy contami- 
nated casualties must wear gas masks and protective aprons, and 
should observe personal decontamination with regard to their 
hands on completion of the emergency operation. Following re- 
moval of mask, protective apron and completion of personal de- 
contamination, personnel who have been attending contaminated 
casualties in such an emergency operating facility may safely re- 
turn to a clean operating room. The U. S. Army Cover, Protective, 
Individual serves well as a protective apron. 
/. In all medical establishments, therefore, there will be set up a 
special facility paralleling the operating room, in which contami- 
nated surgical emergencies can be handled. The general principle 
to be observed is to maintain the normal medical or surgical facili- 
ties as free from contamination as possible, employing an alterna- 
tive facility for the care of such a contaminated emergency casualty. 
g. The employment of multiple facilities as opposed to a cen- 
tralized one is of fundamental importance, even though these fa- 
cilities may lack something in the way of completeness. The same 
principle applies to First Aid Stations in areas subject to aerial 
attack by the enemy. 
h. The basic plan and principles to follow are those outlined for 
Areas A, B, C, D and E, A diversity of plans, employing these 
principles, is possible providing adequate means are available for 
handling such contaminated casualties. 
i. The planning for the choking gas casualties presents mainly 
the problem of providing large amounts of oxygen and personnel 
in adequate numbers with the proper training to administer the 
oxygen to such cases. • APPENDIX III 
MEDICAL DEPARTMENT ITEMS FOR FIRST AID AND 
TREATMENT OF CHEMICAL WARFARE CASUALTIES 
Med. Dept. 
Item No. 
Item 
Unit 
Quantity 
1. 9776400 
9766300 
Kit, First-Aid, Gas Casualty, Com- 
plete Containing: 
Container for Kit, First-Aid, 
Gas Casualty 
Each 
1 
1069000 
Amyl nitrite, 10 ampules 
Pkg. 
1 
9102800 
BAL Ointment, two 94-oz. tubes 
Set 
1 
9105000 
Calamine lotion, approx. 2-oz. 
Bottle 
1 
9105800 
Chloroform, approx. 2-oz. 
Bottle 
1 
9107500 
Copper sulfate solution, approx. 
2-oz. bottle 
Set 
1 
9109100 
Eye and nose drops, V2 oz. 
Pkg. 
1 
9109525 
Eye solution BAL, x/z oz. 
Pkg. 
1 
9118700 
Protective ointment, C.W.S. 3 
oz. 
Tube 
1 
9211800 
Pad, cotton approx. 1- by 2-in. 
50 
Pkg. 
1 
2. 9776700 
9776800 
Kit, Treatment, Gas Casualty, Com- 
plete Containing: 
Kit, Treatment, Gas Casualty, 
container 
Each 
1 
9102700 
Section A 
Amyl Salicylate, 8 fluid ounces 
Can 
3 
7493000 
Soap, White, Floating 
Bar 
2 
9104800 
Section B 
Calamine concentrate 
Pkg. 
2 
9116500 
Petrolatum, two 3/5-oz. tubes 
Pkg. 
2 
9109100 
Eye and nose drops 
Pkg. 
4 
9107500 
Copper shlphate solution 
Pkg. 
1 
9105800 
Chloroform 
Pkg. 
2 
9931000 
Section C 
Kit, Water Testing, Screening 
Kit 
1 
9118700 
Protective ointment, CW S 
Pkg. 
4 
9120300 
Sodium Sulamyd 
Pkg. 
1 
9116500 
Petrolatum, two 3/5-oz. tubes 
Pkg. 
3 
9911700 
9107300 
Bottle, Plastic, SV2 to 4 fluid oz. 
Copper sulphate powder, 
Bottle 
1 
approx. 37 grams 
Bottle 
1 
102 103 
Med. Dept. j£em Unit Quantity 
Item No. 
9116300 Ophthalmic disks, fluourescein 
and atropine sulphate Box 1 
9120400 Sulfadiazine tablets Pkg. 8 
Section D 
1069000 Amyl nitrite, 5 minim amp: 10 Pkg. 4 
9116500 Petrolatum, two 3/5-oz. tubes Pkg. 10 
Section E 
9102800 Bal ointment, two %-oz. tubes Pkg. 6 
9109525 Eye Solution, BAL, V2 oz. Pkg. 2 
9116500 Petrolatum, two V2 ounce tubes Pkg. 6 
Section F 
Pamphlet for use of Medical 
Officers Each 1 
3. 9775600 Set, Gas Casualty, M2, contain- 
ing: 
9778910 Packboard, plywood Each 1 
9792200 Unit medical equipment pack, 
empty case Each 1 
9776700 Kit, Treatment, Gas Casualty, 
complete Each 1 
9792300 Unit medical equipment pack, 
empty insert, 1 each for the 
following Each 2 
9903000 Apron, impermeable Each 3 
9926315 Gloves, impermeable, size 11 Pair 3 
4. 9775800 Gas Casualty Case, Aprons and 
Gloves, containing: 
9747000 Blanket Set, small, case, empty Each 1 
9903000 Apron, impermeable Each 20 
9926305 Gloves, impermeable, size 12 Pair 1 
9926310 Gloves, impermeable, size IIV2 Pair 4 
9926315 Gloves, impermeable, size 11 Pair 10 
9926320 Gloves, impermeable, size 10 V2 Pair 5 
5. 1088500 BAL in Oil (Ampule) Pkg. 10 
6. 9815500 Gas Casualty Set, Veterinary, 
Case, Aprons, complete, con- 
taining: 
9751500 Case, utility, canvas, empty Each 1 
9903000 Apron, impermeable Each 8 
9914000 Bucket, canvas, collapsible Each 4 
7. 9815600 Gas Casualty Set, Veterinary, 
Chest A, complete containing: 
9815800 Gas Casualty Set, Veterinary, 
Empty Chest Each 1 
9776100 Insert, plywood, No. 2 Each 1 104 
Med. Dept. 
Item No. 
Item 
Unit 
Quantity 
9773700 
Cover, canvas, dental pack 
chests 
Each 
1 
1372200 
Potassium permanganate, 5 lb. 
Can 
1 
7459000 
Brush scrub 
Each 
5 
9105300 
Calcium hypochlorite, 3% lb. 
Can 
4 
9903000 
Apron, impermeable 
Each 
1 
9926305 
Gloves, impermeable, size 12 
Pair 
1 
9926310 
Gloves, impermeable, size HV2 
Pair 
1 
9926315 
Gloves, impermeable, size 11 
Pair 
3 
9926320 
Gloves, impermeable, size IOV2 
Pair 
1 
8. 9815700 
Gas Casualty Set, Veterinary, 
Chest B complete, containing: 
9815800 
Gas Casualty Set, Vetexlnary, 
empty chest 
Each 
1 
9776100 
Insert, plywood, No. 2 
Each 
1 
9773700 
Cover, canvas, dental pack 
chests 
Each 
1 
1011000 
Acid, boric, 1 lb. 
Can 
1 
1108500 
Butyn sulfate, 10 hypo tablets 
Tube 
2 
1161500 
Cupric sulfate, 1 lb. 
Bottle 
1 
1213500 
Gentian violet, 1 lb. 
Bottle 
1 
1415000 
Sodium bicarbonate, 1 lb. 
Can 
2 
1463500 
Sulfanilamide, 1 lb. 
Bottle 
4 
' 5597000 
Syringe, water 
Each 
5 
7459000 
Brush, scrub 
Each 
5 
7493000 
Soap, white, floating, 6 oz. 
Bar 
10 
9109525 
Eye solution, BAL, % oz. 
Pkg. 
6 
9903000 
Apron, impermeable 
Each 
1 
9914000 
Bucket, canvas, collapsible 
Each 
6 
9926310 
Gloves, impermeable, size IIV2 
Pair 
2 
9926315 
Gloves, impermeable, size 11 
Pair 
2 
9. 9364000 
Oxygen therapy apparatus, closed 
circuit, Boothby-Lovelace. 
10. 9364200 
Oxygen therapy outfit, 20 dual 
outlet, with hose line assembly, 
complete. APPENDIX IV 
CARE OF CONTAMINATED CLOTHING AND EQUIPMENT 
AT MEDICAL INSTALLATIONS 
1. Introduction 
In the event of gas warfare, due care must be exercised at Medical 
Department installations to prevent injury to patients and medical 
attendants from clothing, blankets, or other equipment which has 
become contaminated with blister gases. Proper steps must also be 
taken to obtain timely replacement of items made unusable by con- 
tamination, and to insure the salvage and decontamination of such 
equipment. 
2. Removal of Contaminated Clothing and Equipment 
a. Clothing and equipment contaminated with a blister gas 
should be removed from the casualty at the earliest practicable 
moment, with due regard for the general condition of the patient. 
b. Casualties should not be evacuated from Medical Department 
installations in clothing or blankets known to be contaminated with 
a blister gas; to do so may result in severe skin burns by contact 
with the blister gas and in burns of the eyes and respiratory tract 
from vapors which accumulate in confined spaces such as ambu- 
lances or small rooms. 
3. Disposition of Contaminated Clothing and Blankets 
An area out of doors at a safe distance from the medical installa- 
tion (preferably at least 100 yards downwind) should be desig- 
nated as a clothing dump, and contaminated blankets and clothing 
(except impermeable aprons and rubber gloves) should be trans- 
ferred to this dump as conditions permit. The dump should be 
clearly marked “Danger, Gas.” 
4. Notification of Salvage Officer 
The responsible Medical Department officer should notify (by field 
message or otherwise) the most available salvage officer in his 
unit area, advising him of the existence of the dump of contami- 
nated clothing and blankets, its exact location, and approximate 
size. 
105 106 
5. Replacement of Contaminated Blankets 
a. To prevent the supply of blankets becoming exhausted, it will 
be necessary that those lost by contamination be replaced. 
b. An informal check on the number of contaminated blankets 
sent to the clothing dump should be kept, in order that the approxi- 
mate number or replacements required may be known. 
c. If conditions permit, replacements may be obtained by requi- 
sition through the normal channels of medical supply (for ex- 
ample, regimental medical supply officer) If the time factor or 
tactical situation does not permit replacement through normal 
channels of supply, replacement may be requested from the nearest 
source of supply with which the unit has contact (for example, 
collecting company). 
d. Succeeding echelons in the chain of combat medical supply 
should request replacement of blankets promptly, as their supplies 
are displaced forward. This should operate as far to the rear as the 
medical depot for the area. 
e. Since salvaged contaminated blankets will normally be turned 
over to quartermaster depots following decontamination, the medi- 
cal depot should requisition the necessary replacements from the 
quartermaster depot serving the area. 
6. Apron Protective Impermeable (Medical Department Item No. 
9903000) 
a. The apron, protective, impermeable (Medical Department 
item No. 9903000) is intended for use by personnel of Medical 
Department field installations while treating and handling blister 
gas contaminated casualties. The apron is always worn in conjunc- 
tion with complete permeable protective clothing (par. 1146, FM 
21-40) and impermeable protective gloves (rubber) (Medical De- 
partment item No. 9926305-20). The gas mask is also necessary as 
a part of the complete protective outfit. 
b. Litter bearers moving into dangerously contaminated areas 
should don the complete outfit described above before entering 
such areas. Aid station attendants and others should don the 
complete outfit prior to handling or treating contaminated patients 
and the apron should not be removed until the danger of contami- 
nation has been removed. If treatment of patients is hampered by 
the use of the impermeable gloves, such gloves may be removed 
with comparative safety after removal of all of the patient’s heavily 
contaminated clothing, and the treatment continued wearing pro- 
tective gloves (cotton). Contaminated aprons may be worn with 
safety for many hours in conjunction with permeable protective 
clothing. However, aprons should be decontaminated after each 107 
day of wear, as prolonged contact with the liquid blister gases may 
have a deleterious effect on the coated fabric. The complete outfit 
should also be worn while decontaminating litters, ambulances, 
and other equipment which may have been contaminated in trans- 
porting casualties. 
c. Before donning the apron, the adjustment of leg, waist, neck, 
and sleeve closures of the permeable protective clothing are in- 
spected to determine if a protective gas seal is secured and the pro- 
tective gloves (cotton) are pulled on with gauntlet drawn 
well up over the sleeve of the shirt. With the neck strap of the 
apron buttoned, the head is thrust through the opening made by the 
neck strap and the apron; the left arm is inserted in the respective 
sleeve, and then the right arm and the tie straps and neck straps 
are adjusted to obtain a comfortable fit. The gas mask carrier is 
worn over the apron. Immediately prior to moving into a contami- 
nated area or handling contaminated patients, the gas mask is 
donned and adjusted. The collar of the shirt is turned up, and the 
hood, having been previously buttoned to the back of the shirt, is 
adjusted over the mask. Impermeable gloves are put on prior to 
handling contaminated patients or material. 
d. In removing the apron, the procedure is as follows: After 
removal of the impermeable gloves, the neck strap is unbuttoned 
with the left hand and the two carrier straps released so that the 
canister and carrier hang suspended. The tie straps are released 
and the right arm removed from the sleeve by inserting the gloved 
forefinger of the left hand under the elastic cuff of the other sleeve 
and pulling. This procedure is repeated using the right hand in 
removing the left sleeve. The apron now falls freely from the body. 
Care should be exercised in the removal of the apron so that con- 
taminated surfaces of the apron are not permitted to come into 
contact with the clothing of the wearer or other individuals. De- 
contamination procedure should be applied as soon as practicable 
to contaminated of clothing and equipment. 
7. Disposition of Contaminated Gloves and Aprons 
a. It will not ordinarily be possible for aid stations to decon- 
taminate aprons (Medical Department item No. 9903000) and 
rubber gloves (Medical Department item No. 9926315) during 
combat operations. Hence gloves and aprons of aid stations which 
become contaminated during combat should be placed in a gas re- 
sistant sack and sent by the most available means to the collecting 
company with which they are in contact, to be exchanged for fresh 
aprons and gloves. 
b. The collecting company when operating under combat condi- 
tions will send contaminated gloves and aprons which are received 108 
from aid stations, plus those which become contaminated at the 
collecting station, by the most available means to the supply officer 
for the medical battalion (or regiment, etc.) for decontamination 
and exchange for fresh supplies. 
c. Decontamination of impermeable gloves and aprons for the 
attached medical troops of the division and for the medical bat- 
talion will ordinarily be accomplished by the headquarters section 
of the medical battalion. 
d. Other medical units are responsible for decontaminating their 
own impermeable aprons and gloves. 
8. Replacement of Contaminated Gloves and Aprons 
a. Upon the receipt of contaminated aprons and gloves from aid 
stations, the collecting company will make automatic replacements 
in kind to the installation from which the items were received by 
the most expeditious means available. 
b. Upon the receipt of contaminated aprons and gloves, the head- 
quarters section of the medical battalion will make an automatic 
replacement in kind, to the installation from which the contami- 
nated items were received, by the most expeditious means available. 
9. Decontamination of Blankets and Permeable Protective 
Clothing 
Contaminated blankets and permeable protective clothing removed 
from casualties are removed from the clothing dump by direction 
of the salvage officer. Decontamination of the blankets and pro- 
tective clothing is then performed by Quartermaster Corps laundry 
units. Emergency methods of decontaminating blankets and pro- 
tective clothing are described in TM 3-220. 
10. Decontamination of Aprons 
Impermeable aprons (Medical Department item No. 9903000) may 
be decontaminated by one of the following methods: 
a. Method I. The apron is immersed in water at a temperature 
just below boiling for a period of 3 hours. It is then dried in air 
and returned to service. 
b. Method II. If contamination is light or caused by vapor, the 
materials may be aired in the sun or wind for several days. 
11. Decontamination of Impermeable Rubber Gloves 
The decontamination of impermeable rubber gloves must be done 
carefully to prevent severe chemical burns when subsequently using 109 
them.* The same two methods described in paragraph 10 a and h 
may be used for the decontamination of the gloves with the excep- 
tion that in Method I the gloves are immersed for only 2 hours. 
12. Decontamination of Gas Masks, Web, Canvas, and Leather 
Equipment 
a. Emergency decontamination of gas masks, web, canvas, and 
leather equipment is accomplished by the use of protective oint- 
ment. All visible liquid contamination is first wiped off with rags, 
after which ointment is applied to the contaminated areas and al- 
lowed to remain for 15 minutes. The surfaces are then wiped clean 
with rags. To be most effective, the ointment should be applied 
within 3 minutes after contamination. Generally, it is not practi- 
cable to decontaminate more than 2 square feet of surface by this 
method. Caution: Do not use protective ointment on the lenses of 
gas mask because it etches them severely. Eyepieces will be de- 
contaminated so far as possible by rubbing them with a cloth or 
absorbent paper. 
b. Gas masks, if lightly contaminated by vapor or droplets, 
should be removed from their carriers and aired in the sun and. 
wind at every opportunity. Long exposure to heavy vapor concen- 
trations and heavy liquid contamination will require immersion of 
the mask in plain water maintained just below the boiling point for 
3 hours. DANG should not be used to decontaminate the rubber. 
c. Gas mask carriers, first-aid pouches, and other web and canvas 
equipment may be decontaminated by soaking in water, to which 
2 ounces of sodium carbonate (washing soda) per 10 gallons of 
water have been added, for 1 hour at a temperature just below the 
boiling point. The items are then hung up to dry and returned to 
service. 
d. Shoes, straps, and other leather equipment may be decontami- 
nated by soaking in water heated to a temperature of about 122° 
to 131°F. (about as hot as the hand can stand), for 4 to 6 hours, 
then dried in air without excess heat, treated with Impregnite shoe 
Ml, and returned to service. DANG is suitable for use on leather 
(iTM 3-220). 
13. Care of Litters 
a. Protection. Emergency protection of litters may be accom- 
plished by covering the litter with blister gas resistant materials 
such as the Cover, Protective, Individual or the Sack, Gas Resist- 
ant. 
* In immersing the gloves, care must be taken that the gloves are filled with 
the solution, and that they are kept below the surface. b. Decontamination of Litters. (1) If possible, litters should 
be disassembled and components decontaminated as follows: 
(a) Canvas. Litter canvas may be decontaminated by immer- 
sion in boiling water for 30 to 60 minutes. If available, 2 ounces of 
washing soda (sodium carbonate) to each 10 gallons of water is 
recommended. An alternative decontamination procedure is to 
spray canvas with DANC on both sides repeating two or three 
times and allowing each application of DANC to dry. Subsequent 
washing with soap and water is advisable. 
(b) Wood. A 30 percent aqueous slurry of Bleach Powder 
(Chemical Warfare Issue) is applied and allowed to react for 6 to 
24 hours. Applications are repeated if necessary; the wood is then 
swabbed dry and allowed to aerate at elevated temperatures if pos- 
sible. 
(c) Metal, {untainted). Decontamination is accomplished by 
swabbing or spraying with DANC or available solvents (gasoline, 
kerosene, etc.) then washing with soap and water and finally dry- 
ing with rags and aerating several hours. 
(2) If the litter cannot be disassembled or conditions do not 
permit disassembly, the litter should be sprayed with DANC sev- 
eral times, allowing each application to dry; visible liquid contami- 
nation should be rubbed off and the litter should be allowed to aerate 
as long as conditions permit. APPENDIX V 
TREATMENT OF BURNS 
1. General 
Burns, as discussed in this appendix, include all cases with damage 
of the skin and underlying tissues due to heat, chemicals or elec- 
tricity. 
2. Fundamentals of Treatment 
a. The prevention and treatment of shock. 
b. The prevention and control of infection. 
c. The relief of pain. 
d. The prevention of contracture and scarring by proper splint- 
ing and early skin grafting. 
3. Treatment 
a. General. (1) Proper steps for the prevention or treatment 
of shock should be instituted. In the presence of extensive burns, 
large quantities of plasma (12 units or more) may be required in 
the first 24 hours. Parenteral fluid replacement other than that 
attained by means of plasma or whole blood transfusion should be 
accomplished by means of 5 percent glucose in sterile distilled 
water. The intravenous administration of sodium chloride solu- 
tion should be reserved for those burn cases in which mineral de- 
pletion occurs, such as that resulting from persistent vomiting. 
Transfusion of fresh whole blood is often needed as early as the 
second day to combat the severe anemia which appears following 
extensive burns; when anemia exists, whole blood transfusion is 
particularly indicated as a preliminary to skin grafting. 
(2) When indicated, specific antibacterial therapy should be in- 
stituted. Penicillin is the drug of choice and should be given intra- 
muscularly in doses of 25,000 units every 3 hours as long as indi- 
cated. For cases in which sulfadiazine is used, it should be given 
orally with an initial dose of 4 grams (grains 60). Subsequent 
doses of sulfadiazine should be given only under the direction of a 
medical officer. Great care must be exercised in the use of sulfoni- 
mides in burned patients because of the danger of kidney damage. 
The presence of renal damage due to the burn and extensive loss 112 
of fluid from the burned surfaces with resultant decrease in urinary 
output increase the danger of renal complications due to sulfoni- 
mides. When adequate urinary output (1500 cc of urine per day) 
is obtained, maintenance doses of sulfadiazine, 1 gram (grains 15) 
every 4 hours, should be given. Four grams (grains 60) of sodium 
bicarbonate should be given with the initial dose of sulfadiazine 
and 2 grams (grains 30) every 4 hours thereafter to keep the 
urine alkaline. 
(3) Prophylaxis against tetanus is indicated in all patients with 
second and third degree burns. Army personnel who have previ- 
ously received tetanus toxoid should receive a step-up dose of 1.0 
cubic centimeter. Those individuals who have not previously re- 
ceived tetanus toxoid should be given 1500 units of tetanus anti- 
toxin (after careful skin-testing for possible sensitivity to horse 
serum) immediately and weekly during the period of healing. 
(4) Pain should be relieved by adequate doses of morphine. In 
the presence of pronounced anoxia large doses of morphine are 
dangerous, and under such circumstances the dose should not ex- 
ceed 14 grain (0.016 grams). In the presence of shock, morphine 
administered subcutaneously may not be absorbed due to the poor 
circulation. If repeated doses are given, the return of normal cir- 
culation may result in complete absorption and morphine toxicity. 
b. First-Aid Emergency Treatment of Burned Area. (1) 
The burned surface will be covered with a liberal amount of sterile 
petrolatum, or if this is not available boric acid ointment. The area 
should then be covered with strips of fine mesh gauze (44 mesh 
gauze bandage is satisfactory). Over this should be placed a thick 
layer of sterile gauze dressings, such as large or small first aid 
dressings. Finally a gauze or muslin bandage should be firmly 
applied over the dressings. 
(2) Contamination of the burned surface by organisms from the 
nose and throat is responsible for many of the severe infections 
which occasionally develop. Therefore, to minimize contamination 
from this source, masking should be practiced by surgeons and 
assistants. 
(3) The prompt administration of plasma is of utmost impor- 
tance in the emergency treatment of burns. 
c. Treatment of Burned Area When Patient Arrives Where 
Hospital Facilities Exist. The burned areas will be treated as 
follows, using standard operating room technique with patients 
and attendants fully masked. 
(1) In cases in which the surface appears clean no further prep- 
aration is necessary. 
(2) Where the burned surface is grossly soiled, the areas are 
to be cleaned gently using cotton and neutral soap and water. The 113 
area will then be rinsed with sterile isotonic saline. Green soap and 
brushes will not be used. 
In debridement, loose shreds of epidermis will be removed. Small 
intact blisters will be left undisturbed. Large blisters may be 
evacuated by means of sterile needle and syringe. General anaes- 
thesia should be avoided and morphine used to alleviate pain dur- 
ing cleansing, debridement and application dressings. 
(3) (a) Tannic acid and all other tanning agents or escharotics 
will not be used. The burned area will be covered with sterile petro- 
latum or boric acid ointment if the former is not available. Strips 
of fine mesh gauze should then be applied, followed by a smooth, 
thick layer of sterile dressings, absorbent cotton, cotton waste or 
cellulose. The dressings should be held in place by an even, firmly 
applied bandage of stockinette or some form of elastic bandage. 
(b) The dressings should extend well beyond the burned area, 
and in cases involving the extremities it should include all of the 
extremity distal to the burn. Adjacent burned surfaces on fingers 
and toes should be separated by vaseline gauze and thin dressings 
prior to the application of pressure dressings. 
(c) It is of utmost importance to observe the state of the cir- 
culation in a burned extremity with this type of dressing, particu- 
larly during the first day when edema is developing. If undue pain, 
coldness, or cyanosis appear, the bandage should be split. 
(d) The use of infrequent dressings in the treatment of burns 
is especially desirable. For this reason, the initial dressing in a 
clean case should not be disturbed for the first 10 to 12 days. Im- 
mobilization of the burned part by splinting should be carried out 
where feasible. 
(e) Thereafter slough will begin to separate and may be re- 
moved surgically when possible. 
(4) (a) Early epithelization is one of the most important fac- 
tors in preventing contractures and in obtaining an optimal func- 
tional and cosmetic result. For this reason skin should be grafted 
onto the granulating surfaces as early as possible. If infection is 
present, it should be controlled preparatory to skin grafting by the 
administration of penicillin in doses of 25,000 units of the sodium 
salt intramuscularly every 3 hours as long as indicated. 
(b) Frequent transfusions of fresh whole blood and plasma 
and a very high protein diet are necessary to maintain nutrition 
and to promote healing. APPENDIX VI 
DETECTION OF CONTAMINATED WATER AND ITS 
PURIFICATION 
1. General 
Contamination of water supplies is to be expected in areas sub- 
jected to attack with chemical warfare agents. This contamination 
may reach harrassing or toxic concentrations and, if undetected, 
can produce a large number of casualties. The presence of dan- 
gerous amounts of chemical warfare agents in water can be de- 
termined by special methods of analysis. The purification of con- 
taminated water is difficult and requires chemicals and equipment 
not regularly issued to troops. Transportation of water may be 
required. Purification should be resorted to only in extreme emer- 
gency. 
a. Caution. Even when chemical tests fail to detect the pres- 
ence of chemical warfare agents, water obtained from sources 
known to be, or suspected of being contaminated must not be con- 
sumed in amounts greater than two or three swallows at a time and 
not more than three canteenfuls during the first 24 hours after 
contamination. To guard against cumulative effects, this water 
should not be used for periods exceeding one week. 
b. Important Agents. The vesicants and the systemic poisons, 
cyanogen chloride and hydrogen cyanide, are the agents most likely 
to cause casualties when introduced into water. It is considered im- 
probable that toxic concentrations of heavy metals and alkaloids 
will be encountered. 
2. Toxic Limits 
The toxic limit for lewisite (L) is 20 ppm (20 mg/1), (10 ppm 
(10 mg/1) as As203), provided the water is chlorinated by the 
standard procedure for bacterial purification and is used for not 
more than 1 week. Unhydrolized nitrogen mustards (HN) in con- 
centrations of 10 ppm (10 mg/1) have produced vomiting in man 
when consumed in 200 cc quantities at a time but have not caused 
actual casualties. In higher concentrations they are extremely 
toxic. Mustard (H) dissolves slowly in water but may be found 
floating in tiny globules, as a film on the surface or collected in 
pools on the bottom. Small droplets when fed with water to rats 
have produced perforating ulcers in the intestinal tract. The limits 
114 115 
for cyanogen chloride (CK) and cyanide (AC) are 25 ppm (25 
mg/1). 
3. Reactions with Water 
The three vesicants, lewisite, mustard, and nitrogen mustards, all 
react with water to form hydrochloric acid and the hydrolysis 
product corresponding to the agent. Lewisite reacts with water 
practically instantaneously, forming the hydrolysis product lewis- 
ite oxide, which is toxic and somewhat vesicant. Mustard (H) re- 
acts with water to form the nontoxic thiodiglycol, A solution con- 
taining 100 ppm (100 mg/1) mustard becomes nontoxic at the end 
of 1 hour. Some types of mustard contain a highly odorous com- 
pound which renders the water nonpalatable even after hydrolysis. 
Nitrogen mustards hydrolyze slowly to a nontoxic product. A solu- 
tion containing 100 ppm may remain toxic for 4 to 6 days. Cyano- 
gen chloride is soluble in water to the extent of 6 to 7 percent by 
weight at one atmosphere pressure and 25°C. This compound hy- 
drolyzes slowly in water forming cyanates which readily decom- 
pose into harmless products. A concentration of 50 ppm will be 
hydrolyzed to 25 ppm in about one week. Hydrocyanic acid and 
many of the cyanide salts are very soluble in water and do not react 
appreciably with it. 
4. Detection 
a. Kit, Water testing, screening, for detection of chemical war- 
fare agents. The Medical Department issues a kit (Medical De- 
partment item No. 9931000) for simple, rapid field tests of water 
for dangerous chemical contaminations. These tests ordinarily are 
performed in the combat zone at the Engineer Corps water supply 
points. Further tests of water furnished by water supply troops 
of the Engineer Corps are not required, unless chemical contamina- 
tion during its transportation from supply points is suspected. In 
combat it may be impracticable, or impossible, to obtain water from 
Engineer Corps water supply points. If it becomes necessary to 
use other water, the unit surgeon will be responsible for determin- 
ing the potability of water procured for the troops of his unit. 
Under such circumstances, the kit, water testing, screening (Medi- 
cal Department item No. 9931000) should be employed by the unit 
surgeon. Tests should be made of the raw water, prior to chlorina- 
tion. If this is found to be free of contamination, it may be used 
after the usual purification by chlorination to render it safe from 
bacterial pollution (ch. 3, EM 8-40). 
b. Description of Water Testing Kit. For the sake of simpli- 
city, analytical procedures have been developed to employ dry re- 
agents which are furnished as tablets or pellets of proper size. 116 
Except for warming with the hand in some of the tests, no heat 
is required. The kit contains equipment for testing 15 samples of 
water. The reagents and equipment are packed in a pocket-sized 
container, approximately 5!/2 by 3% by 1% inches, divided into 10 
compartments. The container is constructed of transparent plastic. 
The kit contains 2 test tubes, a chlorine demand assembly (QM 
11968), a bottle and tube for the detection of arsenicals by a modi- 
fied Gutzeit method, and 7 vials containing reagents and test papers. 
The vials are identified by letters printed on the paper liners. Their 
caps are made of colored plastic matching the color of the paper 
liners. A test tube brush and pipe cleaner are provided for clean- 
ing the apparatus. 
c. Purpose. (1) The field kit for testing water is designed as 
for reconnaissance. It is employed to screen out sources of water so 
contaminated that they cannot be rendered potable by customary 
field methods, such as chlorination in the Lyster bag. 
(2) Negative tests indicate that the water is suitable for chlori- 
nation and may be used by troops, within the limitations. 
(3) If any of the tests are positive, the water should not be used 
until a more complete analysis can be made. 
(4) The main purpose of the kit is to detect contamination of 
raw water. It is not designed for use on treated water as the chemi- 
cal reactions of water treatment invalidate the interpretations. 
d. Analytical Procedures. A booklet issued with the kit gives 
specific directions for each test. Nontechnical language is used and 
the reagents are referred to by the letters on the vials. These di- 
rections must be followed exactly. Briefly, the tests involve the fol- 
lowing chemical processes: 
(1) Arsenicals are converted to arsines through the action of 
hydrogen, produced by the action of sodium acid sulfate on zinc. 
The arsine reacts with a sensitized paper to produce a stain. This 
is sensitive to 5 ppm. 
(2) pH is determined by indicator paper. 
(3) Mustards are detected by means of the DBS reagent; 5 ppm 
(5 mg/1) of unhydrolyzed nitrogen mustard and 15 ppm of unhy- 
drolyzed sulfur mustard can be detected. Cyanogen chloride pro- 
duces a yellow color with the DB3 reagent. 
(4) The chlorine demand or chlorine uptake is determined by 
means of halazone tablets and an orthotolidine testing assembly. 
(QM 11968). This test detects the presence of other agents, such 
as the cyanides, not specifically tested for. 
(5) If no evidence of contamination is found, odor and taste 
can be tried with safety. 117 
e. Interpretations. 
Test Indication of positive results 
Arsenicals 1,4-inch stain on test paper. 
pH Below 6 when compared with color 
standards. 
Mustards Any blue or red color no matter how 
faint and transitory. 
Chlorine Demand No color in solution or color lighter than 
that of band in plastic tube. 
Taste and Odor A lacrimating or chlorinous odor, a bit- 
ing and/or peppery chlorinous taste, 
any taste or odor of a known war gas. 
If one or more of the above tests gives a positive result, the water 
will be considered contaminated. 
/. Limitations. (1) If the tests are carefully performed, the 
threat of serious casualties from contamination of the water with 
known agents will be avoided. 
(2) The tests provided by the kit will not screen out traces which 
are harmless when the water is used for short periods of time. 
When arsenic is detected, even though the water is passed as safe 
by the kit (that is, an arsenic content which gives a stain shorter 
than 1/4 inch on the test paper), the water should be used for drink- 
ing and cooking purposes not to exceed 1 week, because of possible 
cumulative effects. 
(3) Water may give a negative test for nitrogen mustards and 
still give symptoms if consumed in large quantities. Hence the 
water should not be used without special purification (by Engineer 
Corps Water Supply Troops) even if the faintest blue color de- 
velops in the test for mustards. 
(4) The tests provided by the kit are not quantitative, and will 
therefore not serve as a guide for the purification of field water 
supplies. More elaborate methods are available to the Division 
Medical Inspector and the Laboratory, Army. These methods are 
described in detail in TB MED 37 and changes thereto. The special 
equipment is Kit, Water Testing, Poisons, Treatment Control, Med. 
Dept, item No. 9930700. 
5. Action Required if Water is Found to be Contaminated by Chem- 
ical Agents 
Whenever positive tests are obtained with the kit, water testing, 
screening, the water will be considered contaminated and the fol- 
lowing actions taken; 
a. The unit commander will be notified that the water source is 
contaminated and is unfit for drinking purposes. 118 
b. The unit commander will establish the necessary safeguards 
to prevent troops from drinking the contaminated water. 
c. An alternative source of uncontaminated water should be 
sought and, if found, should be employed. 
d. If a source of uncontaminated water cannot be found, consid- 
eration should be given to moving to a different location, or to im- 
porting purified water to the area. 
e. In any event, the contaminated water should not be used by 
troops until it is purified by the water supply troops of the Engineer 
Corps. 
/. Contamination discovered in otherwise suitable water should 
be reported as promptly as possible to the headquarters of the di- 
vision, or other comparable command, so that the matter can be 
brought to the attention of the division medical inspector and the 
commanders of Engineer Corps water supply unit for necessary 
action. 
6. Scale for Issue of Water Testing Kits 
The Kit, Water Testing, Screening has been added to the contents 
of the Kit, Treatment Gas Casualty (Med. Dept, item No. 9776700) 
and therefore is available to battalion medical sections and to medi- 
cal units so equipped. It is available also on separate issue to Engi- 
neer Corps water supply units and to the Medical Inspectors of 
Divisions and higher echelons. When the contents have become ex- 
hausted, the complete kit can be replaced through the usual chan- 
nels of medical supply. 
7. Use of Suspected Water 
a. Water suspected of being contaminated but giving negative 
tests with the Kit, Water Testing, Screening can be used sparingly, 
after chlorination, for periods not to exceed one week. 
h. When suspected water is used, great care should be taken not 
to stir up material from the bottom as it may contain chemical 
agents when the water above does not. 
8. Procedure in Case of Heavy Contamination 
When winter is too heavily contaminated to pass the screen kit test, 
every effort should be made to secure another source or to have pure 
water supplied from elsewhere. To meet emergencies, Sanitary 
Corps officers are provided with equipment for making more com- 
plete analyses. The methods for treatment are outlined briefly 
belowr. Only trained personnel should undertake such procedures. 9. Purification of Contaminated Water 
119 
a. Water must be withdrawn from the intermediate levels with 
minimum disturbance of the surface and no disturbance of the 
bottom. 
b. Treatment of Large Volumes. (1) The contaminated 
water is pumped into a canvas reservoir and a quantitative analysis 
made by a Sanitary Corps officer. 
(2) It is then treated with activated carbon (200 mesh) in the 
following doses: 
(a) For lewisite, 30 ppm (30 mg/1) carbon for each ppm (mg 
1) lewisite. 
(b) For mustard, 30 ppm (30 mg/1) carbon for each ppm 
(mg/1) mustard. 
(c) For nitrogen mustard, 60 ppm (60 mg/1) carbon for each 
ppm (mg/1) nitrogen mustard. 
(8) The carbon and water are mixed for 20 minutes to insure 
complete absorption of the agent by the carbon. 
(4) 175 ppm (175 mg/1) of coagulant is added to the carbon- 
dosed water, together with sufficient alkali to give optimal coagu- 
lation. 
(5) After thorough, gentle mixing, the water is allowed to coag- 
ulate and clarify by sedimentation for 30 minutes. 
(6) The supernatant water is filtered through the portable water 
purification unit, at normal rate of 10 gpm. or preferably more 
slowly. 
(7) The filtered water must be tested quantitatively to see that it 
meets the following requirements: 
(a) Mustards, not more than 2 ppm (2 mg/1). 
(b) Lewisite (arsenicals), not more than 20 ppm (20 mg/1). 
(c) PH above 5. 
(d) Chlorine demand, less than 5. 
(e) No chemical odor or taste 
c. Treatment in Lyster Bags. (1) When the portable water 
purification unit is not available, small volumes can be purified 
by using two Lyster bags. 
(2) If testing equipment is available to identify the contaminat- 
ing agents and determine their concentrations, add activated car- 
bon in the dosages given in 5(2) above to the water in one Lyster 
bag. If the identities and concentrations of contaminants are un- 
known, add 2 pounds of activated carbon. 
(3) Stir for 20 minutes. 
(4) Add 1 ounce of alum and sufficient alkali to give optimal 
coagulation. These chemicals should be dissolved separately in 
small volumes of water prior to their addition to the Lyster bag. 120 
(5) After thorough, gentle mixing, allow to coagulate and clari- 
fy by sedimentation for 30 minutes. 
(6) Siphon the supernatant water to another Lyster bag (pref- 
erably through a filter). 
(7) After testing to insure that the requirements of b (7) above 
are met the water in the second Lyster bag must be chlorinated. 
10. Chlorination of Contaminated Water 
Chlorine reacts with some of the chemical agents making it diffi- 
cult to remove them by the activated carbon and alum treatment. 
Therefore, chlorination should be carried out only after filtration 
through the portable purification unit, and the chlorine feed-line 
must be connected to the effluent pipe from the filter. In the case 
of treatment in the Lyster bag, chlorine is added in the secona 
Lyster bag. When contamination is suspected, no chlorinating 
compounds should be added until the water has been clarified. APPENDIX VII 
CHEMICAL AGENT CONTAMINATION OF FOOD, 
FORAGE, AND GRAIN 
1. General 
a. Contamination of foodstuffs, by chemical warfare agents may 
occur from contact with vapor, sprays or splashes of liquid, or 
solid chemicals. Unprotected food, forage, and grain supplies may 
be so contaminated that their consumption produce gastrointesti- 
nal irritation or systemic poisoning. The vesicants and arsenicals 
are the most dangerous. 
b. Food supplies in storage are not likely to be seriously conta- 
minated if reasonable precautions are taken to protect them 
against chemical attack. For this reason, large supplies of food 
should not be condemned en masse simply because they have been 
exposed to the possibility of chemical contamination. A prompt 
and careful survey of the supplies may reveal that only a few items 
have been so seriously contaminated as to require special treat- 
ment. Prompt segregation of the heavily contaminated portions 
will prevent or minimize contamination of the remainder. Gen- 
erally, foods not especially packed in protective packages consti- 
tute the major difficulty. The availability of fresh supplies and 
available means of decontamination will dictate whether or not re- 
clamation of these contaminated items is worth while. The Quar- 
termaster Department’s present methods of packing foods for 
oversea shipment greatly minimizes the danger of contamination. 
2. Susceptibility to Contamination 
The vesicants and chlorpicrin are readily soluble in fats. They will 
be absorbed by foods of high fat content, and because of diffusion 
throughout the material, it may be impossible to remove them. 
Coagulation of protein by agents such as the arsenical vesicants 
which are acidic or acid-forming may limit diffusion of the agent 
in high protein foods. Hydrolysis of acid-forming gases in foods 
of high water content causes decomposition products which render 
the food unpalatable. Foods of low water and fat content will be 
relatively less easily contaminated by chemical agents and less 
difficult to decontaminate. Mustard gas used by the enemy may 
contain considerable quantities of an arsenical agent, and this fact 
should be kept in mind. 
121 122 
3. Protection Afforded by Wrapping Materials 
In determining the disposition of packaged and stored supplies 
which have been contaminated, consideration must be given to the 
nature of the contaminant as well as to the type of foodstuff and 
the security afforded by the packaging material. Some of these 
factors are outlined as follows: 
a. Airtight bottles and sealed tins give complete protection 
against vapor and liquid. 
b. Wooden barrels, well sealed for the exclusion of air, give 
complete protection against vapor and moderate amounts of liquid. 
c. Wooden boxes, not sealed for the exclusion of air, give little 
protection against vapor or liquid. 
d. Waxed paper boxes, well sealed for the exclusion of air, give 
good protection against vapor and fair protection against liquid. 
e. Paper wrapping gives poor protection against vapor and very 
little against liquid. 
/. Foil and cellophane wrappings, sealed for the exclusion of 
air, give good protection against vapor and liquid. 
g. Ordinary textiles in a single layer packaging give practically 
no protection against vapor and liquid. 
h. Coverings of sod and earth give good protection against vapor 
and liquid. 
i. Open shelters give protection against liquid sprays and 
splashes. Closed buildings give protection against both vapors and 
liquids. 
j. Generally, double layers greatly increase the protective effi- 
ciency of packaging materials. 
k. Special Quartermaster rations such as D, K, TEN-IN-ONE, 
Mountain, and Parachute Emergency are so packaged as to protect 
the enclosed foods for many hours even when the outside of the 
package is heavily contaminated with the liquid agent. 
4. Storage of Food Supplies 
When it is necessary to store bulk food supplies which are poorly 
protected by packaging, measures should be instituted to make the 
storage space as gasproof as possible. The most vulnerable food 
should be placed in the least exposed positions, keeping in mind the 
fact that the vapors of chemical warfare agents are heavier than 
air and tend to accumulate in low places. In the field, tarpaulins 
covering food supplies give fairly good protection against vapor 
and liquid agents. 
5. Reclamation of Contaminated Supplies 
a. General. Food supplies which have become contaminated 
should be handled only by those trained in decontamination methods 123 
and equipped with protective clothing and gas masks. Before un- 
dertaking any decontamination procedures, a careful survey should 
be made to determine the extent of contamination. From informa- 
tion gained on this survey, the exposed items should be divided into 
three groups for separate treatment as described below. 
b. Group I. This group will consist of packaged items which 
have been exposed only to the vapors of the agent. A consideration 
of the factors outlined in paragraph 3 above will serve as a basis 
for the evaluation of the seriousness of contamination. Generally, 
the items in this group will be safe to issue to troops after a brief 
period of airing to remove clinging vapors. 
c. Group II. This group will consist of packaged items the out- 
side of which have been contaminated with the liquid agent. At- 
tempts to decontaminate porous packaging materials such as card- 
board or wood are likely to be unsuccessful and may actually result 
in spreading the contamination. The correct procedure in hand- 
ling such items is to strip off the outer contaminated wrapping 
and examine the inner layer to see if penetration of the agent has 
occurred. If it has, continue stripping off layers until an unconta- 
minated layer is reached. Items packed by the Quartermaster De- 
partment are usually packaged in boxes within boxes so such a 
procedure is feasible. When an inner uncontaminated package is 
reached, it should be placed in Group I. If the agent has penetrated 
to the food itself, place in Group III. Canned goods may be decon- 
taminated by any of the usual chemical methods such as bleach 
slurry or decontaminating solution noncorrosive (Chemical War- 
fare Service Issue, DANG) followed by washing in water. 
d. Group III. This group will consist of unpackaged or poorly 
packaged items which have been exposed to the gaseous or liquid 
agent. The general decontamination procedure to be followed in 
order is: trimming of surface fat and grossly contaminated areas; 
washing with water or 2 percent sodium bicarbonate solution; boil- 
ing in water. Boiling in water may be eliminated when the contami- 
nation has been only with the vapors of the lung irritants or lacri- 
mators. When such an exposure has been light, aeration for a short 
time may be used for decontamination. Frying, roasting, or broil- 
ing will not remove traces of vesicants from meats. In general, sal- 
vage of foods heavily contaminated with droplets of the vesicants, 
especially the arsenical vesicants, is not practicable. More detailed 
directions are given below. 
e. Lung Irritants. This group of agents offers relatively little 
danger to food products. With the exception of chlorpicrin, these 
decompose rapidly upon contact with the water in foods, to form 
comparatively harmless compounds which may alter the flavor. 
Decontamination can be accomplished by washing, supplemented, 124 
where possible, by aeration. Chlorpicrin is slightly soluble in water, 
and is soluble in fat and most organic solvents. Its removal from 
foods of low water and fat content can be accomplished by aeration. 
/. Lacrimators and Irritant Smokes. (1) Large stocks of 
supplies, when protected by covers or packages, probably cannot be 
contaminated with a sufficient quantity of the lacrimators or irri- 
tant smokes to warrant their destruction. These agents are not 
easily decomposed by hydrolysis and it would be difficult to reclaim 
foods heavily contaminated by them. 
(2) Dry provisions contaminated by lacrimators can be decon- 
taminated by aeration. 
g. Vesicants. (1) When contaminated with liquid mustard or 
a liquid nitrogen mustard, foods of high water or fat content are 
unfit for consumption and reclamation is not practical. When foods 
have been exposed to vesicant vapor, they can be reclaimed by 
washing with soda solutions and rinsing with clear water, inten- 
sive cooking, or in the case of dry provisions, by 24 to 48 hours’ 
aeration. Lean meat can be reclaimed by boiling in water for 
hour or more, or in the case of the nitrogen mustards, with a 2 
percent solution of baking soda. The water must be discarded after 
boiling. 
(2) Lewisite, ethyldichlorarsine, and phenyldichlorarsine read- 
ily hydrolyze to poisonous arsenical oxides. Foods contaminated 
with these agents cannot be reclaimed. 
h. Screening Smokes. (1) HC, FM, FS, and WP smokes are 
nontoxic. (They may alter the taste of foods by acids produced on 
contact with moisture, but do no damage otherwise. 
(2) Liquid FM (titanium tetrachloride) can be washed from 
foods. Liquid FS (sulfur trioxide-chlorosulfonic acid solution) is 
highly corrosive and forms strong acids on contact with moisture. 
It may render unfit for use foods which cannot be washed readily. 
After trimming, washing, or cooking, if the food does not taste too 
acid, it is safe to use. 
(3) Unburned particles of white phosphorus are poisonous and 
must be removed from foods. Fats and oils may dissolve poisonous 
amounts of the agent and should be discarded. 
i. Other Agents. Carbon monoxide, arsine, and hydrocyanic 
acid will have little effect upon food supplies. Hydrocyanic acid is 
water soluble and foods with high water content may become unfit 
for consumption after exposure to high concentrations of that 
agent. The effect of cyanogen chloride on foods is not known. As 
a precaution, foods exposed to the vapors of this material should be 
considered toxic. 
j. Meat from Gassed Animals. It may be necessary to use ani- 
mals for food after they have been exposed to liquid splashes of 125 
chemical warfare agents. Economics may justify the early 
slaughter of exposed animals before the effect of such exposure is 
shown. If such animals are slaughtered in the preliminary stages 
of poisoning and all tissues exposed to the gas (lungs, local areas) 
are discarded, there is no objection to the consumption of the meat, 
provided the animal passes an otherwise satisfactory meat inspec- 
tion. This is true even of animals poisoned by arsenical agents, 
since the edible tissue will contain amounts of arsenic too small to 
be toxic. Organs such as the liver, brain, heart, kidney, and lungs 
will contain relatively more arsenic than the musculature, and 
should be discarded. The meat should be well cooked. 
k. Forage and grain exposed to vapor contamination by chemical 
agents can be decontaminated by aeration. Supplies so treated, 
especially if mixed with larger amounts of uncontaminated sup- 
plies, produce no ill effects when fed to animals. Forage, which is 
heavily contaminated by liquid vesicants, especially arsenicals, 
should not be used. INDEX 
Paragraphs 
AC. (See Hydrocyanic acid.) 
Acid, boric, U.S.P. No. 1011000 9c(5); 36, app. V 
Adamsite. {See Diphenylaminechlorarsine-DM.) 
Ammonia. (See Incidental gases.) 
Amyl nitrite No. 1069000 30e(l) 
Amyl salicylate No. 9102700 2, app. Ill 
Anesthesia for chemical casualties 5d(8) 
Animal casualties 39-46 
Chlorine, symptoms and treatment 40d 
Chloropicrin, symptoms and treatment 40c 
Ethyldichlorarsine, injuries and treatment. 41 d 
Incendiary agents 44 
Incidental gases 46 
Lacrimators and irritant smokes 42 
Lewisite, injuries, decontamination, and treat- 
ment 41c 
Mustard, injuries, decontamination, and treat- 
ment 416 
Nitrogen mustard, injuries and treatment. . . . 41e 
Phosgene, symptoms and treatment 40a 
Screening smokes 43 
FM 43c 
FS 436 
HC mixtures 43d 
WP 43a 
Systemic poisons 45 
AC 456 
CK 456 
SA 45c 
Apron, impermeable No. 9903000 8c; oe, app. II, 3, 4, 
6, 7, app. Ill 
Arsine, (SA) (See Systemic poisons.) 
Atropine, No. 1086000 5d(8), 9e(3), 10/ 
(2) 
Atropine, sulfate (see Ophthalmic disks) No. 
9116300 96(4) 
BAL in oil, No. 1088500 He (3), 23d, 32c, 
41e(l); 4, app. 
Ill 
BAL ointment No. 9102800 96(1-4), 116(2), 
He(3), 41c(2); 
5d(2) app. II; 
1, 2, app. Ill 
126 127 
Barbiturates 5d(5), 9e(3) 
BBC. (See Brombenzyl cyanide.) 
B, B-dichlordiethyl sulfide, (See Mustard.) 
Blanket set, small case, empty No. 9747000 4, app. Ill 
Bleach paste 96(9), 9c(9), 416 
(2) 41c(2) 
Blister gases. (See Vesicants.) 
Blood and nerve poisons. (See Systemic poisons.) 
Boric acid ointment. (See Burns, treatment.) 
Brush, scrub No. 7459000 7, app. Ill 
Bucket, canvas, collapsible, No. 9914000 6, app. Ill 
Burns, treatment App. V 
Boric acid ointment 416(2); 36(1), 3c 
(3) app. V 
Fundamentals of treatment 2, App. I 
Glucose 3a(2), app. V. 
Isotonic saline 32c; 3c(2), app. V 
Morphine 5d(5), 96(4), 9d 
(3) 9e(3), 28; 
3a(4), 3c(2), 
app. V 
Penicillin, sodium No. 1606800 5d(6),96(4), (5), 
9c (8), 9d(3); 
3a(2), 3c(4), 
app. V 
Plasma 5d(8), 9e(3), lie 
(4) 28; 3a, 36 
(3), app. V 
Protein diet 3c (4), app. V 
Skin grafting 3c (4), app. V 
Sodium bicarbonate 5d(6), 9c(8), 32c, 
42, 436; 3a(2), 
app. V 
Sodium chloride 3a (1), app. V 
Sterile petrolatum, No. 1606800 96(4), 9c(5); 36 
(1) 3c(3), app. 
V 
Sulfadiazine 5d(6)(6), 9c(8), 
9d(3); 3a(2), 
app. V 
Sulfonamide 5d(6), 416(2); 3a 
(2) app V 
Tetanus antitoxin 3a(3), app. V 
Tetanus toxoid 3a (3), app. V 
Butyn sulfate No. 1108500 416 (2) ; 8, app. Ill 
Brombenzyl cyanide (BBC) 15a 
Calamine, concentrate, No. 9104800 2, app. Ill 
Lotion No. 910500 9c(4) ; 1, app. Ill 
Calcium hypochlorite, No. 9105300 7, app. Ill 
Carbon dioxide-oxygen mixtures 5d(3), 286(4), 34# 
Carbon monoxide. (See Incidental gases.) 
Cardiac stimulants 5d(8) 
Case, utility, canvas, empty, No. 9751500 6, app. Ill 
Paragraphs 128 
Casualty agents 2c (1) 
Casualties, principles in handling of App. II 
Choking gas casualties 6t, app. II 
Decontamination of wounded 4, app. II 
Detailed procedure for receiving contam- 
inated casualties 5d, app. II 
Objectives desired 3, app. II 
Rear zone contaminated casualties 6, app. II 
Reception of contaminated casualties 5, app. II 
Responsibility of medical facilities 2, app. II 
Vesicant gas contaminated casualties 5, app. II 
Chemical agent, contamination of food, forage 
and grain App. VII 
Chemotherapy 5d 
Phosgene 5 d(6) 
Chloracetophenone (CN) 2a(3), 15 
Solution CNB 15 
Solution CNS 15 
Chlorine 4a, 7 
Diagnosis 7 
Pathology 7 
Prognosis 7 
Symptoms 7 
Treatment 7 
Chloroform No. 9105800 , 17d 
Chloropicrin (PS) 4a, 6 
Diagnosis 6c 
Pathology 6a 
Prognosis 6e 
Symptoms 65 
Treatment Qd 
Chlorovinyldichloroarsine. (See Lewisite.) 
Choking gases. (See Vomiting gases.) 
CK. (See Cyanogen chloride.) 
Cl. (See Chlorine.) 
Classification of agents 2 
By persistency 26 
By physiological action 2a 
By tactical use 2c 
Codeine 5d(5) 
Cod liver oil ointment 416(2) 
CN (See Chloracetophenone) 
Combustible metal incendiaries. (See Thermite 
and magnesium.) 
Combustible oil incendiaries. (See Oil incendi- 
aries.) 
Container, for kit, first aid, gas casualty, No. 
9766300 1, app. Ill 
Contaminated clothing and equipment, care at 
medical installations App. IV 
Apron, protective impermeable No. 9903000 4, app. Ill, 6, app. 
IV 
Care of litters 13, app. IV 
Paragraphs 129 
Decontamination of aprons Gd, app. IV 
Decontamination of blankets and permeable 
protective clothing 19, app. IV 
Decontamination of gas masks, web, canvas, 
and leather equipment 12, ap. IV 
Decontamination of impermeable rubber 
gloves 11, app. IV 
Disposition of contaminated clothing and 
blankets 3, app. IV 
Disposition of contaminated gloves and 
aprons 7, app. IV 
Notification of salvage officer 4, app. IV 
Procedure for removal of the protective 
apron Gd, app. IV 
Removal of contaminated clothing and 
equipment 2, app. IV 
Replacement of contaminated blankets . 5, app. IV 
Replacement of contaminated gloves and 
aprons 8, app. IV 
Copper sulfate 
Powder No. 9107300 2, app. Ill 
Solution No. 9107500 27, 43a(2) ; 1, app. 
Ill 
Cupric sulfate No. 1161500 8, app. Ill 
Cyanogen chloride (CK). (See Systemic poi- 
sons.) 
DA. (See Diphenylchlorarsine.) 
DB:i reagent. (See Water contamination-analyti 
cal processes.) 
Decontamination of— 
Aprons 10, app. IV 
Canvas 12, app. IV 
Eyelashes and lids 95(3) 
Food, forage and grain 5, app. VII 
Gasmask 12, app. IV 
Leather 12, app. IV 
Rubber gloves 11, app. IV 
Web 12, app. IV 
Diet, protein. {See Burns, treatment.) 
Diphenylaminechlorarsine (DM) (Adamsite) . .2a(4), 17 
Diphenylchlorarsine (DA) 18 
Diphenylcyanarsine (DC) 18 
Disposition of personnel with vesicant burns . App. I 
Analysis of burns 1, App. I 
Cutaneous injury 4, app. I 
Arms 4c, app. I 
Burns caused by exposure to high dos- 
ages 45(3), app. I 
Burns caused by exposure to low dosages45 (4), app. I 
Casualty criteria 4, app. I 
Extensive vesication of the trunk 45(1), app. I 
Genitalia 4/, app. I 
Hands 4d, app. I 
Paragraphs 130 
Paragraphs 
Localized vesication of the trunk 46(2), app. I 
Lower extremities 4e, app. I 
Sensitization due to multiple exposures 
of mustard 46(5), app. I 
Trunk and neck 46, app. I 
Definition of casualty and non-casualty 4, app, I 
Eye Injuries 2, app. I 
Disposition of eye patients 2a, app. I 
Droplets 2d, app. I 
Mild injury 2c, app. I 
Moderate injury 2c, app. I 
Severe injury 2c, app. I 
Respiratory effects 3, app. I 
Laryngeal involvement 3/, app. I 
Latent period 3c, app. I 
Lesions produced by low and high con- 
centrations 36, app. I 
Lung parenchyma 36, app. I 
Mucous membrane 3a, app. I 
Nasal changes 3d, app. I 
Pharynx 3c, app. I 
Trachea and bronchi 3g, app. I 
Secondary bacterial infection 6, app. I 
Disabling sites 6e, app. I 
Evacuation 6d, app. I 
Manifestation 6c, app. I 
Occurrence 6c, app. I 
Respiratory tract effects 6/, app. I 
Secondary infection in mustard con- 
junctivitis Gg, app. I 
Systemic effects 5, app. I 
Duration 5a, app. I 
Evacuation 5c, app. I 
Mental Depression 56, app. I 
DM. {See Diphenylaminechlorarsine.) 
ED. (See Ethyldichlorarsine.) 
Effect of weather conditions on chemical agents. 9a 
Epinephrine hydrochloride 23d 
Ethyldichlorarsine (ED) 12 
Decontamination 12e 
Diagnosis 12d 
Pathology 126 
Prognosis 12g 
Properties 12a 
Symptoms 12c 
Treatment 12/ 
Expectorants, phosgene 5d(7) 
Eye, Irrigation of the. (See Mustard and lew 
isite, eye.) 
Eye and Nose Drops No. 9109100 6d, 96(4), 9d(3), 
15c(2) 22e; 1, 2, 
app. Ill 131 
Eye solution BAL No. 9109525 llc(5) ; 1, 2, app. 
Ill 
Fluorescein disks. (See Ophthalmic disks.) 
FM. (See Titanium tetrachloride.) 
Food and forage contamination App. VII 
Food contamination ' . App. VII 
Occurrence of contamination 1, app. VII 
Prevention of contamination 16, app. VII 
Protection against contamination 3, app. VII 
Reclamation of contaminated food 5, app. VII 
Storage of food to prevent contamination . . , 4, app. VII 
Susceptibility to contamination 2, app. VII 
Forage and grain contamination 5k, app. VII 
Decontamination of contaminated forage and 
grain 5k, app. VII 
Liquid contamination of forage and grain 5k, app. VII 
Use of contaminated forage and grain 5k, app. VII 
Fundamentals of first aid and treatment (See 
also Burns, treatment.) 3 
Clothing 3a(2) (c) 
Eyes 3a(2) (a), (b) 
Skin 3a(2) (d) 
Gas casualty case, aprons and gloves, No. 
9775800 4, app. Ill 
Gas casualty set, veterinary 7, 8, app. Ill 
Case, aprons No. 9815500 6, app. Ill 
Chest, “A” complete, No. 9815600 7, app. Ill 
Chest, “B”, complete, No. 9815700 8, app. Ill 
Chest, empty, No. 9815800 7, app. Ill 
Gentian violet powder No. 1213500 416(2); 8, app. Ill 
Gloves, impermeable, No. 9926300 4, app. Ill 
Glucose, (See Burns, treatment.) 
Gutzeit method. (See Water contamination, ar- 
senicals.) 
H. (See Mustard.) 
Halazone tablets. (See Water contamination- 
analytical processes.) 
Harrassing agents 2c(2) 
HC mixture. (See Screening smokes.) 
HCN. (See Systemic poisons.) 
Hydrocyanic acid (AC). (See Systemic poisons.) 
Hydrogen sulfide. (See Incidental gases.) 
Incendiary agents 2c(3), (4), 24-28 
Protection 25, 26, 27, 286(3) 
Treatment 25, 26, 27, 286 (4) 
Incidental gases 33-37 
Diagnosis 34e, 35e 
Occurrence 346,356,376 
Pathology 34c, 35c, 366, 37e 
Paragraphs 132 
Paragraphs 
Prognosis 34h, 35g, 36e, 37/ 
Properties 34, 34a, 36a, 37a 
Protection 34/ 
Symptoms .34d, 35d, 36c, 37d 
Treatment 34g, 35/, 36d, 37e 
Irritant smokes. (See Vomiting gases.) 
Isotonic saline. (See Burns, treatment.) 
Kit 
First aid, gas casualty, No. 9776400 1, app. Ill 
Treatment, gas casualty, No. 9776700 2, app. Ill 
Container, No. 9776800 2, app. Ill 
Water testing, screening, No. 9931000 (See 
also Lewisite.) 2, app. Ill 
Lacrimators 15-17 
Eyes 2a (3), 15c (2) 
First aid 15c (1) 
Skin 15c (2) 
Symptoms 156 
Treatment 15c(l),(2) 
Lewisite (L) 11 
Decontamination 116(2), 11c (4), 
(5) 
Eye 116 
Pathology 116(1), 11c (2), 
lle(l), (2) 
Prognosis 116(1), 11c (3), 
lld(2), (3) lie 
(2) 
Respiratory tract lid 
Skin 11c 
Symptoms 116(1), llc(l), 
lld(l), lie(1) 
Systemic effects lle(l) 
Treatment 116(2), llc(6)~ 
(11), lld(2), 
lle(3) 
Lung edema. (See Pulmonary edema.) 
Lung irritants. (See choking gases.) 
Lyster bag. (See water contamination-purifica- 
tion of contaminated water.) 
Magnesium and its alloys. (See Incendiary 
agents.) 
MG. (See Protective ointment.) 
Medical department items App. Ill 
Mixed blister gases 14 
Decontamination 146 (1) 
Eyes 146(1) 
Skin ’ 146(2), 14c(2) 
Treatment 14c(l), (2) 
Typical mixtures 14a 133 
Paragraphs 
Morphine. (See Burns, treatment.) 
Mustard (H) 2a(2),2c(1),9 
Decontamination 96(2), (3), 9c(9) 
Diagnosis 9c (3) 
Eye 8a, 96 
Pathology 96(1), 9c (1), 9d 
(1) 9e(2) 
Prognosis 9e(4) 
Properties 9a 
Respiratory tract 8a, 9d 
Skin 8a, 9c 
Symptoms 96(1), 9c(2), 9d 
(2) 9e(l) 
Systemic and gastrointestinal 9e 
Treatment 9c(4)-(7), 9d(3), 
9e (3) 
Nitrogen mustards (HN) 10 
Decontamination 106 (2), 10c (2) 
Diagnosis f 10/(4) 
Eye 106 
Gastrointestinal tract 10c 
Prognosis 106(3), 10c(3), 
10d(4),10/(3) 
Respiratory tract lOd 
Skin 10c 
Symptoms and pathology 106(1), 10c (1), 
10d(l),(2),10/ 
(1) 
Systemic effects 10/ 
Treatment 106(2), 10d(3), 
10/(2) 
Nitrous fumes. (See Incidental gases.) 
Nonpersistent agents 26(2) 
Nose and eye drops No. 9109100. (See Eye and 
nose drops.) 
Nose gases. (See Vomiting gases.) 
Oil inceniaries. (See Incendiary agents.) 
Ointment protective. (See Protective ointment.) 
Ophthalmic disks, fluorescein and atropine sul 
fate, No. 9116300 96(4), (9), 106 
(1), 22c; 2, app. Ill 
Orthotolidine. (See Water contamination-analy- 
tical processes.) 
Oxygen deficiency 38 
Acclimatization 38c 
Prognosis 38c 
Symptoms 386 
Treatment 38d 
Oxygen therapy 5d (3), 406(2) 
Apparatus 5c?(3) 
Apparatus, closed circuit, No. 9364000 9, app. Ill 134 
Outfit, 20 dual outlet, hose line assembly, 
No. 9364200 10, app. Ill 
Packboard, No. 9778700 3, app. Ill 
Pad, cotton, No. 9211800 1, app. Ill 
Penicillin, {See Burns, Treatment.) 
Persistent agents 26(1) 
Petrolatum sterile. (See Burns, treatment.) 
Phenyldichlorarsine (PD) 13 
Action 13ft 
Pathology 13c 
Properties 13a 
Symptoms 13d 
Treatment 13e 
Plasma. {See Burns, treatment.) 
Phosgene 2a, 2c(1), 4a(5) 
Convalescent care 5e 
Diagnosis 5c 
Pathology 5 a 
Prognosis * 5/ 
Symptoms 5 ft 
Treatment 5d(l)-(8) 
Potassium permanganate, No. 1372200 40ft (2); 7, app. Ill 
Protective ointment, No. 9118700 9c (9), 10c(2), 11c 
(5) 416; 1, 2, 
app. Ill 
PS. {See Chloropicrin.) 
Pulmonary edema 4a, 5a, 5d, 6a, 7, 
35c, 366, c, d, 
37c, e 
Treatment 5d 
Venesection 5d(4), 406(2) 
Pulmonary irritants. {See Lung irritants.) 
Respiratory stimulants. {See also Arsine.) ..,5d(8) 
Screening smokes 19-23 
Pathology 21a, 22a, 236 
Prognosis 21d, 22d, 23e 
Symptoms 21ft, 226, 23c 
Toxicity 23a 
Treatment 21c, 22c, 23d 
Sedation, phosgene 5d(5) 
Set, gas casualty, M2, No. 9775600 3, app. Ill 
Soap, white floating, No. 7493000 8, app. Ill 
Sodium bicarbonate. {See Burns, treatment.) 
Sodium chloride. {See Burns, treatment.) 
Sodium nitrite 30e(l) 
Sodium sulamyd, No. 9120300 96(4), 96(5); 2, 
app. Ill 
Sodium thiosulfate, No. 1449500 30 
Solvents, mustard 9c (9) 
Sternutators. {See Vomiting gases.) 
Paragraphs 135 
Paragraphs 
Sulfadiazine. (See Burns, treatment.) 
Sulfonamides. (See Burns, treatment.) 
Sulfathiazole ophthalmic ointment No. 1464000. . 96 (4), (5) 
Sulfur trioxide-chlorsulfone acid (FS). (See 
Screening smokes.) 
Syringe, water, No. 5597000 8, app. Ill 
Systemic poisons( blood and nerve) 2a(5), 29-32 
Diagnosis 30d 
Pathology 305,316,326 
Prognosis 31e 
Properties 30a, 31a, 32a 
Symptoms 30c, 31c 
Treatment 30e (1), 31d 
Tannic acid 416(2) 
Tear gases. (See lacrimators.) 
Tetanus antitoxin. (See Burns, treatment.) 
Tetanus toxoid. (See Burns, treatment.) 
TH. (See Thermite.) 
Thermite (TH), (See Incendiary agents.) 
Titanium tetrachloride. (See Screening smokes.) 
Unite medical equipment pack, empty No. 
9792300 3, app. Ill 
Venesection. (See Pulmonary edema.) 
Vesicants 2a(2), 8-14 
Vomiting gases (Nose gases, irritant smokes, 
sternutators) 2a(4), 16-18 
Diagnosis 17c, 18 
Pathology 17a, 18 
Prognosis 17e, 18 
Respiratory tract 166 
Symptoms 166, 176, 18 
Treatment 17d, 18 
Water contamination App. VI 
Action required if contaminated by chemical 
agents 5, app. VI 
Action required if contaminated heavily by 
chemical agents 9, app. VI 
Action of chemical agents with water 3, app. VI 
Agents, important 16, app. VI 
AC 16, app. VI 
CK 16, app. VI 
H 16, app. VI 
PIN , 16, app. VI 
L 16, app. VI 
Analytical processes involved in the detec- 
tion of water contamination 4d, app. VI 
Arsenicals 4d, app. VI 
Chlorine demand 4d, app. VI 
CK 4d, app. VI 136 
Paragraphs 
H 4d, app. VI 
HN 4c?, app. VI 
pH 4d, app. VI 
Detection 4d, app. VI 
Interpretation of analytical tests 4d(5), app. VI 
Limitation of tests 2, app. VI 
Toxic limits of contaminated water 2, app. VI 
Use of suspected water 7, app. VI 
White phosphorous (WP). (See Incendiary 
agents.) 
White phosphorus. (See Screening smokes.)