CHAPTER VIII
STATISTICAL CONSIDERATION OF GAS CASUALTIES
GAS CASUALTIES a
The important rôle played by the combat gases during the World War is clearly shown from the casualty tables compiled in the Office of the Surgeon General. The total number of Army officers and enlisted men injured in battle was 224,089, of whom 70,552,b or 31.49 per cent, were reported as victims of gas poisoning. There were 13,691 deaths resulting from all battle injuries treated, of which 1,221, or 8.92 percent, were attributed to the effects of the war gases. Tables 1 and 2 show the admissions to hospitals by divisions and by months of occurrence for gas casualties. The case mortality from the various kinds of gas is shown in Table 3.
TABLE 1.- Admissions for gas poisoning, by organization, American Expeditionary Forces. Absolute numbers and percentages of total number1
TABLE 2.- Admissions for gas poisoning, by months of occurrence, American Expeditionary Forces. Absolute numbers and percentages of total number 1
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TABLE 3.- Admissions for gas poisoning, by gas, American Expeditionary Forces. Absolute numbers, deaths, and case mortality rates 1
The records just quoted apply to officers and men of the Army who came under the care of the Medical Department. No record is available as to the number killed on the battle field by deleterious gases.
Gassing necessitated the discharge for disability of 2,853 officers and men. Discharges for disability for battle casualties totaled 20,588; gas, therefore, was responsible for 13.8 percent of all discharges for disability for battle casualties.
The time lost in hospital during treatment for gas poisoning amounted to 2,947,199 days, or 16.8 percent of all time lost in hospitals from battle injuries. The average amount of time lost for each patient admitted for gas poisoning was 41.77 days and for those who recovered 42.25 days. Of 69,301 gas patients whose injury did not prove fatal 33,253, or 47.13 percent, were on sick report for less than 29 days, the average time lost for this class of cases being 13.45 days. Table 4 gives the number of admissions by gas. The kind of gas was not specified in 47.61 per cent of all cases, chlorine was responsible for 2.61 percent, mustard for 39.28 per cent, phosgene for 9.69 percent, and arsine for 0.82 percent. For the admissions in which the offending gas was definitely specified, 4.99 percent due to chlorine, 74.96 percent to mustard gas, 18.49 per cent to phosgene, and 1.56 percent to arsine.
TABLE 4.- Admissions for poisoning by gas, officers and enlisted men, American Expeditionary 1
STATISTICAL ANALYSIS OF 546 AUTOPSY RECORDS OF GASSED CASES
In order to obtain further information relative to the effects of the war gases, a detailed study was made of a series of autopsy protocols received in the office of the Division of Laboratories and Infectious Diseases, American Expeditionary Forces. This series consisted of 546 autopsy protocols of men who had
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been exposed to the combat gases, although in all cases the gas was not responsible for death. While most of these fatalities were from the American forces, a few occurred in the Allied or German armies.
In analyzing this series of cases the clinical records and the reports of gas officers were frequently consulted for facts which were not obtainable from the protocols.
These autopsies were performed, in some instances, by medical officers trained to a certain extent in war-gas pathology, but, generally speaking, the records were filed by medical officers without a previous knowledge of the lesions to be expected from gas. Such records, therefore, give prominence only to the most notable gross lesions present. Since such lesions were usually those associated with the most striking phases of the clinical course, they are not without value. However, certain pathological changes due to gas poisoning are not apparent from these records.
An attempt to group the cases in the series definitely according to the gas or gases producing the lesions was found almost impossible; hence an arbitrary classification was employed. Gas groups are shown by the method adopted with a degree of accuracy sufficient for all practical purposes. The series is arranged in four groups:
A. Cases in which gas poisoning was apparently the principal immediate cause of death.
B. Cases in which the effect of gas poisoning was markedly augmented by subsequent infection with ordinary pyogenic organisms.
C. Cases of recent gas poisoning in which the principal immediate cause of death was gunshot wound or infectious disease.
D. Cases with a history of previous gas poisoning in which no apparent relationship existed between the poisoning and death.
Group A includes practically all cases in which death resulted from the effects of the suffocative gases (green cross substances-phosgene, diphosgene, chloropicrin, etc.), since deaths nearly always occurred with them before infections had had a chance to become established. Group B includes nearly all deaths due to mustard gas (yellow cross), or deaths resulting from a mixture of mustard gas with other gas used at the same time. Group C consists almost entirely of cases in which gas (usually mustard gas) played only a contributory role. Group D includes cases in which gas played no important part in the cause of death but in which there was a history of gassing at some previous date, and in which an effort was made to see what effect the former gassing had had on the tissues when subjected to a gross and microscopic examination. In addition, the relation of the gas poisoning to latent or active tuberculosis was studied.c
Table 5 shows the various months in which exposure to gas occurred. By June, 1918, our troops had gained enough experience to make it difficult for the enemy to produce serious casualties by the use of green cross substances (phosgene, chloropicrin, etc.). Therefore, Group A now shows few cases. It should be stated, however, that during the rapid advance by our troops which occurred during the late months of the war it was difficult to get opportunities to examine Group A cases. They were comparatively few in number and some died soon after exposure and were disposed of on the battle field.
c For pathological details see Chap. V1. The present discussion is intended merely to bring out some practical points in reference to deaths from gas poisoning.
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TABLE 5.- Deaths from exposure to gas, by groups and by months of occurrence
Table 6 shows the type of gas to which the fatal cases coming to autopsy had been exposed, as shown by the clinical and gas officers' records.
There is no record of a case in this series of autopsies that was exposed to blue cross gas (chlorarsine) alone.
TABLE 6.- Medical and gas officers' record of the type of gas to which the fatal cases coming to autopsy had been exposed
Table 7 gives, by groups, the gases believed to have been responsible for the lesions found. The list of casualties at home during the manufacture of war gas, the general casualty list from the battle field, hospital experience, and the findings in this series of autopsies, do not permit one to escape the con- clusion that mustard gas (yellow cross) was preeminent in chemical warfare.
TABLE 7.- Series of fatal cases coming to autopsy by groups and by the gas believed to have been caused by lesions found
Table 8 shows the character of the gas attacks to which these cases were subjected. Enemv projector attacks met with a certain amount of success in the early months of the American participation in the war, hut later (against alert and well-trained troops) they produced comparatively small results. Near the close of the fighting a rifled projector " was employed a few times.
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but without noteworthy improvement in efficiency as compared with the old projector, except in its slightly increased range and the bare possibility of employing mustard-gas filling, which, up to that time, had never been used in such attacks.
TABLE 8.- Character of gas attacks sustained
The duration of life after gassing is indicated in Table 9.
TABLE 9.- Duration of life after gassing, by groups
Group A.- These patients usually died within 24 to 48 hours, and sequelae due to infection seldom occurred, contrary to the case in other kinds of gas poisoning.
Group B.- The majority of the fatalities in this group occurred between the close of the first week and the early part of the third week. Deaths were the result of infection which followed the gassing. Those dying later than the period mentioned usually developed one or more of the sequelfe common to any of the respiratory diseases.
Group C.- The duration of life after gassing was not closely related to the gas lesion found in the members of this group, since the gas was secondary in importance to some other disease or to some type of external violence such as gunshot wound which was immediately responsible for death.
Group D.- These deaths and the duration of life following the onset of the illness appear unrelated to gas unless it be admitted that in some instances a latent disease was fanned into activity by the exposure to gas.
Table 10 shows the causes of death. In certain cases under Group B in which there had been a light exposure to mustard gas, the respiratory lesions were very similar to those found in influenzal pneumonia. This disease was prevalent during the later part of the fighting period, and it is possible that some confusion existed in a few cases listed under Groups B and C.
TABLE 10.– Causes of death
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Table 11 shows the associated diseases present other than those mentioned as a cause of death. Tuberculosis was present as either an active or a latent process in about 18 percent. While diphtheria is recorded as having been present in some of the cases in the series the cultures were never tested for their toxicity on animals and therefore the organisms recovered may have been only the pseudodiphtheria bacillus, which is very apt to appear in some cases of irritation in the oral cavity and upper respiratory tract.
TABLE 11.- Associated diseases other than those mentioned in Table 10 as cause of death
Table 12 summarizes the record of the principal lesions described in the autopsy protocols, analyzed according to groups.
TABLE 12.– Principal lesions described in the autopsy protocols of groups A and B
Table 13 shows the distribution of burns and pigmentation as described at autopsy.
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TABLE13.- Distribution of burns and pigmentation as described at autopsy, by region and by group
Table 14 indicates bacteriology, ante mortem and post mortem combined, of this series of cases.
TABLE 14.- Bacteriology of cases studied
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Table 15 clearly shows the similarity of the organisms recovered in cultures from these cases with those from the usual respiratory diseases studied at autopsy. There is the same predominance of the streptococcus and pneumococcus.
TABLE 15.- Organisms isolated in the series of cases
AFTER-EFFECTS OF GAS POISONING
A study of poisonous gases in the American Expeditionary Forces during the World War. It appears from the Annual Report of the Surgeon General for 1920 that the total number of casualties from gas poisoning was 70,552, of which 1,843 were caused by chlorine, 6,834 by phosgene, 27,711 by mustard gas, and the remainder (33,587) by various unidentified gases. The original contemplation was to base this study on 1,000 cases each of chlorine, phosgene, and mustard-gas casualties, the three most important gases employed in the war; but of the 1,843 casualties from chlorine gas reported, sufficiently complete records of only 838 cases could be found. However, to bring up the series to the contemplated 3,000 (3,014), records of 160 casualties caused by either unknown, mixed, or two different gases at different dates are included.
The physical and mental status of each of these cases at the termination of treatment in Army hospitals, or at the time of final separation from the service having been determined, this status was then followed, through the courtesy and cooperation of the United States Veterans' Bureau, up to the present time (January to August, inclusive, 1024, this being the period in which reports were obtained from the Veterans' Bureau). Complete tables were compiled for each gas and for the mixed gases; the results are summarized in Table 16.
It is believed that the results thus presented are reasonably accurate, though necessarily they are not absolute by reason of difficulties encountered, in some instances, in the interpretation, sometimes arbitrary, of illegible. ambiguous, or contradictory records, many of which were probably written under stress of fire. In some instances an associated injury existed or an extraneous complication developed, prolonging hospitalization, the entire period of which, consequently, should not be charged to gas. The term "gassed" or "effects of gas," without qualifying expression, appeared frequently; it is probable that in the haste and confusion of demobilization some disabilities (usually small percentages--5 or 10 percent) from the effects of gas were noted on discharge papers, possibly on the mere strength of the soldier's statement that he had been "gassed," and after only a very cursory routine examination.
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It was originally necessary, and for a while was the established policy in the Veterans' Bureau, to award compensation to claimants upon certification by any physician, not in the bureau employ, pending subsequent careful examination by a bureau physician. For this reason the value of the results in the tables presented indicating the number awarded compensation, which was subsequently discontinued, is depreciated; although by far the greater number of these discontinuances were in all probability due to recoveries, or at least to improvements to degrees less than 10 percent (the minimum for which compensation is allowed) from actual impairments. This should not apply, however, to other results shown; for instance, to those at present under compensation, inasmuch as, with the development of the Veterans' Bureau, examinations were standardized and made at periodic intervals.
For a clear comprehension of the subjoined table, it is necessary for the reader to understand that the Veterans' Bureau which, by legislative enactment,1 culminated from the original Bureau of War Risk Insurance, provides for disabled veterans of the World War by means of a system of hospitalization, when indicated; by monetary compensation based on a standard of $80 per month for total incapacity (100 percent), varying by degrees to the minimum (10 percent) incapacity for which compensation is allowed; or by vocational training, which included also a monetary allowance, in various professions, crafts, and trades. Vocational training is allowed, when desired, to claimants with disabilities of less than 10 percent, who are ineligible, therefore, for compensation. Many claimants under compensation alternate periods of compensation with periods of vocational training, and for these reasons the terms "compensation" and "vocational training" are employed synonymously for the purpose of this study. However, in this presentation there are only eight instances of vocational training following disallowance of compensation. In the many cases in which the compensatory status exacerbated (luring the compensation period, the figures representing the degree of compensation indicate the percentage last awarded. It should be borne in mind that the entry, "no claim made," has reference here solely to disability from gassing. In some instances the Veterans' Bureau records show that compensation is being paid, but for some condition for which the gassing was in nowise responsible.
In the prosecution of this study four tables were prepared, three relating, respectively, to chlorine, phosgene, and mustard gas casualties, the fourth to various mixed gases, and gases, variety unknown (on file, Historical Division, Surgeon General's Office).
SUMMARY OF TABLE OF 838 CHLORINE GAS CASUALTIES
The average period of treatment in hospital of the casualties from chlorine gas is shown to be 53.5 days. Of the 838 casualties from chlorine gas considered, the deaths of 28 are recorded, 16 of these having been caused by traumatism other than gassing, and 12 by disease, 19 occurring in service and 9 after discharge from service. Of the 12 caused by disease, 6 occurred in service and 6 after discharge from service. Of the 6 occurring in service, 1 died of bronchopneumonia 5 days after exposure; 1 of bronchopneumonia 9 days after date of gassing; 1 of bronchopneumonia 193 days after date of gassing (readmitted to hospital after original admission and returned to duty-may or may not have
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been due to gas); 1 of lobar pneumonia 57 days after date of gassing; I of purulent pleurisy 92 days after date of gassing (readmitted to hospital for after-effects of gas after original admission and return to duty); and 1 of tuberculous meningitis 229 days after date of gassing. Of the 6 deaths from disease occurring after discharge from service, the records do not indicate gas as a causative factor, with the possible exception of 1 from pulmonary tuberculosis which occurred 962 days after date of gassing, after having received 100 percent compensation, which began 830 days after date of gassing. It therefore appears that 2 deaths are directly attributable to gas; 3 of the others possibly depending on gas as the causative factor. Only one death among those separated from the service on surgeon's certificate of disability or awarded a disability rating upon demobilization is recorded; this was by suicide 32 years after date of gassing, the patient having been discharged on surgeon's certificate of disability for psychoneurosis, neurasthenia, effort syndrome, and myocarditis, the cause of which is not determinable from the records.
Twenty were discharged on surgeon's certificate of disability--9 for disabilities directly attributed to gas, 1 for disability in part caused by gas, 6 for disabilities not caused by gas, and 4 for disabilities the causes of which are indeterminable from the records. Of the 9 cases attributed to gas, the average disability was 31.4 percent and the average period between date of gassing and date of discharge was 298 days. The disabilities were: Pulmonary tuberculosis, 2; bronchitis, 2; pleurisy, 1; neurocirculatory asthenia, 1; heart (tachycardia, dyspnea, and neurocirculatory asthenia), 1; "effects of gas," 1; and nephritis, 1. Of these 9 cases the records show that 7 are now under compensation, the compensable disability in some instances not being identical with the disability for which discharged; 1, discharged for pulmonary tuberculosis, inactive, made no claim, and 1, discharged for nephritis, made claim which was disallowed. The case attributed in part to the effects of gas was discharged by reason of gunshot wound of right shoulder, as the major disability, with tracheitis due to gas as a secondary condition; disability 25 percent; discharged 438 days after date of gassing. This case is now under compensation, 25 percent, for disease of upper respiratory tract. Of the 4 disabilities the causes of which are indeterminable from the records, 1 was discharged 310 days after date of gassing, 10 percent disability, for tuberculous epididymitis and pulmonary tuberculosis, chronic, inactive, and is now receiving 100 percent compensation for pulmonary tuberculosis, chronic, and tuberculous epididymitis; 1 was discharged 423 days after date of gassing, disability, 10 percent for neurasthenia, effort syndrome, and myocarditis, and received 100 percent compensation for psychosis until terminated by death; 1 was discharged 345 days after date of gassing, disability, 30 percent, for bronchitis and neurocirculatory asthenia, and is now receiving 10 percent compensation for pulmonary tuberculosis; and the fourth was discharged 390 days after date gassed, disability, 30 percent, for otitis media, bilateral, and is now receiving compensation, 32 percent, for pulmonary tuberculosis and otitis media, bilateral.
The records show that 49 cases were rated a disability at time of discharge from service, 39 being directly attributable to gas, 9 to other causes, and 1 cause indeterminate. Of the 39 cases attributed to gas, the average disability rating was 11.15 percent and the causes recorded were bronchitis, 24;
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pleurisy, 1; laryngitis, 1; valvular heart disease, 2; eyes (1 keratitis, 1 conjunctivitis), 2; and "after effects of gas," 9. The average disability of the 24 discharged with bronchitis was 12.5 per cent and the average interval between date of gassing and date of discharge was approximately 240 days. The 1 indeterminate case is recorded as discharged with a disability of 25 percent for defective vision, right, the cause not being given. Of the 39 cases attributed to gas, 19 are now receiving compensation, in most instances for the same condition noted upon demobilization as the disabling factor. Of the remaining 20, 6 have made no claim for compensation, 4 claims made have been disallowed, and compensations, after having been awarded and paid, for varying periods, to 10, have been discontinued.
Of this series of 838 cases, 19 died in service, and the records of the United States Veterans' Bureau show that 360 cases have made no claim for compensation, 179 claims have been disallowed, 3 claims are pending action, 86 compensations were awarded and subsequently discontinued after varying periods, and 191 are now under compensation or vocational training. Of the 86 discontinued compensations, 5 were for pulmonary tuberculosis, 44 bronchitis, 13 heart abnormalities, 2 upper respiratory tract conditions, 9 "gassed," and 13 all others. The average compensation period of the 5 tuberculosis cases was 986 days and of the 44 bronchitis cases 1,073 days. Only one of the five compensations for pulmonary tuberculosis was discontinued by death.
Of the 191 cases under compensation or vocational training the com- pensable disabilities recorded are: Pulmonary tuberculosis, 60; bronchitis, 68; disease of the upper respiratory tract, 6; disease of heart, 21; disease of eyes, 7; disease of nervous system, 17; "gassed," 4; all others, 8. Of the 60 tuberculosis cases, the average disability is 53 per cent and the average period between the date of gassing and beginning of compensation is 379.5 days. Of the 68 cases of bronchitis the average disability is 20.46 percent, and the average period between the date of gassing and beginning of compensation is 357.8 days. Of the total number under compensation, 32 are receiving the maximum rate of 100 percent and 67 are receiving the minimum rate of 10 percent.
SUMMARY OF TABLE OF 1,000 PHOSGENE GAS CASUALTIES
The average period of hospitalization of the casualties from phosgene gas is shown to be 44.7 days. Of the 1,000 casualties from this gas considered, the deaths of 37 are recorded, 26 of which occurred in service and 11 after discharge from service; 17 were caused by traumatism other than gassing, and 20 by disease. Of the 20 caused by disease, 11 occurred in service and 9 after discharge from service. Of the 11 occurring in service, 1 died within 24 hours and 1 within 48 hours from the effects of phosgene gas; 1 within 6 days, of which no symptoms are recorded; 4, of bronchopneumonia, 25, 36, 40, and 200 days, respectively, from date of gassing (these 4 cases were originally re- turned to duty 2, 3, 6, and 22 days, respectively, from date of gassing, and were readmitted to hospital only a few days prior to death); 2, of lobar pneumonia, 125 and 144 days, respectively, from date of gassing, 1 of which was originally in hospital for only 26 days, dying the day following readmission, no details being recorded, other than that there was a complication of diphtheria mentioned in connection with the death of the other; 1 of pulmonary abscess, 130 days after date of gassing, originally in hospital only 3 days, and
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died 10 days after readmission: and 1 of tuberculous meningitis, 240 days after date of gassing. Of the 11 deaths occurring after discharge from service, 2 were caused by traumatism and 9 by disease. Of the 9 caused by disease, 5 were from pulmonary tuberculosis, occurring from 18 to 54 months after date of exposure to gas, all of which were under 100 percent compensation for tuberculosis, and gas may or may not have been a factor in the death. Of these 1 was in hospital for only 10 days from date of gassing, compensation beginning 309 days after date of gassing; 1 was in hospital for 45 days from date of gassing for bronchitis, compensation beginning 292 days after date of gassing. The other three were in hospital for 16, 72, and 53 days, respectively, from date of gassing and were awarded compensation 115, 934, and 223 days, respectively, from date of exposure to gas. Gas is not indicated as a causative factor in the deaths of the remaining 4 occurring after demobilization. It therefore appears that only 3 deaths can be directly attributed to gas, gas being a possible factor, which can not be definitely determined from the records, in the deaths of several others. No death among those separated from service on surgeon's certificate of disability or awarded a disability rating upon demobilization is recorded.
Of these 1,000 cases, 10 were discharged on surgeon's certificate of disability, 4 for disabilities directly attributed to gas, 1 for disability in part caused by gas, and 5 for disabilities not caused by gas. Of the 4 cases attributed to gas the average disability was 33.75 percent, and the average period between the date of gassing and the date of discharge, 219 days; the disabilities were, bronchitis, 3, and valvular heart disease, mitral insufficiency, 1. The records show that these 4 cases are now under compensation for the conditions for which discharged. The case attributed in part to the effects of gas was discharged for bronchitis and dyspnea on exertion, 186 days after date of gassing, with a history of pneumonia in 1902 and in 1909. This case is now receiving 10 percent compensation for bronchitis and tuberculosis.
The records show that 54 cases were rated a disability at time of discharge from service, of 41 cases being attributed to gas, 1 partly due to gas, and 12 to causes other than gas. Of the 41 cases attributed to gas the average disability rating was 9.39 per cent and the causes recorded were pulmonary tuberculosis, 3; bronchitis, 31; disease of upper respiratory tract, 1; disease of heart, 3; "after effects of gas," 2, and dyspnea, 1. The average disability of the 3 discharged with tuberculosis was 11.66 percent, and the average interval between the date of exposure and the date discharged was 167 days. The average disability of the 31 discharged with bronchitis was 9.2 percent and the average interval between the date of gassing and date discharged was 237 days. The one case with disability partly due to gas is recorded as having been discharged with a disability of 10 percent, 138 days after date gassed. for goitre (existed prior to enlistment), and "history of gas." Of the 41 cases attributed to gas, 22 are now receiving compensation, in most instances for the same disability recorded upon demobilization as the disabling factor. Of the remaining 19, 4 have made no claim for compensation, 4 claims have been disallowed, 1 claim is pending action, and compensations, after having been awarded and paid for varying periods to 10, have been discontinued. The 3 cases with the disability rating for tuberculosis upon discharge have all been compensated for tuberculosis, 2 now remaining under compensation, and the third having been discontinued after a compensation period of 1,569 days.
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Of this series of 1,000 cases. 26 died in service and the records of the United States Veterans' Bureau show that 446 have made no claim for compensation, 212 claims have been disallowed, 4 claims are pending action, 112 compensations awarded have been discontinued after varying periods, and 200 are now under compensation or vocational training. Of the 112 discontinued compensations, 9 were for pulmonary tuberculosis, 63 for bronchitis, 8 for heart abnormalities, 4 for upper respiratory tract conditions, 9 for "gassed," and 19, all others. The average compensation period of the 9 tuberculosis cases was 905 days and of the 53 bronchitis cases, 1,150 days. Five of the compensations for tuberculosis discontinued were terminated by death. Of the 200 cases under compensation or vocational training, the compensable disabilities recorded are: Pulmonary tuberculosis, 42; bronchitis, 91; disease of the upper respiratory tract, 9; disease of the heart, 16; disease of eyes, 3; disease of nervous system, 20; disease of kidneys, 2; "gassed," 6; all others 11. Of the 42 tuberculosis cases, the average disability is 56.6 percent, and the average period between the date of gassing and beginning of compensation is 421 days. Of the 91 cases of bronchitis, the average disability is 26.2 percent, and the average period between the date of gassing and beginning of compensation is 328.7 days. Of the total number under compensation, 33 are receiving the maximum rate of 100 percent and 77 the minimum rate of 10 percent.
SUMMARY OF TABLE OF 1,016 MUSTARD GAS CASUALTIES
The average period of treatment in hospital of the casualties from mustard gas is shown to be 62.55 days.
Of the 1,016 casualties from mustard gas considered, the deaths of 63 are recorded, 40 of which occurred in service and 23 after discharge from service, 17 having been caused by traumatism other than gassing and 46 by disease. Of the 46 caused by disease, 26 occurred in service and 20 after discharge from service. Of the 26 occurring in service, 7 resulted from bronchopneumonia or other immediate effects of gas within 7 days from date of gassing; 14 occurred within 30 days, from bronchopneumonia or other immediate effects of gas, including a pseudomembranous laryngitis in one instance, various burns, with accompanying edema and toxemia, in three instances, and a tracheitis or a tracheobronchitis in a number of instances; 1 occurred 62 days after date of gassing, from lobar pneumonia (originally in hospital 51 days, death 2 days subsequent to readmission); 1 occurred 61 days after date of gassing, from broncho- pneumonia, ulcerated larynx, and pulmonary tuberculosis; 1 occurred 157 days after date of gassing, from lobar pneumonia (originally in hospital 63 days, and died 7 days subsequent to readmission); 1 occurred 197 days after date of gassing, from bronchopneumonia, pneumothorax, and empyema; and 1 occurred 14 davs after date of gassing, from cerebrospinal meningitis, which developed 2 days prior to death and which bore no relationship to gas. Of the 14 cases which died within 30 days from date of exposure to gas, 10 sustained minor gunshot wounds, associated with the gassing, but the records do not indicate that these injuries operated as a factor in the cause of death, with the possible exception of 1 case which died, 10 days after date of gassing, from bronchopneumonia, and which developed a B. welchii infection of a gunshot wound of the ankle.
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Of the 23 deaths occurring after discharge from service, 3 were caused by traumatism and 20 by disease. Of the 20 caused by disease, 11 were due to pulmonary tuberculosis, occurring from 587 to 1,995 days after date of gassing. Of these 11, 8 were receiving 100 per cent compensation for tuberculosis, gas origin being indicated in the case of 2, and the records, in the case of the other 6, showing that 1 was in hospital only 4 days, no symptoms recorded, and received compensation 967 days after date when gassed; 1 was in hospital 6 days, no symptoms recorded, and received compensation 866 days after date when gassed; 1 was in hospital 40 days, slight bronchial symptoms, and received compensation 249 days after date when gassed; 1 was in hospital 33 days, symptoms pharyngitis and bronchial soreness, and received compensation 169 days after date when gassed; 1 was in hospital 42 days, symptoms bronchitis, and received compensation 172 days after date when gassed; and 1 was in hospital 58 days, symptoms conjunctivitis, and received compensation 1,174 days after date when gassed; 1 was receiving 100 per cent compensation for adhesions subsequent to pneumonia, which followed gassing, and 2 made no claim for compensation (the records show definitely that 1 of these was not of gas origin). Two died of pneumonia, 833 and 1,154 days, respectively, after exposure to gas, the one being under 10 per cent compensation for pharyngitis and conjunctivitis, and the other under 20 percent compensation for atrophy of optic nerve and cardiac hypertrophy. Gas is not indicated as a causative factor in the death of the remaining 7, occurring from disease, after demobilization. It appears, therefore, that 24 deaths were directly attributed to gas and that gas was a possible factor in the deaths from pneumonia and from tuberculosis of a number of others, the primary cause of which can not be determined from the records. Of the 11 deaths from pulmonary tuberculosis, after discharge from service, 3 had been discharged on surgeon's certifi- cate of disability (2 for pulmonary tuberculosis and the third for adhesions from pneumonia, following gas). Of the other 9 deaths from disease after discharge from service, only 1 had been discharged on surgeon's certificate of disability (for mental deficiency, moron), and he died, 1,842 days after date of gassing, from valvular heart disease. Of the deaths from disease, after dis- charge from service, only 1 had been awarded a disability rating upon demobilization, for atrophy of right testicle, existing prior to enlistment, and bronchitis, 35 percent disability, 103 days after date of gassing. This case was under 10 percent compensation for bronchitis and pulmonary tuberculosis, and was terminated by death from encephalitis, 862 days after exposure to gas.
Of the cases of this group 27 were discharged on surgeon's certificate of disability, 12 for disability directly attributed to gas, 4 for disability in part caused by gas, 10 for disability not caused by gas, and 1 for disability, cause indeterminable from the records. Of the 12 cases attributed to gas, the average disability was 21.9 per cent and the average period between date of gassing and date of discharge, 274 (lays; the disabilities were: Pulmonary tuberculosis. 2; pleurisy, 1; bronchitis, 6; nervous system, 2; and corneal opacity, 1. The records show that: The 2 discharged for pulmonary tuberculosis died from pulmonary tuberculosis (one, 1,137 and the other 1,955 days after date gassed); 1 discharged for pleurisy died from tuberculosis 587 days after (late gassed; of the 6 discharged for bronchitis, 1 was disallowed compensation, 3 claims for bronchitis were awarded and the compensation subsequently discontinued.
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1 is receiving compensation for bronchitis, and 1 is receiving compensation for a heart condition; of the 2 discharged for conditions of the nervous system, 1 made no claim and the other is receiving compensation for practically the same condition for which discharged; 1, discharged for corneal opacity, is being compensated for the same condition. Of the 4 with disability attributed in part to gas, 1 was discharged, 50 percent disability, for a preexisting retinochoroiditis, aggravated by gas, 241 days after exposure to gas, and was awarded 30 percent compensation for same 241 days after date gassed, which was subsequently discontinued; 1 was discharged, 50 percent disability, for endocarditis, mitral incompetency (line of duty), and mental deficiency, moron (existed prior to enlistment), 239 days after date of gassing and is receiving 75 percent compensation for valvular heart and hypomania; 1 was discharged with 35 percent disability, for bronchitis, adhesions following appendectomy, flat-foot, tachycardia, and dyspnea, 282 days after date of gassing, and is receiving 20 percent compensation for bronchitis; and 1 was discharged with 40 percent disability for dypsnea, cough, prolonged expiration and goiter, 316 days after date gassed, and is receiving 10 per cent compensation for " gassed ." The case for which the cause of discharge is indeterminable from the records was originally in hospital 28 days, readmitted 150 days later with pain in side, had a history of measles 11 months before first admission, was discharged, 50 percent disability, for pleuritic adhesions, 422 days after exposure to gas, and is receiving 50 percent compensation for pulmonary tuberculosis.
The records show that 57 cases were rated a disability at time of discharge from service, 33 cases being attributed to gas, 6 partly due to gas, 15 to causes other than gas, and 3 to causes indeterminable from the records. Of the 33 cases attributed to gas, the average disability rating was 11.36 per cent and the causes recorded are: Bronchitis, 24; pleurisy, 1; functional disorder of heart, 1; eyes, 2 (1 defective vision and 1 conjunctivitis); "history of gassing," 1; dyspnea, 1; and "after effects" of gas burns, 3. The average disability of the 24 discharged with bronchitis was 12.29 percent, and the average interval between date of gassing and date of discharge was 207 (lays. Of the 33 cases attributed to gas, 17 are now receiving compensation, in most instances for the same disability recorded under demobilization as the disabling factor; 7 were awarded compensations which were subsequently discontinued; 5 made no claim, and claims of 4 were disallowed. Of the 6 cases with disabilities partly due to gas, 1 was discharged with 15 percent disability for bronchitis and flat-foot, 1 with 35 percent disability for bronchitis and atrophy of right testicle; 1 with 10 percent diasbility for bronchitis and flat-foot; 1 with 25 percent disability for tuberculosis (existed prior to enlistment), aggravated by gassing; 1 with 5 percent disability for bronchitis and gunshot wound of left ankle, and 1 with 10 percent disability for gunshot wound of finger, neurasthenia, and "gassed." Of the 3 cases discharged with disabilities the causes for which are indeterminable from the records, 1 was discharged, disability, 10 percent, 226 days after date of gassing, for thickened pleura, following bronchopneumonia, which developed 136 days after an original stay in hospital of only 17 days, and is now receiving 10 percent compensation for pulmonary tuberculosis; 1 was discharged, disability, 10 percent, 228 days after date of gassing, for "harsh, high-pitched breathing," after an original stay in hospital
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of 63 days, during which no symptoms are recorded, and is receiving 25 per cent compensation for pulmonary tuberculosis; and 1 was discharged, disability, 10 percent, 173 days after date of gassing, for "harsh, high-pitched breathing," after an original stay in hospital of 29 days, with readmission period of 30 days, for lobar pneumonia, and whose claim for compensation was disallowed.
Of this series of 1,016 cases, 40 died in service; the records of the United States Veterans' Bureau show that 467 have made no claim for compensation; 194 claims have been disallowed; 6 claims are pending action; 117 compensations awarded have been discontinued after varying periods; and 192 are now under compensation or vocational training. Of the 117 discontinued compensations, 20 were for pulmonary tuberculosis, 66 for bronchitis, 8 for heart abnormalities, 1 for pharyngitis, 9 for "gassed," and 13 all others. The average compensation period of the 20 tuberculosis cases was 998 days and of the 66 bronchitis cases 1,179 days. Nine of the discontinued compensations for tuberculosis were terminated by death. Of the 192 cases under compensation or vocational training, the compensable disabilities recorded are: Pulmonary tuberculosis, 63; bronchitis, 79; laryngitis, 1; disease of heart, 10; disease of eyes, 6; disease of nervous system, 15; "gassed," 7; all others, 11. Of the 63 tuberculosis cases the average disability is 41.5 per cent and the average period between date gassed and beginning of compensation is 397 days. Of the 79 cases of bronchitis, the average disability is 29.34 percent, and the average period between date of gassing and the beginning of compensation is 301 days. Of the total number under compensation, 24 are receiving the maximum rate of 100 percent and 67 the minimum rate of 10 percent.
SUMMARY OF TABLE OF 160 CASUALTIES FROM MIXED GASES, AND GASES, VARIETY UNKNOWN
The average period of hospitalization of the total casualties from gases recorded and classified in this study as mixed is shown to be 67 days. Of the 160 casualties from mixed gases considered, the deaths of 4 are recorded, 3 of which occurred in service and 1 after discharge from service; 3 were caused by traumatism and 1 by disease. The death caused by disease occurred in service from bronchopneumonia, 13 days after date of gassing; therefore only 1 death in this series is attributed to gas. No death is recorded among those discharged on surgeon's certificate of disability or with disability on demobilization.
Five were discharged on surgeon's certificate of disability, 3 for disabilities directly attributed to gas, 1 for disability not due to gas, and 1 for disability cause indeterminable from the records. Of the 3 cases attributed to gas, the average disability on discharge was 28.3 percent and the average period between date of gassing and date of discharge was 350 days. The disabilities were: Pulmonary tuberculosis, 1; disability, 35 percent, discharged 429 days after date of gassing, now receiving 100 percent compensation for tuberculosis; 1 for dyspnea, cough and effort syndrome, disability, 50 percent, discharged 252 days days after date of gassing, awarded compensation for bronchitis, since discontinued; and 1 for myocarditis, cardiac hypertrophy, and dilatation, disability, 20 percent, discharged 369 days after date of gassing, now receiving 10 percent compensation for mitral insufficiency. The case for which the cause for discharge is indeterminable was discharged, disability, 50 percent, 273 days after date of gassing for cardiac hypertrophy, dvspnea, and tachycardia, after
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an original stay in hospital of 92 days for bronchitis, with a readmission 90 days later for effort syndrome, and is now receiving 25 percent compensation for bronchitis.
Twelve cases were rated a disability at time of discharge from service. Of these, 10 were attributed to gas and 2 to causes other than gas. Of the 10 attributed to gas, the average disability rating was 12.3 percent and the causes recorded were: Pulmonary tuberculosis, 1, disability 331/3percent; bronchitis, 7; "disordered heart," 1; and "nervousness," 1. The average disability of the 7 discharged with bronchitis was 10 per cent and the average interval between date of gassing and date of discharge was 247 days. Of the 10 cases attributed to gas, 4 are now receiving compensation (2, including the case discharged with pulmonary tuberculosis, for the same disability existing upon discharge; the I discharged with "disordered heart," for pharyngitis; and the 1 discharged with nervousness," for pulmonary tuberculosis): 3 were awarded compensa- tions which were subsequently discontinued; and 3 made no claim for compensation.
Of this series, totaling 160 cases, 3 died in service, and the records of the United States Veterans' Bureau show that 60 have made no claim for compensation. Thirty-four claims have been disallowed,24 compensations were awarded and discontinued after varying periods, and 39 are now under compensation or vocational training. Of the 24 discontinued compensations, 2 were for pulmonary tuberculosis, 16 for bronchitis, 1 for "throat and tonsils," 2 for "gassed," and 3, all others. The average compensation period of the 2 tuberculosis cases was 1,206 (lays and of the 16 bronchitis cases, 1,283 days. None of the discontinued compensations were terminated by death. Of the 39 under compensation or vocational training, the compensable disabilities recorded are: Pulmonary tuberculosis, 9; bronchitis, 15; pharyngitis, 1; disease of heart, 8; disease of eyes, 1; "gassed," 2; all others, 3. Of the 9 tuberculosis cases, the average disability is 49.4 percent and the average period between date of gassing and beginning of compensation 395 days. Of the 15 bronchitis cases the average disability is 20 percent and the average period between date of gassing and beginning of compensation 287 days. Of the total number under compensation, 3 are receiving the maximum rate of 100 percent and 14 the minimum rate of 10 percent.
SUMMARY OF STUDY OF 3,014 GAS CASUALTIES
Table 16 consists of a résumé of the four tables summarized in the preceding text. The average period of hospitalization of the entire 3,014 gas casualties was found to be 54.34 days. The hospitalization period appears to have been greater for the mustard gas than for either the chlorine or phosgene gas casualties, the probable explanation being that surface burns in many instances prolonged hospitalization.
Of the 79 deaths from disease, 30 (0.99 percent of total cases, 22.72 percent of total deaths and 37.97 percent of total deaths from disease) were obviously due to the effects of gas, 12 dying within 10 days, 15 within 30 days, I in 61 days, I in 1,137 days, and 1 in 1,955 days. All but the last 2 of these died in service and 24 of the 30 died from the effects of mustard gas. Of the 44
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TABLE 16.-A study of 3,014 gassed cses, American Expeditionary Forces (1917-18) wih a view to determine after-effects. Numbers and percentage of the total number of cases of the series and of certain specific classes for each result
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deaths from disease occurring in service, none was from pulmonary tuberculosis, although the 1 in 61 days from bronchopneumonia was additionally diagnosed ulcerative laryngitis and pulmonary tuberculosis, chronic; 29 (36.70 percent of total deaths from disease) were from pneumonia and 28 were attributable to the immediate effects of gas. Of the 35 deaths from disease after demobilization, 17 (0.56 percent of total cases, 12.87 percent of total deaths, and 21.51 per cent of total deaths from disease) were from pulmonary tuberculosis, 2 of which were directly attributable to gas, the primary causes of the tuberculosis in the remaining 15 being indeterminable from the records. The average period between date gassed and date of death of these 17 cases was 1,374 days, the longest individual period being 1,995 days. The report of the United States Bureau of the Census for 1920 2 shows that the annual death rate from pulmonary tuberculosis per 100,000 population, in the registration States of 1900, for males for the age period 20 to 24 years, is 127.6 percent, which is equivalent to 3.84 per 3,014, the total number considered here. At this rate, the death rate would be 19.22 percent for 5 years, which is approximately the period over which the 17 deaths from tuberculosis of this series occurred, the most recent death occurring 1,995 days after date gassed. It appears, therefore, that the number of deaths from pulmonary tuberculosis among these gassed cases is somewhat less than the rate shown by the Census report for 1920 for males 20 to 24 years of age. The office of gas as a causative factor in the deaths from disease of 21 cases is not determinable from the records, and it is possible that some of these deaths were indirectly due to gas. It should be understood that these discontinuances other than by death were due to improvement to a degree less than 10 per cent incapacity.
Of the 622 (20.63 percent) now under compensation, at an average rate of 38.42 percent, 174 (5.77 percent) are being compensated for pulmonary tuberculosis, at an average rate of 49.58 percent, and 253 (8.39 percent) for bronchitis, at an average rate of 25.28 percent. The smaller comparative number under compensation for pulmonary tuberculosis, appearing among those gassed by phosgene, ordinarily would indicate that phosgene was less conducive to pulmonary tuberculosis than either chlorine or mustard gas: but it is apparent that the number under compensation for bronchitis, among those gassed by phosgene, is greater than that among those gassed by either chlorine or mustard gas: then, too, the average percentage of compensation for pulmonary tuberculosis appears less among those gassed by mustard gas than among those gassed by either chlorine or phosgene gas, and it was observed in the records that among the cases gassed with mustard gas the proportion of 100 percent compensations for bronchitis was greater than the proportion of 100 percent compensations for bronchitis among the other two gases. It is possible, therefore, that an explanation of this difference in incidence of pulmonary tuberculosis may be reduced to a question of diagnosis, or gravity of the cases of bronchitis involved. Of the total number receiving compensation, 55 (1.82 percent) are receiving compensation for diseases of the heart, 52 (1.72 percent) for diseases of the nervous system, 17 (0.56 percent) each for diseases of the eyes, and of the upper air passages. Of the total number receiving compensation, 92 (14.79 percent) are receiving the maximum rate of 100 per cent and 225 (36.17 percent) the minimum rate of 10 per cent. There are 1,333 (44.22 percent) who have made no claim for compensation: 619 (20.53 percent) were awarded compensation which was subsequently discontinued after varying periods, and 13 (0.43 percent) claims are pending.
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Among the noteworthy evidences of the effects of poison gases apparent from the results shown are: The great preponderance of effects of the respiratory organs; the comparative rarity of persistent effects on the eyes and upper respiratory passages; the greater proportion of deaths from the immediate or recent effects of mustard gas, while in its remote effects there is little or no difference from those of chlorine or phosgene; and a death rate, from pulmonary tuberculosis, over a period in excess of 5 years, less than the rate contained in the Census report for 1920 for males, from 20 to 24 years of age. The selectivity factor of those in military service is probably off-set by the proportion of colored, among whom the rate is higher, included in the Census report.
REFERENCES
(1) Bull. No. 16, W. D., August 13; 1921.
(2) Mortality Statistics, 1920, Department of Commerce.
