21st Century Textbooks of Military Medicine - Medical Aspects of Chemical Warfare - Nerve Agents, Incapacitating Agents, Riot Control, Toxins, Defense, Decontamination (Emergency War Surgery Series)
U.S. Military, Department of Defense, U.S. Army, Borden Institute, Surgeon General
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MEDICAL ASPECTS OF CHEMICAL WARFARE
Published by the Office of The Surgeon General Department of the Army, United States of America and US Army Medical Department Center and School Fort Sam Houston, Texas
Foreword
The US military has been concerned with the risk of chemical warfare for decades. By the end of the twentieth century, however, scenarios for the use of chemical weapons expanded beyond the battlefield as terrorist organizations began employing them against civilian populations. This development is not surprising, given that a great percentage of the world's population now has the ability and knowledge to develop weapons of mass destruction, particularly chemical weapons.
In 1995, Aum Shinrikyo, a well-funded Japanese religious cult with chemical expertise, released sarin, a deadly nerve agent, in five separate subway cars in downtown Tokyo. The attack not only caused panic, but also overwhelmed the medical response system. In Baghdad, Iraq, on May 18, 2004, a small amount of sarin was dispersed by a shell that exploded near a US military convoy, and on April 6, 2007, a chemical, first weaponized during World War I, reappeared when a suicide bomber in Baghdad detonated a truck loaded with chlorine gas, killing 20 people and wounding 30 others.
Although the events of September 11, 2001, did not involve chemical weapons, they did underscore terrorists' willingness to use unconventional weapons and shocked the United States into awareness of its own vulnerability to terrorist attacks. The use of chemical agents by terrorist groups is now a recognized threat to the American population and to US troops deployed abroad. We know terrorist groups have the knowledge and the financial support to design and disperse chemical weapons. Also, as our world becomes more highly industrialized, chemicals, some of which are highly toxic, are used in numerous manufacturing processes; the world's population is at risk of exposure to these lethal chemicals through their inadvertent release from manufacturing plants and accidents during their transportation or intentional release by terrorists.
Medical Aspects of Chemical Warfare is the most comprehensive source of information available on chemical agents. This text is strongly recommended reading for all military medical personnel. It should be placed in the reference libraries of every military medical treatment facility. It will serve to both enhance the knowledge and skills, and increase the level of preparedness and response capability, of those responsible for chemical casualty care. Many civilian medical professionals will also find this textbook to be a valuable reference as their hospitals prepare for the possibility of treating casualties of an accidental or deliberate exposure.
Lieutenant General Eric B. Schoomaker
The Surgeon General * US Army * Washington, DC * January 2008
PREFACE
A significant concern for the United States and its allies is that an ever-growing number of terrorist organizations will employ chemical warfare agents in an attack on military forces or civilians. As a result, efforts to prepare for such an attack have expanded and are now supported by the Department of Health and Human Services and Department of Homeland Security, as well as the Department of Defense.
Since its initial publication in 1997, this textbook has provided military physicians, nurses, physician assistants, and medics with the knowledge and skills to medically manage chemical agent casualties. This expanded second edition will not only continue to be an essential reference tool for military personnel, but should also become a requisite guide for civilian healthcare providers, first responders, and government agencies responsible for emergency preparedness, response, and management.
I would like to offer my sincere thanks to the physicians, nurses, scientists, and support personnel who have contributed to this textbook either directly or indirectly. These professionals are recognized worldwide and are the foremost experts in the medical aspects of chemical warfare. Their overall goal is to provide the medical force with the understanding of the chemical agent threat, how to respond, and how to deliver quality chemical casualty care.
Major General George Weightman
Medical Corps, US Army
Commanding General, US Army Medical Research and Materiel Command
Fort Detrick, Maryland
January 2008
PROLOGUE
The original edition of Medical Aspects of Chemical and Biological Warfare has been a tremendous resource for the past 10 years. Much has transpired, however, since its publication; in particular the terrorist attacks of September 11, 2001. As a result, this revised edition covers solely chemical warfare, and information on biological warfare is now published in a separate volume. Also, while the earlier edition focused on medical management of patients, a conscious effort was made in this edition to include discussions of cutting-edge science that has led to significant medical therapeutic advances.
This expanded edition covers four themes: (1) the history of chemical warfare; (2) medical diagnosis and treatment for chemical casualties; (3) the mechanisms and science behind treatments and advances in therapy; and (4) homeland security. The book addresses innovative new technologies, such as nerve agent bioscavenger enzymes, as well as advances in personal decontamination, wound healing, protective equipment, and more.
I would like to recognize and thank Lieutenant Colonel Shirley D Tuorinsky of the Army Nurse Corps, who served as the senior editor for this book. Her 2 years of thoughtful and relentless effort have resulted in a quality product of which we can all be proud.
Colonel Timothy K. Adams Veterinary Corps, US Army Commander, US Army Medical Research Institute of Chemical Defense
Fort Detrick, Maryland
February 2008
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Chapter 1 - INTRODUCTION TO THE CHEMICAL THREAT
THOMAS B. TALBOT, MD*; BRIAN LUKEY, PhD+, and GENNADY E. PLATQFF Jr, PhD*
Introduction * A TIMELINE OF CHEMICAL WARFARE AGENTS * Early Chemical Weapons From the Cold War to Disarmament * The Current Age * The Current Threat Of Chemical Proliferation * Managing the Stockpile * The Terrorist Threat * The Future Chemical Threat * Joint Medical Lifecycle Management * The Role Of The US Army Medical Research Institute Of Chemical Defense * Development of Medical Countermeasures * Education and Educational Products
Introduction
It has been nearly 90 years since the United States Armed Forces last encountered chemical weapons on the battlefield. Despite this long respite, images of poisonous chemical clouds and descriptions of sudden and horrifying death continue to foment apprehension and terror. The mention of chemical weapons elicits outrage and fear of the unknown. Soldiers confronted with even a nonspecific threat of a chemical environment must bear the inefficiencies of cumbersome and hot protective garments. Medical personnel face an unseen pathogen and the prospect of managing mass chemical casualties they are inexperienced in treating.
Chemical weapons are a classic model of weapons of mass destructive effect that result in substantial contamination of personnel and equipment. Chemical weapons are the original weapons of mass destruction, and they are ideally suited as agents of great psychological effect. Although the law in the United States prohibits using chemical weapons against an adversary, this policy is not shared by all nations or by nonstate entities; therefore, to be effective, military medical personnel must be knowledgeable and trained to deal with a chemical weapon attack.
In a chemical environment, military healthcare providers must be:
• prepared to handle military and civilian casualties resulting from chemical agents;
• cognizant of what constitutes a chemical threat and the military tactics that could be employed against the force because they may be called on to render advice from both individual and public health perspectives;
• familiar with the acute and chronic medical effects of chemical agent exposure in order to plan appropriate medical support; and
• knowledgeable of the diagnostic tools available to identify specific chemical agents to which their patients may have been exposed and aware of the most effective treatments for acute intervention and prevention of long-term sequelae.
The chemical threat may involve overt or clandestine use of single or multiple agents. Some of these may be classic chemical agents developed for military applications. Other agents may be highly toxic industrial compounds that are produced in great quantities and can have comparable effects; increased interest in the training, education, and research of toxic industrial compounds is now emphasized in both the military and civilian populations. Additionally, the advent of more formidable nonstate entities and terrorist organizations interested in the mass lethality and the powerful psychological effects of these agents has resulted in an increased concern for the potential use of chemical weapons.
Chemical warfare agents need not be lethal to be disruptive. The resultant mass casualty scenario, psychological effects, diversion of medical resources, need for decontamination, and impairment of fighting ability are all desirable outcomes for those that might deploy these agents. In a situation where there are few physical indicators of a chemical attack, the medical practitioner may be the first to recognize the effects of chemical exposure. An increased incidence of symptoms consistent with nerve, vesicant, blood, or respiratory agent exposure should raise immediate suspicion of poisoning. Healthcare providers must be familiar with the signs and symptoms of a chemical exposure or the possibility of the combined use of chemical and biological warfare agents in both military and civilian settings.
The offensive use of chemical agents continues to be an attractive alternative to some nations and nonstate entities. One reason for this is that chemical agents can be dispersed over large areas and can penetrate well-defended positions. They can be employed against specific targets (eg, headquarters control centers) with effects that include delayed or immediate incapacitation, disorientation, or death.
The goal of this chapter is to provide an encapsulated historical overview of chemical weapons, discuss the current chemical threat, and guide readers in the organization of this textbook.
A TIMELINE OF CHEMICAL WARFARE AGENTS
Early Chemical Weapons
The modern era of chemical weapons began during World War I with the 1915 introduction of chlorine gas on the battlefield of Ypres, Belgium. Chemical weapons were effective in this theater because of the fixed positions of highly concentrated troop formations. Initial lethal weapons of concern included pulmonary agents such as chlorine and phosgene, for which countermeasures were initially inadequate or nonexistent. As the use of chemical weapons increased, the gas mask was developed as an initial countermeasure. The mask was refined and improved upon during the course of World War I, and newer models are still being developed today.
The use of mustard agent during World War I was ultimately responsible for the majority of casualties from the war. By targeting the skin, eyes, and lungs, mustard rendered a large number of soldiers ineffective as part of the fighting force. The grotesque pattern of injury that resulted from exposure had a major psychological impact, demonstrating that a chemical weapon need not be lethal to be strategically effective. During this period, mustard agent became known as "the king of war gases."
In 1918 lewisite was produced in the United States, but large-scale production and stockpiling came too late for it to be used in the war. However, lewisite eventually became the primary vesicant stockpiled by the Soviet Union. Meanwhile in France and Austria, experiments with cyanide produced mixed results. Cyanide was novel because it produced nearly instant incapacitation and was highly lethal. However, its non-persistent properties and low specific gravity made it unsuitable for the open field and trench environment of the day.
By World War II, Germany had made tremendous progress with the innovation of agents toxic to the nervous system. The G-series nerve agents, such as tabun (North Atlantic Treaty Organization [NATO] designation: GA) and sarin (NATO designation: GB), featured the instant incapacitation and lethality of cyanide and were effective at much lower concentrations. The G-series agents also had superior dispersal characteristics. These new nerve agents were not used during the war, though, and the Allies discovered them and developed countermeasures only after the conflict.
From the Cold War to Disarmament
During the Cold War, the United Kingdom invented the V-series nerve agents, which were weaponized by the United States and Soviet Union. V-series nerve agents are toxic in even smaller doses than G agents and are persistent in the environment. They were considered an ideal area denial weapon by both the western powers and the Eastern Bloc.
The 1960s was a period of experimentation using incapacitating and psychedelic agents that impaired combat performance without being lethal. During the 1970s and 1980s, the Soviet Union continued to increase the size of its chemical stockpile and initiated a massive program named "Foliant" to produce newer and deadlier agents.
During the Reagan administration, the United States produced a binary chemical weapon deterrent. Binary weapons are chemically identical to traditional nerve agents, but differ in that the final chemical reaction occurs only after a projectile is fired, allowing safe storage and transportation of the weapon.1 Simultaneously, during the Iran/Iraq war, mustard agent returned to the battlefield, and an incapacitating agent similar to 3-quinuclidinyl benzilate (often called "BZ," a glycolate anticholinergic) named "Agent 15" was developed.
The Current Age
The results of the 1993 Paris Convention, known as the "Chemical Warfare Convention," were in effect by 1997 and resulted in a period of disarmament by nation-states. Meanwhile, terrorist organizations developed interests in chemical weapons and had some success in producing and employing them. The most recent public application of chemical warfare occurred in 2002 at the Nord-Ost Moscow theater. In an attempt to free 850 hostages being held by Chechen rebels, the Russian government used a supposedly opiate-based incapacitating agent called Kolokol-1, which resulted in the deaths of 42 terrorists and at least 129 hostages. Another concerning development was noted when dissident scientist Vladimir Mirzayanov publicly stated that his country was circumventing the Chemical Warfare Convention by developing a new generation of nerve agents.2-4
Readers interested in more information on the historical aspects of chemical warfare can find the information in chapters 2 through 4. These chapters offer a thorough review of the history of chemical warfare, the medical management of chemical casualties, and the chemical threat.
THE CURRENT THREAT OF CHEMICAL PROLIFERATION
The Chemical Warfare Convention now includes 181 signatory countries.5 Since it became effective in 1997, some progress destroying large chemical arsenals has been made.
Managing the Stockpile
The global declared stockpile of chemical weapons is about 70,000 tons. Of this, the stockpile declared by the United States is 30,599 tons of unitary agent and 680 tons of binary components.6 As of 2007, about half of the US stockpile has been destroyed: two of seven chemical demilitarization facilities have completed their destruction missions.7 Russia has had a more difficult time destroying its declared 40,000 tons of agent, which consists largely of nerve agent and lewisite.8 The reportedly poor security of storage facilities and the very slow pace of demilitarization pose a challenge for both Russia and the international community.9 These conditions may present an unintended proliferation risk.10 Further details about the global stockpile and demilitarization are presented in Chapter 4.
The Terrorist Threat
It is well known that terrorists have a strong interest in chemical weapons. For example, in 1995 several followers of the Aum Shinrikyo cult carried out a nerve agent attack with sarin in the Tokyo subway system. The media has reported that Al Qaeda and its operatives have also had a fascination with weapons of mass destruction, including chemical weapons. Of particular concern are revelations that Al Qaeda had plans to employ cyanide devices against civilians in New York City subways.11 Several cyanide plots have been thwarted prior to execution, yet plans for a crude but potentially effective cyanide dispersal device have been posted on jihadist Web sites since 2005.12 Because the next chemical attack may occur in the civilian arena, there are implications for both the civilian first responder and for the armed forces. The military may be called upon for consultation or response in such a situation, making it necessary for it to work with civilian populations.
The Future Chemical Threat
There are myriad toxic chemicals that could be considered agents of concern for the future chemical threat. Also, the possibility that existing classes of agents may be enhanced for more lethal effects must always be considered so that countermeasures are developed. The potential future chemical threat is as wide ranging as an adversary's imagination and budget allow.
JOINT MEDICAL LIFECYCLE MANAGEMENT
In 2003 the US Army was made the executive agent for the chemical/biological program to coordinate and integrate all research, development, and acquisition programs for all the services. As of 2007 the program includes the Joint Program Executive Office (JPEO), the Joint Science and Technology Office, the Joint Test and Evaluation Executive Office, the Joint Combat Developer, and the Joint Requirements Office. These offices are dedicated to delivering joint fighting capabilities, including medical treatment.
To counter the chemical threat, sustain combat power, and maintain a healthy force, the military established the JPEO in April 2003. The JPEO integrates a systems approach to address agent delivery, doses on target, downwind dispersal, dose absorbed, and symptoms. The Chemical Biological Medical Systems Joint Project Management Office is specifically responsible for medical systems. It addresses chemical casualty medical pretreatment and posttreatment, medical surveillance, and medical diagnostics to counter the threat and leverage the joint services research and development programs for combat personnel.
The Chemical Biological Medical Systems Joint Project Management Office is responsible for developing, procuring, fielding, and sustaining premier medical protection and treatment capabilities against chemical and biological warfare agents. Medical products are submitted through the US Food and Drug Administration for licensing or approval. The management office is composed of a headquarters and support element and two joint product management offices: the Joint Vaccine Acquisition Program (which focuses on developing, testing, producing, and storing vaccines) and Medical Identification and Treatment Systems.
Medical Identification and Treatment Systems manages the development, acquisition, and fielding of products used for the prophylaxis, treatment, and diagnosis of chemical and biological warfare agent exposure in US service members. Medical Identification and Treatment Systems products range from specific hardware devices that enable medical personnel to diagnose biological warfare agent exposure to drugs that prevent or mitigate the actions of chemical or biological agents.
Science and technology (research and development) is overseen by the Defense Threat Reduction Agency chemical/biological directorate. The Defense Threat Reduction Agency must interact at many levels, including with the executive agent or the Army acquisition executive (who takes direction from the defense acquisition executive), the Joint Requirements Office (which addresses user community needs and requirements), the deputy assistant to the secretary of defense for chemical and biological programs (which provides program oversight), the Joint Staff, the US Army Chemical School, the joint program managers, and the JPEO. The medical mission of the Defense Threat Reduction Agency is to safeguard America and its allies from weapons of mass destruction (chemical, biological, radiological, nuclear, and high-yield explosives) by providing medical capabilities to reduce, eliminate, and counter the threat and mitigate its effects. The Defense Threat Reduction Agency manages the medical research and development programs and funding, including the Department of Defense medical missions at the US Army Medical Research Institute of Infectious Diseases and the US Army Medical Research Institute of Chemical Defense (USAMRICD).
THE ROLE OF THE US ARMY MEDICAL RESEARCH INSTITUTE OF CHEMICAL DEFENSE
USAMRICD is the lead Department of Defense laboratory dealing with the medical aspects of chemical defense. It focuses on medical research, training, and education for medical chemical defense. USAMRICD activity involves basic research, clinical studies, therapeutics, and other areas of research. USAMRICD also partners with major military and civilian organizations throughout the country and abroad.
Development of Medical Countermeasures
USAMRICD builds on basic research to support soldiers through the development of medical counter-measures and therapeutics. Current projects include the use of both simple and catalytic bioscavengers for prophylaxis and treatment of nerve agent casualties. Additional research areas of interest include the new oximes and neuroprotective compounds that mitigate the effects of nerve agent exposure. Studies investigating the use of midazolam as a new generation nerve anticonvulsant are in advanced stages. There is an increase in medical vesicant research to identify the specific biochemistry of injury as well as to develop novel protectants and treatments. Cyanide and pulmonary agent research has been increasing in pace as well. Other work at USAMRICD involves developing medical diagnostics and personnel decontamination research. Work on equipment and detection gear is conducted by USAMRICD's partner institute, the Edgewood Chemical Biological Center.
Education and Educational Products
The chemical casualty care division is responsible for training military medical personnel in the practice of medical defense, medical decontamination, and triage. It also provides education for other military branches, civilians, government agencies, and foreign nationals. Courses are accredited as continuing medical education for physicians, nurses, and emergency medical technicians, and for college credit.
The courses taught onsite at the chemical casualty care division include the Medical Management of Chemical and Biological Casualties Course, which is produced jointly with the US Army Medical Research Institute of Infectious Diseases. The course consists of lectures, a field exercise, and a unique primate lab experience. It has been recognized as the gold standard for this type of training by the Office of The Surgeon General and the Government Accountability Office. Other courses include the Field Management of Chemical and Biological Casualties, which targets front echelon care. This course includes multiple field exercises to encourage proficiency in the field medical decontamination station. The Hospital Management of Chemical Biological Radiological Nuclear and Explosives Course is a preparatory course for mass casualty chemical, biological, radiological, nuclear, and explosives events. It includes instruction on regulations regarding these events and cooperation with civilian and military authorities at other echelons.
The chemical casualty care division is responsible for a large volume of educational products. These products include publication content for educational materials as well as pocket manuals for the field management of chemical casualties and medical management of chemical casualties. The chemical casualty care division produces several software products, such as reference materials, distance and online training courses, educational games, and interactive simulations.
ORGANIZATION OF THIS VOLUME
Awareness and interest in weapons of mass destruction, medical chemical defense research, and education and training of military personnel and civilians has increased dramatically in the last few years. The need for an updated and resultant text dedicated to the medical aspects of biological and chemical weapons would not fit into a single textbook. Hence, this text differs from the earlier version of the Textbooks of Military Medicine: Medical Aspects of Chemical and Biological Warfare because biological and chemical agents are discussed in separate volumes. This text is primarily relevant to military medicine; however, due to the increased interest in chemical casualty treatment that now exists within civilian communities, the information provided within this text can be considered an excellent resource for both military and civilian healthcare providers.
Chapters 2 through 4 offer greater depth concerning the history of chemical warfare and the basic principles of chemical warfare. "History of Chemical Warfare" takes a broad view of the historical context and significant events in the field. "History of the Chemical Threat" breaks the 20th century down into decade-long segments and provides a fresh perspective on prior military and political developments. "The Medical Aspects of Medical Management" chapter has radically changed over the years and presents this history from multiple perspectives. It includes detailed accounts of the chemical warfare management experience in the United States, as well as a revealing exploration of British, Canadian, French, Russian, and German experiences.
SUMMARY
The chemical warfare threat to the United States has changed dramatically in recent years, becoming less obscure. Chemical weapons that are being destroyed under the Chemical Warfare Convention by major nation -states are increasingly attractive to pariah states and terrorists. In the current environment, the United States may experience a higher likelihood of a chemical attack on its military forces and civilian population, more so than ever before in the history of chemical warfare and terrorism.
Given the changing chemical threat, this textbook has broadened in scope and depth and now encompasses an entire volume. This expanded text attempts to be a comprehensive guide to the full spectrum of these agents and to provide information on the state of the art in medical therapeutics.
REFERENCES
1. Tucker Jonathan B. War of Nerves: Chemical Warfare from World War I to Al-Qaeda. New York, NY: Pantheon Books; 2006: 245.
2. Englund W. Ex-Soviet scientist says Gorbachev's regime created new nerve gas in '91. Baltimore Sun. September 16, 1992:3A.
3. Englund W. Russia still doing secret work on chemical arms. Research goes on as government seeks U.N. ban. Baltimore Sun. October 18, 1992:1A.
4. Smithson AE, Mirzayanov VS, Lajoie R, Krepon M. Chemical Weapons Disarmament in Russia: Problems and Prospects. Washington, DC: Henry L. Stimson Center; October 1995. Report No. 17.
5. The United States Department of State, Bureau of International Security and Nonproliferation, and the United States Department of Commerce, Bureau of Industry and Security. The United States Chemical Weapons Convention Web site. Convention on the Prohibition of the Development, Production, Stockpiling and Use of Chemical Weapons and on their Destruction. Available at: http://www.cwc.gov. Accessed June 12, 2007.
6. United States Office of the Assistant Secretary of Defense, "Chemical weapons stockpile information declassified," news release, January 22, 1996. Document 024-96.
7. US Army. US Army Chemical Materials Agency Web site. Available at: http://www.pmcd.army.mil. Accessed December 2006.
8. Russian Munitions Agency Web site. Available at: http://www.munition.gov.ru/eng/zapasho.html. Accessed November 2006.
9. US House Armed Services Committee. "GAO finds Russia lacks plan for destruction of poison gas stockpile." News release, April 27, 2004.
10. Suskind R. The untold story of al-Qaeda's plot to attack the subways. Time. June 19, 2006.
11. Salama S. Special report: manual for producing chemical weapon to be used in New York subway plot available on al-Qaeda websites since late 2005. WMD Insights: Issues and Viewpoints in the International Media. 2006;7.
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Chapter 2 - HISTORY OF CHEMICAL WARFARE
COREY J. HILMAS, MD, PhD*; JEFFERY K. SMART, MA+; and BENJAMIN A. HILL, Jr, DO, MS, MEd*
INTRODUCTION
Chemical Concoctions Used In Battle Chemical Warfare Proposals In The US Civil War
WORLD WAR I
THE 1920s
THE 1930s: GROWING THREAT OF CHEMICAL WARFARE
WORLD WAR II
THE 1950s
THE 1960s: DECADE OF TURMOIL
THE 1970s: THE NEAR END OF THE CHEMICAL CORPS THE 1980s: RETURN OF THE CHEMICAL CORPS
THE 1990s: A NEW AGE OF CHEMICAL WARFARE AND TERRORISM
PREVENTING CHEMICAL WARFARE AND TERRORISM IN THE 21ST CENTURY
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INTRODUCTION
A chemical agent is a substance "intended for use in military operations to kill, seriously injure, or incapacitate man because of its physiological effects."1(p1-1) Chemical warfare agents cause injuries directly by irritation, burning, or asphyxiation, and indirectly by contaminating ground so that it cannot be safely occupied, creating smoke screens to obscure operations or reduce the accuracy of an enemy's firepower, and damaging an enemy's equipment by incendiary action. In short, chemical warfare is the use of any synthetic compound or material designed and used for the purpose of harming others. In the modern era, chemical agents have been divided into five categories: nerve agents, vesicants, choking agents, blood agents, and incapacitants. Excluded from consideration in this chapter are riot control agents, chemical herbicides, and smoke and flame materials.
Chemical warfare evolved from studies of plant poisons by ancient Egyptian and Indian civilizations to the studies of Aristotle, Mithridates, Galen, da Vinci, and Nobel scientists at the turn of the 20th century.2 The concept that chemicals can be used as deadly poisons on a small scale has been understood since the start of written civilization, and evidence of their use has pervaded myth and history for thousands of years. Some scholars suggest that the English colonists at Jamestown were poisoned with arsenic trioxide by Spanish operatives intent on maintaining a monopoly in the New World. Throughout history, individuals used plant poisons and chemicals to remove romantic and political rivals, despotic rulers, prisoners, and even unwanted spouses. Despite these small-scale uses of chemical poisons before the 20th century, military use of chemicals was rare. In the early 20th century, World War I changed the face of warfare with the use of chemicals on a massive scale.
This chapter, the first in a series of three chapters on the history of chemical warfare, focuses on the historical development of chemical warfare, its large-scale use during World War I, post-World War I incidents of chemical warfare, legislative efforts to ban chemical agent use, chemical warfare plans during World War II, and chemical warfare and terrorism today. The discussion will emphasize the historical experiences of the United States on the battlefields of Europe, Asia, and North Africa. It will be followed by Chapter 3, History of the Medical Management of Chemical Casualties, and Chapter 4, History of the Chemical Threat, Chemical Terrorism, and the Implications for Military Medicine.
CHEMICAL CONCOCTIONS USED IN BATTLE
Toxic Smokes
The first recorded history from civilizations in Egypt, Babylon, India, and China contain references to deadly poisons. The first pharaoh, Menes, cultivated, studied, and accumulated poisons from plants, animals, and minerals in 3000 BCE . Egyptians also investigated the lethal effects of hydrocyanic acid.2 Beginning in 2000 BCE, the great dynasties in India used smoke screens, toxic sleep-inducing fumes, and incendiary devices on a large scale during battle.2,3 Chinese writings from 1000 BCE contain recipes for the production of poisonous, noxious, and irritant vapors for use in war, including arsenic-containing "soul-hunting fog." The Chinese also developed stink bombs of poisonous smoke and shrapnel, along with a chemical mortar that fired cast-iron "stink" shells.4
The powerful city-states of ancient Greece also experimented with chemical concoctions. During the First Sacred War in 590 BCE, Athens and Sicyon plotted to lay siege to the fortified city of Kirrha in retaliation for the harassment of pilgrims to the Oracle of Apollo at Delphi. Solon, the sage of Athens, had the River Pleistos, the main water supply to Kirrha, poisoned with hellebore roots, causing diarrhea that led to the defeat of the besieged city (as described by Pausanias in 150 BCE). Thucydides described the first use of chemical warfare in Western civilization, by Sparta against Athens, in his History of the Peloponnesian War (431-404 BCE). During the siege of Plataea in 428 BCE, wood was saturated with pitch and sulfur to generate arsenic smoke, and then burned under the walls of the city to produce poisonous choking fumes (as well as fear and panic). A rainstorm minimized the effect, but the strategy was successfully employed again by Sparta and its allies during the siege of Delium, an Athenian fortification, in 424 BCE . Dating from the 4th century BCE, Mohist sect manuscripts in China describe chemical tactics employed against entrenched, well-defended armies in caves and tunnels, using bellows to pump smoke from burning balls of mustard and other toxic plants.3,4 Chemical warfare was also practiced during the time of the Roman empire. About 200 BCE, the Carthaginians left mandrake root in wine to sedate the enemy.4 Inhabitants of Ambracia in Epirus used toxic smoke to deter the Romans from breaching their walls.5 Between 82 and 72 BCE the Romans used a toxic smoke that caused blindness and choking pulmonary symptoms when inhaled, similar to phosgene.6 This tactic allowed the Romans to defeat the Spanish Charakitanes in only 2 days. During the 15th century CE, arsenic smokes were used by Christians against the invading Turks at the siege of Delium. Austrian historian von Senfftenberg wrote about the arsenic cloud: "It was a sad business. Christians must never use so murderous a weapon against other Christians. Still, it is quite in place against Turks and other miscreants."7(p7)
Greek Fire and Flaming Concoctions
The Greeks found ways to use their static burning concoctions of pitch, sulfur, tow, and resinous wood chips with incendiary arrows, flaming pots shot from catapults, and fire cannons mounted on boats. The most famous of all the ancient methods of chemical warfare, Greek fire, helped ensure the success of the Byzantine Empire. Although the exact formula for Greek fire has been lost to history, the ingredients included resin, pitch, sulfur, naphtha or petroleum, quicklime, and saltpeter. Discharged from tubes in the bows of ships, the mixture ignited on contact with water and burned on the surface of the sea. Greek fire was invented by Kallinikos (sometimes called Callinus), who arrived in Constantinople in 668 CE after fleeing Muslim-occupied Syria. The Byzantines had used naphtha siphons and squirt guns in 513, but Kallinikos's idea to pump pressurized naphtha through bronze tubes to ignite enemy ships broke the Muslim siege of Constantinople in 677 CE, enabling the Byzantine navy to rule the seas and the Byzantine empire to flourish for many years.3
Poison Projectiles in Siege Warfare
The Renaissance spawned an interest in novel war machines and chemical weaponry. Leonardo da Vinci proposed a machine in the 15th century to fire shells filled with a powder mixture of sulfur, arsenic, and verdigris (copper acetate).8 Aimed at ships' galleys, the projectiles poisoned the lungs of anyone in the vicinity of the dispersed powder. In the 1600s incendiary shells filled with sulfur, tallow, rosin, turpentine, saltpeter, and antimony were used to start fires in sieges. Similar toxic smoke projectiles were designed and used during the Thirty Years War (1618-1648). In 1672, during his siege of the city of Groningen, Christoph Bernhard van Galen, the Bishop of Munster, employed several different explosive and incendiary devices containing belladonna alkaloids intended to produce toxic fumes. In response to the use of poison projectiles, the French and Germans signed the Strasbourg Agreement just 3 years later on August 27, 1675. This was the first documented international agreement to ban the use of "perfidious and odious" toxic devices.4 In addition to their use as gaseous poisons, militaries also used chemicals to gain an advantage under the cover of thick haze. In 1701 Charles XII of Sweden used chemical smoke screens to obscure his crossing of the Dvina River under a gas cloud.9
In 1854 Lyon Playfair, a British chemist, proposed a cacodyl cyanide artillery shell for use against enemy ships as a way to resolve the stalemate during the siege of Sevastopol. Although British Prime Minister Lord Palmerston considered the idea, the British Ordnance Department rejected it, calling it as "bad a mode of warfare as poisoning the wells of the enemy."10(p22) Playfair's response was used to justify chemical warfare into the next century:
There was no sense in this objection. It is considered a legitimate mode of warfare to fill shells with molten metal which scatters among the enemy, and produced the most frightful modes of death. Why a poisonous vapor which would kill men without suffering is to be considered illegitimate warfare is incomprehensible. War is destruction, and the more destructive it can be made with the least suffering the sooner will be ended that barbarous method of protecting national rights. No doubt in time chemistry will be used to lessen the suffering of combatants, and even of criminals condemned to death.10(pp22-23)
A few years later, citizens of the fragmenting United States began considering the first American proposals for chemical warfare.
CHEMICAL WARFARE PROPOSALS IN THE US CIVIL WAR
New York schoolteacher John Doughty is credited with developing the first American proposal for chemical warfare. Pitching his idea to the War Department in 1862, Doughty advocated the offensive use of chlorine gas by launching an artillery shell filled with 2 to 3 quarts of liquid chlorine. After the shell exploded, the chlorine gas would rout "an entrenched enemy" or ward "off the attacks of iron-clad vessels and steam rams."9(p6) Doughty added:
If the shell should explode over the heads of the enemy, the gas would, by its great specific gravity, rapidly fall to the ground: the men could not dodge it, and their first intimation of its presence would be by its inhalation, which would most effectually disqualify every man for service that was within the circle of its influence; rendering the disarming and capturing of them as certain as though both their legs were broken.11(p27)
Although Secretary of War Edwin M Stanton apparently never answered it, Doughty's letter was later published in the Journal of the American Military Institute.9 The idea was one of many suggestions and inventions flooding the War and Navy Offices during the time, including a proposal by Joseph Lott of Hartford, Connecticut, for using hand-pumped fire engines to spray chloroform on Confederate garrisons to anesthetize troops prior to their capture.12 Over 50 years after Doughty's original proposal, the German army developed chlorine gas cylinders and eventually chlorine bombs to combat trench warfare in World War I.
During the 1864 siege of Petersburg, General Ulysses Grant's army was stalled outside the city. Forrest Shepherd, a professor of agricultural chemistry at Western Reserve University, proposed mixing hydrochloric and sulfuric acids to create a toxic cloud to defeat the entrenched Confederate defenders.11 Because chemical warfare was viewed as inhumane at the time, Grant never acted upon the plan. Other such ideas were recorded during the war. Union Army Captain EC Boyton proposed the use of a cacodyl glass grenade for ship-to-ship fighting.11 Lieutenant Colonel William W Blackford, a Confederate engineer, designed a sulfur cartridge for use as a counter tunneling device.13 The Confederates also considered using Chinese stink bombs against the Union troops. With the possible exemption of Black-ford's cartridge, none of the proposals were applied on the battlefield.
WORLD WAR I
Chemical Warfare Use by France, Great Britain, and Germany
Most casualties in warfare from the Middle Ages until the First World War were the result of cold steel, wooden projectiles, and fast-moving metals propelled by explosives. World War I ushered in a new style of fighting involving stalemates of trench warfare, and synthetic chemists tested new chemical weapons in the arena of "no man's land." Trenches made bullets less useful and reduced mobility, but poison gas could uproot a well-entrenched enemy.
All of Europe was caught in the crisis of 1914 after the murder of Archduke Francis Ferdinand at Sarajevo. Declarations of war among Austria-Hungary, Serbia, Germany, France, Russia, and Great Britain soon followed. The United States remained neutral for several years under President Woodrow Wilson's policy. Although few expected the 19th century chemical proposals to become instrumental in tactical operations on the battlefield, the highly skilled research scientists and chemists of the principal combatants quickly adapted chemicals as primary weapons. Early in the war, French intelligence and captured German prisoners warned the Triple Entente (the United Kingdom, France, and Russia) of the numerous German factories being built along the Rhein that were capable of synthesizing vast quantities of toxic chemicals for use on the battlefield. Despite international efforts to restrict chemical weapons in the late 19th and early 20th centuries (see Chapter 4, History of the Chemical Threat, Chemical Terrorism, and Its Implications for Military Medicine), as both sides became rooted in their labyrinth of trenches in the early stages of World War I, the armies turned to chemical warfare.
Early Allied Chemical Warfare Plans
Despite the long-held belief that Germany was the first to use chemical agents during World War I, the French were actually the first; in August 1914, they fired toxic gas from rifles in the form of ethyl bromoacetate tear gas grenades. The French had tested ethyl bromoacetate grenades before the war, and they continued to use tear agents against the Germans throughout the conflict. However, the ineffectiveness of these weapons caused poison agents to remain unnoticed until the Second Battle of Ypres in 1915.
The British also examined their chemical technology for battlefield use in the early stages of the war, investigating tear agents but later turning to more toxic chemicals. In January 1915 several chemists at the Imperial College gassed a representative of the War Office, successfully demonstrating the use of ethyl iodoacetate as a tear gas. A suggestion for using sulfur dioxide as a chemical weapon, after being rejected for the army by Field Marshal Lord Kitchener, was presented to Winston Churchill at the admiralty in March 1915. The proposal included a plan to use a sulfur dioxide cloud against the Germans, a smoke screen to provide cover, and gas-proof helmets for British troops. Churchill rejected the plan but formed a committee the following month to discuss the use of smoke on land and sea.14
German Chemical Warfare Plans
Possibly aware of the Allied interest in chemical weapons, the Germans also pursued war applications for chemical technology. The strong German dye industry and the plethora of scientists in Berlin created an ideal situation for developing offensive chemical weapons. Professor Walther Nernst, recipient of the 1920 Nobel Prize in chemistry, suggested placing trinitrotoluene (TNT) in a 105-mm shrapnel shell with dianisidine chlorosulphonate, an agent known to cause irritation to the mucous membranes.15 Germans called these "Nernst Ni-Shrapnel" or "ni-shells," partly derived from the German word for sneezing powder, "niespulver." After the French deployed tear gas, Germany saw no reason to refrain from using its own chemical weapons.
Western Front: The Battle at Neuve-Chapelle
Germany first tested the Nernst weapon on the western front. On October 27, 1914, 3,000 of these shrapnel irritant shells fell on British and Indian troops near Neuve-Chapelle in Northern France. Although the British were unprepared for such an attack, the soldiers suffered no ill effects. The Germans remained convinced that chemicals had merit, however, and continued to experiment with new gas formulations.15
Eastern Front: T-Shells at the Battle of Bolimov
Three months after Neuve-Chapelle, the Germans tried xylyl bromide (a form of tear gas) on the Russian front in Poland. The Battle of Bolimov, launched on January 31, 1915, preliminary to the Second Battle of the Masurian Lakes, was the site of the German army's first extensive use of poison gas. Germany employed a new gas shell ("Tappen-shell," "T-shell," or "T-Stoff") that contained an explosive charge for producing a duel shrapnel and poison effect, designed by Professor Hans von Tappen of the Kaiser Wilhelm Institute for Physical Chemistry and Electrochemistry in Berlin. For the new weapon, von Tappen made two improvements to Nernst's shells. First, he stabilized the chemical liquid within the shell casing to reduce tumbling when fired from a standard 15-cm howitzer, increasing the shell's accuracy and range. Second, he designed a shell casing to prevent accidental mixing of the extremely reactive chemical substances inside. Each shell contained 7 lb of xylyl bromide, a burster charger for splinter effect, and a lead lining to prevent contact between the burster charge and the chemical payload.15,16 However, the firing of 18,000 shells at Russian positions around Bolimov proved entirely unsuccessful. The Russians easily repulsed the overconfident German attack and the German gas failure halted any further assaults on Bolimov. The chemical failed for several reasons. The winter weather was too cold to cause the liquid to vaporize to the gaseous state, and the agent was either blown back towards the German lines or fell harmlessly to the ground. Also, xylyl bromide was a weakly irritating tear gas, and the liquid could not be dispersed in sufficient concentration to cause damage. Although aware that the Germans had attempted an attack with poison gas, the Russians did not widely report it to their Western allies because of its failure. The Germans again attempted to use T-shells on the western front at Nieuport in March 1915, with similar results.14,17,18 Although unsuccessful, these experiments provided Germany with the experience to improve future attempts. Poison gas next appeared with much greater success on the western front in April 1915, during the Second Battle of Ypres.
Development of Chlorine
Fritz Haber, professor at the Kaiser Wilhelm Physical Institute of Berlin (and later the 1918 Nobel Laureate in chemistry), directed German field operations involving chemical warfare. Haber is credited with the concept of creating a toxic cloud from chemical cylinders in late 1914. Learning the lessons from von Tappen's T-shells, Haber suggested the use of large commercial gas cylinders as a delivery system instead of artillery shells, which were in short supply. He also postulated that gas from storage cylinders would cover a far broader area than gas dispersed from artillery shells. In addition, neither the T-shell nor the chlorine gas cylinders technically violated the Hague ban on projectiles. Haber selected chlorine because it was readily available from the German dye industry and satisfied requirements for military application: it was lethal, immediately effective, nonpersistent, and volatile. Chlorine could form a toxic gas cloud dense enough to resist dilution in a moderate wind but with no prolonged influence over the terrain.15
The Second Battle of Ypres
During October and November 1914, the French, British, and Belgian forces had stopped the advance of Germany's Schlieffen Plan, at great costs to both sides. The First Battle of Ypres had resulted in a stalemate, with each side entrenched. Germany selected the front of the Fourth Army facing the French at Ypres as the location for a gas attack. On March 10, 1915, Pioneer Regiment 35, under Haber's guidance, placed 1,600 large and 4,130 small cylinders (containing a total of 168 tons of chlorine) opposite the Allied troops defending Ypres.15 The chosen site was a sector between Bixschoote and Langemarck in Belgium, a tactical weak point where French and British forces joined.9 The English-speaking troops consisted of Canadians and the British 28th Division. The French troops were the 87th Territorial and 45th Algerian Divisions.9 Pioneer Regiment 35 waited for winds to shift to the west toward Allied trenches before the actual gas attack was delivered late in the afternoon on April 22,14,15,17,19 when the weather and wind patterns were ideal for a toxic cloud.
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WAR OF THE CHEMISTS
During World War I, chemists on both sides investigated over 3,000 chemical substances for potential use as weapons. The war between the nations was just as much a war between the chemists. Germany had two future Nobel Laureates in chemistry on their side, and France had one as well. The adoption of poison gas by the Germans in World War I is attributed to Professor Walther Hermann Nernst, a well-known physical chemist in Berlin. In recognition for his services to the German Empire, he was made a count late in the war. However, World War I was the setting for a strategic match between rival chemists, with Germany's Fritz Haber pitted against his French counterpart, Victor Grignard. Fritz Haber played a major role in the development of chemical warfare in World War I. He developed early gas masks with absorbent filters and masterminded the first chlorine attacks at Ypres, Belgium. In his studies of the effects of poison gas, Haber discovered a simple mathematical relationship between the concentration (C) of the gas and the amount of time (t) it was breathed in, expressed as C x t = k, where k is a constant. In other words, exposure to a low level of gas for a long time can cause the same result (eg death) as exposure to a high concentration for a short time. This relationship is known as "Haber's rule."
Haber's rival was Francois Auguste Victor Grignard, a French chemist and professor at the University of Nancy. During World War I, he was transferred to the new field of chemical warfare and worked on the manufacture of phosgene and the detection of mustard gas. His Nobel Prize in chemistry was awarded for devising a new method for creating carbon-carbon bonds in organic synthesis termed "the Grignard reaction," which allowed the means of synthesizing larger organic compounds from smaller starting materials.
Haber's wife opposed his work on poison gas and committed suicide with his service weapon after he personally oversaw the first use of chlorine in Ypres, Belgium. Haber defended gas warfare against accusations that it was inhumane, saying that death was death, by whatever means it was inflicted. In the 1920s he developed the cyanide gas formulation Zyklon B, which was used as an insecticide, especially as a fumigant in grain stores. The Nazis later used Zyklon B (hydrogen cyanide) gas chambers disguised as shower stalls beginning with the first and longest running Schutzstaffel camp at Dachau. In 1934, the Nazis forced Haber, a German Jew, to emigrate. Haber was a patriotic German who was proud of his service in World War I, for which he was decorated. He struggled to cope with the new reality that his enormous contributions to German industry were disregarded during his vilification by the Nazi regime. He died in exile in Basel after a grave illness.
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The Allies claimed that 5,000 troops fell victim to the chlorine cloud (although this number was probably inflated for propaganda purposes).9,20 The gas attack was successful, but the Germans grossly underestimated the chlorine's effects and, lacking sufficient supplies and reserves for an assault, failed to capitalize on the retreating Allied positions.14,15,17,19 Any further possible German advance was stopped by Canadian troops at Kitchener's Wood while the British and French hastily organized a defensive front during the next 48 hours.9
Two days later, Germans conducted a second chlorine gas attack against the Canadian First Division northeast of Ypres, near Saint Julien, and four more cylinder gas attacks during May in the Ypres sector.
The German gas-aided capture of Hill 60 on May 5 was a significant blow to the Allies.
Although the Allies expressed great indignation about this inhumane and unfair weapon (despite their own development of chemical weapons), the Germans believed their use of nonprojectile shells to form gas clouds was within the guidelines of the Hague ban. The comments of General von Deimling, commanding general of the German Fifteenth Corps at Ypres, written sometime after the war, reflected the reason for initiating chemical warfare:
I must confess that the commission for poisoning the enemy, just as one poisons rats, struck me as it must any straight-forward soldier: it was repulsive to me. If, however, these poison gases would lead to the fall of Ypres, we would perhaps win a victory which might decide the entire war. In view of such a high goal, personal susceptibilities had to be silent.21(p5)
Despite the numbers of Allied casualties and prisoners, the battle was a mixed success. The Germans failed to take advantage of their success, but the Allies, made aware of the pending gas attack when British pilots spotted the gas cylinders in the German trenches, were also unprepared.21 One British soldier remarked:
Nobody appears to have realized the great danger that was threatening, it being considered that the enemy's attempt would certainly fail and that whatever gas reached our line could be easily fanned away. No one felt in the slightest degree uneasy, and the terrible effect of the gas came to us as a great surprise.22(p3)
Another observer, however, realized a profound change had occurred: "The most stupendous change in warfare since gunpowder was invented had come, and come to stay. Let us not forget that."23(p3)
Although chlorine had its disadvantages and the German attack against Ypres halted short of its objective, chemical warfare became a mainstay of German assaults and Allied counterattacks on the Ypres salient throughout the rest of the war. The Ypres sector became an experimental stage for the Germans to develop and test new gases on other battlefronts. A third battle occurred at Ypres in 1917 (at which the young Adolf Hitler was seriously wounded during an Allied chlorine gas attack).
After the success at Ypres, Haber turned German attention back to the eastern front to atone for the failure of xylyl bromide T-shells. In May 1915 German troops again attacked Russians at Bolimov, releasing 263 tons of chlorine gas from 12,000 cylinders along a 7.5-mile line, killing 6,000 Russian soldiers. Two more gas cloud attacks on the same positions caused 25,000 more Russian casualties.15 The Russians had initially devoted few resources to the development of chemical protective equipment. Consequently, they were more vulnerable to gas attacks than the British and French and suffered the greatest number of chemical casualties in World War I.
All of the first chemical attacks of World War I were in the form of chemical vapor clouds projected from cylinders, totaling nearly 200 by the end of the war. Although the largest chlorine attack occurred in October 1915 at Reims, when the Germans released 550 tons of chlorine from 25,000 cylinders, chemicals delivered by artillery shells soon became the norm.9,15 The Germans learned that a vapor cloud was dependent on wind direction and strength, neither of which could be predicted with any amount of accuracy. These initial chemical attacks also proved that an infantry attack synchronized with a discharged vapor cloud was extremely dangerous.
Allied Chemical Warfare Retaliation
Only weeks after recognizing the potential of chemical weapons at Ypres, the British and French began planning a chemical retaliation, which became a three-pronged strategy to develop their own (1) protective devices for troops; (2) offensive toxic gas weapons; and (3) systems to deliver the toxic gases to enemy lines. The Allies developed their first protective mask the day after the first German chlorine attack, and in September 1915 they launched their own chlorine attack against the Germans at Loos, Belgium. These moves initiated a deadly competition to develop better protective masks, more potent chemicals, and long-range delivery systems to disperse the agents more widely. The Germans quickly replaced chlorine with phosgene, which was more effective. In May 1916 the Germans started using diphosgene, and 2 months later the French tried hydrogen cyanide (HCN), then cyanogen chloride. In July 1917 the Germans introduced mustard agent to provide a persistent vesicant that attacked the body in places unprotected by gas masks. Both sides also mixed agents and experimented with camouflage materials to prevent quick agent identification.4
The Battle of Loos
In the aftermath of Ypres, it became apparent that lacking an offensive gas capability would impair troop morale, and the British cabinet approved the use of chemical agents. It took 5 months to plan the large-scale gas attack at Loos, which involved chlorine-filled cylinders clustered in batteries along the front rather than spaced far apart in one continuous line. The British had a major numerical advantage against the Germans, reaching 7-to-1 in some places along the front. British commander General Douglas Haig began the offensive with a 4-day artillery bombardment by six divisions, planning to follow the bombardment with the release of 5,500 cylinders containing 150 tons of chlorine gas from the British front line.15(p11),20(p14-17)
The gas attack occurred on September 24 with only minimal success. Unfavorable and shifting winds reduced the effectiveness of the chlorine gas cloud, the number of chlorine cylinders was insufficient to cover the front line, and inadequate reserve divisions were available to exploit a breakthrough (a lesson learned by the Germans at Ypres).20 A British shell shortage also prevented sustained artillery barrages.15 On the other hand, British Commander-in-Chief Sir John French acknowledged that although it failed to penetrate the German lines, the "gas attack met with marked success, and produced a demoralizing effect in some of its opposing units."15,16,23,24
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PHOSGENE
Chlorine's deficiencies were overcome with the introduction of phosgene, first used by Germany in December 1915. Phosgene, also known as carbonyl chlorine (COCl2), is a highly toxic gas first synthesized by the chemist John Davy (1790-1868) in 1812 by exposing equal quantities of carbon monoxide and chlorine to sunlight. "Phosgene" comes from Greek, literally meaning "generated by light." Phosgene is colorless and 18 times more potent than chlorine. It is often only detected by its characteristic "moldy hay" odor. One disadvantage of phosgene as a chemical warfare agent was that it was lightweight and readily dissipated, but this problem was surmounted by addition of the heavier chlorine. The chlorine supplied the necessary vapor to help eject phosgene from containers. The British employed a chlorine-phosgene mixture they codenamed "white star," which was used heavily during the Battle of the Somme. Phosgene is a particularly insidious poison, as exposure often has no initial symptoms. Symptoms usually appear within 24 hours, but can take up to 72 hours to manifest. The gas combines with water in the tissues of the respiratory tract to form carbon dioxide and hydrochloric acid. The acid then dissolves the membranes in the lungs. Fluid fills the lungs, and death results from a combination of blood loss, shock, and respiratory failure. Phosgene was far more lethal than any other common-use gas weapon; 85% of western front soldiers were killed as the result of chemical attack by phosgene.