Medical Aspects of Chemical Warfare (2008) - The Black Vault

Medical Aspects of Chemical WarfareINTRODUCTIONMuch that is known today about the medicalmanagement of chemical casualties resulted fromexperience with the large number of chemical casualtiesmanaged during World War I. However, becausechemicals have scarcely been used on the battlefieldsince then, the US armed forces have yet to apply thechemical lessons learned from that war on a large scale.This chapter continues the series of history chapters inthis textbook begun in Chapter 2, History of ChemicalWarfare, which provides a detailed history of chemicalweapons in World War I and subsequent incidentsof their use on the battlefield, which gave rise to thecasualties discussed here. Chapter 4, History of theChemical Threat, Chemical Terrorism, and Its Implicationsfor Military Medicine, will provide further insightinto the subject.Integrating the specifics of chemical casualty supportwithin general medical and surgical supportinvolves numerous command and staff actions. Theseactions interface at all command echelons and with allcomponents of a commander’s staff. For example, theability to train the appropriate number of personnelinvolves personnel actions, and knowing what medicalmateriel needs to be emplaced requires gatheringmedical intelligence.World War I provided insight intohow to manage all aspects of medical support in theevent of a chemical attack. Specialty care personnel,physicians, nurses, and first responders required training,and how these trainees performed in the theater ofcombat required operations and planning action.The medical logistics portion of a unit suppliestrained troops with the specific tools and equipmentto perform their specialty missions. None of these staffactions can exist without the establishment, direction,and supervision of leadership elements throughoutevery echelon of military organization. However, theinitial management of chemical casualties did notalways have the defined leadership and staff actionsit does currently; the management process has beenrefined as the nature of chemical warfare and its resultingcasualties have evolved over time. Because militaryphysicians base treatment regimens on both the qualityand quantity of the anticipated combat injuries,the main focus of this chapter is World War I, whenorganized paradigms were first developed to handle apotentially massive influx of chemical casualties.HISTORY until World War IAlthough historians do not agree on what devicesshould be considered the first chemical weapons, thesigns and symptoms of weapon-induced pathologywere documented long before World War I. From theearliest times, physicians managed natural “chemical”casualties. Animal and plant agents, such as jellyfish;man-o-wars; spitting snakes; skunks; poison ivy, sumac,and oak; and stinging nettles provided physicianswith a variety of casualties and clinical presentations. 1,2Around the recorded times of early Troy (1200 b c e),weapons such as arrows were wrapped with flammableplant fibers (flax, hemp, or straw) and set afire, andmilitary physicians used appropriate medications andtherapies to treat the resulting injuries. 3 The Chineseused arsenic and sulfur tactically during 1000 to 700b c e to produce irritating fogs, fumes, and poisonoussmoke balls that affected soldiers’ airways. One specificconcoction that called for aconite root, wolfsbane,and croton bean engendered blisters and pustules inairways and on skin surfaces. 3 As a result, casualtytypes broadened from pulmonary and respiratory todermatological (vesicant).Around 600 b c e Solon documented that helleboreroots thrown into a river gave rise to profuse diarrhea,forcing military physicians to manage the resultingsevere dehydration without intravenous fluid resuscitation.3 In History of the Peloponnesian War, Thucydidesdescribed chemical warfare and the types of casualtiesit produced during the 5th-century b c e conflictbetween Athens and Sparta. Thucydides tells howSparta’s allies, the Boethians, took an Athenian fort atDelium in 424 b c e with an engine filled with lightedcoals, sulfur, and pitch, which made a great blaze andset fire to the fort walls. The defenders abandoned thefort, leaving pulmonary casualties in need of medicaltreatment. 4 Later, Romans used mucous-membraneirritants against the Ambracians, allies of Corinth, during193 to 189 b c e. The medical management of thesecasualties undoubtedly involved removing them fromirritant sources and flushing irritated surfaces withcopious amounts of water. In the 9th century c e, LeoIX of Byzantium, writing on warfare, described handthrown“vases filled with quicklime,” the effects ofwhich had been known since the Peloponnesian War.Quicklime was one of three combustible substancesknown in the Mediterranean at that time (the othertwo were sulfur and pitch). When broken, the vasesof quicklime let loose an overpowering odor that suffocatedanyone nearby. 5From that point onward, various types of chemicalweaponry were engaged. Over time, military physiciansdeveloped the most effective leadership, stafforganization, and curative techniques to maintain theeffectiveness of the fighting force during and following78