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+*** START OF THE PROJECT GUTENBERG EBOOK 76801 ***
+
+
+
+
+
+  _For official use only_
+
+                       MEDICAL RESEARCH COMMITTEE
+
+
+
+
+                                AN ATLAS
+                                   OF
+                             GAS POISONING
+
+
+[Illustration: [Logo]]
+
+                                  1918
+
+
+
+
+The Medical Research Committee have made the necessary arrangements for
+the preparation and reproduction of the drawings shown in this Atlas.
+The Atlas is printed for distribution in size uniform with the series of
+Reports issued by the Chemical Warfare Medical Committee with the
+sanction of the Director-General A.M.S. and of the Controller of the
+Chemical Warfare Department, Ministry of Munitions. The arrangements
+have been facilitated by the co-operation of the American Red Cross
+Society, who have undertaken to provide part of the present issue of
+this Atlas for official distribution in the American Army Medical
+Service.
+
+
+The following Reports of the Chemical Warfare Medical Committee have
+already been issued:
+
+No. 1. Notes on the Pathology and Treatment of the Effects of Pulmonary
+Irritant Gases. (_March_, 1918.)
+
+No. 2. The Histological Effects produced by Gas Poisoning and their
+Significance. (_April_, 1918.)
+
+No. 3. The Symptoms and Treatment of the Late Effects of Gas Poisoning.
+(_April_, 1918.)
+
+No. 4. Polycythæmia after Gas Poisoning and the Effect of Oxygen
+Administration in the Treatment of Chronic Cases. (_April_, 1918.)
+
+No. 5. The Reflex Restriction of Respiration after Gas Poisoning.
+(_April_, 1918.)
+
+No. 6. Investigations into the Reaction of the Blood after Gas
+Poisoning, and the Results of the Administration of Saline and other
+Substances. The Effects of Bleeding and of the Injection of Calcium
+Chloride. (_April_, 1918.)
+
+No. 7. Changes observed in the Heart and Circulation and the general
+After-Effects of Irritant Gas Poisoning. (_April_, 1918.)
+
+No. 8. Reports on Fatal Cases of Poisoning. (i.) Ethyl iodoacetate.
+(_June_, 1918).
+
+
+
+
+                                AN ATLAS
+
+                                   OF
+
+                             GAS POISONING
+
+
+These drawings have been reproduced by the permission of the
+Director-General of Medical Services, B. E. F., and they are presented
+as a supplement to the official memoranda on the Nature and Treatment of
+Gas Poisoning that have already been issued by General Headquarters to
+Medical Officers.
+
+The drawings illustrate only the chief features in the pathology of the
+lesions produced by Enemy Gas, and the primary aim of their distribution
+is that of general instruction for Officers who are not already familiar
+with the subject by experience in the field.
+
+The copyright of all these drawings is reserved and the contents of the
+Atlas must be regarded as confidential and not to be communicated to the
+press.
+
+  B. E. F. FRANCE.
+      AUGUST 1, 1918.
+
+Out of all the various substances used by the Enemy in Gas Warfare only
+two have been chosen for illustration of their effects in this Atlas.
+They are Phosgene (COCl_{2}), and Di-chlorethyl-sulphide,
+(C_{2}H_{4}Cl)_{2}S, or ‘Mustard Gas’.
+
+=Phosgene= is the chief of all the many gasses and liquids that are used
+for their effects as _pulmonary irritants_. Chlorine belongs to this
+group and was the first Poison Gas used by the Germans in April 1915,
+but it has long since been superseded by more effective chemical
+substances. The pulmonary irritants are inhaled as gasses or vapours.
+They may cause some watering of the eyes, but the chief effect noticed
+at once is a catching of the breath or a choking sensation so that the
+chest feels gripped and incapable of free respiration. Coughing and
+vomiting may follow, and then after a delay of time varying from a few
+minutes to several hours an inflammatory reaction appears in the lungs
+themselves, with the development of an acute oedema that may commence
+insidiously and yet progress so rapidly as soon to be an immediate
+menace to life itself.
+
+The alveoli fill with oedema fluid, which then rises into the bronchial
+tubes and may appear in a most abundant expectoration of thin frothy
+fluid. Aeration of the blood is seriously interfered with, because the
+air sacs are either drowned with oedema fluid or burst by the efforts of
+coughing. Moreover the actual circulation through the lungs is
+embarrassed, both by the pressure of the oedema fluid on the capillary
+vessels and by the local thrombosis that occurs in many places in the
+smaller lung vessels. The blood itself is concentrated by the loss of
+serum so that the count may rise to even eight or nine million red
+corpuscles to the cu. mm. and this change probably adds to the
+difficulties of the circulation.
+
+The gassed man can no longer get the oxygen that he wants, and he either
+dies in obvious asphyxia with progressive circulatory failure, or he
+collapses as the result of some muscular effort that suddenly makes a
+greater call for oxygen and so reveals the deficiency of the supply.
+Death is the result simply of this inflammatory oedema of the lung, and
+it occurs chiefly in the first and second day after exposure to
+Phosgene. A few cases may chance to develop secondary bacterial
+infections of the lungs and to succumb to a later broncho-pneumonia, but
+they are relatively rare.
+
+The main clinical features of acute Phosgene poisoning may therefore be
+summarized as follows:
+
+
+(i) Catching of the breath, choking, and coughing _immediately_ on
+exposure to the gas.
+
+(ii) Inability to expand the chest in a full breath after removal from
+the poisoned air.
+
+(iii) Vomiting, hurried shallow respiration, and sometimes coughing with
+an abundant expectoration, follow. Pain is felt behind the sternum and
+across the lower part of the chest. Fine râles are heard in the axillae
+and over the back.
+
+(iv) Cyanosis next appears, in association either with a full venous
+congestion or with the pallid face of circulatory failure. The
+development of these dangerous symptoms may occur after many hours’
+delay, and sometimes with unexpected rapidity in an apparently slight
+case as the result of muscular effort.
+
+(v) Death, which may or may not be preceded by mild delirium or
+unconsciousness, rarely occurs after the first or second day.
+
+
+=Di-chlor-ethyl-sulphide= is spoken of as being a _vesicant_. It may
+exert its irritant action either as a vapour in low concentration in the
+air or by direct contact from splashes of the liquid. The liquid or
+vapour clings to the clothing of men exposed to Yellow Cross shells, and
+thus slowly exerts its continuously irritant action on their bodies.
+
+No irritant effect at all is felt on first exposure, whatever the
+concentration may be, but after a delay of about two to six hours the
+skin and mucous membranes begin to react with a progressive inflammation
+that may result in local necrosis and desquamation of these covering
+membranes. There is intense conjunctivitis; the skin turns an angry red,
+and this erythema is soon followed by skin blistering here and there
+over the face and body. The passage of the vapour down the respiratory
+tract may cause such severe injury to the lining mucous membranes of the
+trachea and bronchioles that they are eventually destroyed and sloughed
+away. Bacterial infection then seizes upon these raw surfaces, and the
+patient may die from secondary septic broncho-pneumonia.
+
+Death is never the direct result of the action of the poisonous vapour.
+From the 2nd day onward through the first and second week severely
+affected men may die, but only as the result of secondary bacterial
+infection. This poison therefore differs entirely from the lung
+irritants such as Phosgene, which kill directly and speedily by flooding
+the lungs with oedema fluid.
+
+The main features of poisoning from Mustard Gas may be resumed as
+follows:
+
+
+(i) _Delay_ of the irritant effect for at least two to three hours, and
+then a comparatively slow development of the various inflammatory
+reactions.
+
+(ii) Vomiting, and a sense of burning in the eyes, with discomfort in
+the throat, hoarse cough, and some retro-sternal pain.
+
+(iii) Intense conjunctivitis that temporarily ‘blinds’ the man.
+
+(iv) Burning of the exposed skin surfaces and of the moist areas in the
+axillae and groin, followed by blistering, excoriation, and brown
+staining.
+
+(v) Inflammatory necrosis of the mucous membrane of the trachea and
+bronchi, with the secondary development of infective bronchitis or
+septic broncho-pneumonia.
+
+(vi) Death is relatively uncommon: it occurs later than the first day
+and only as the result of septic complications.
+
+
+ No.
+
+  I. Microscopic section of human lung from phosgene shell poisoning.
+       Death at the nineteenth hour after gassing.
+
+ II. Blue type of asphyxia from phosgene poisoning, with intense venous
+       congestion.
+
+ III. Pallid type of asphyxia from phosgene poisoning, with circulatory
+       failure.
+
+ IV. Gangrene of foot caused by vascular thrombosis from chlorine
+       poisoning.
+
+  V. Erythema of skin from general exposure to the vapour of Yellow
+       Cross substance.
+
+ VI. Blistering of buttocks by mustard gas.
+
+ VII. Burning of scrotum and penis by mustard gas.
+
+ VIII. Brown staining from mustard gas.
+
+ IX. Ulceration of trachea by mustard gas.
+
+  X. Microscopic section of human lung from mustard gas poisoning, with
+       death at end of second day (40 hours).
+
+ XIA. Severely burned eye in the acute stage.
+
+ XIB. Slightly later stage of acute burning.
+
+ XIIA. Stage of resolution after severe burning.
+
+ XIIB. Late stage of resolution.
+
+ XIIIA. Drawing of the cornea in the acute stage of severe burning.
+
+ XIIIB. Drawing of cornea in the stage of resolution after severe burning.
+
+
+
+
+                              PLATE NO. I
+ Microscopic section of human lung from phosgene shell poisoning. Death
+                 at the nineteenth hour after gassing.
+
+
+The piece of lung shown is almost entirely useless for aeration of the
+blood. Most of the pulmonary alveoli are filled with oedema fluid, and
+the walls of the air sacs are burst asunder in many places. The rounded
+edges of these torn walls can be recognized both in the areas of
+emphysema and in the parts that are flooded with oedema fluid. The
+bronchus also is filled with oedema fluid, but it should be noted that
+its lining epithelium is intact and pus cells have not accumulated in
+the secretion. The blood vessels of the alveolar network are congested;
+and intravascular thrombosis is frequently found in these smaller
+vessels, though it is not actually shown in the area of this section.
+
+The main changes in the lung are:
+
+  Congestion, and occasional thrombosis, of the network of pulmonary
+  blood vessels.
+
+  Abundant outpouring of inflammatory oedema fluid both into the tissues
+  and into the air spaces of the alveoli and bronchi.
+
+  Disruptive emphysema of the weakened lung tissue.
+
+The result of these changes is that the blood circulation through the
+lungs is impeded, and the respiratory exchange of gasses between the
+blood and the air in the lung is seriously diminished. The gassed man is
+in danger of death by asphyxia so long as his lung is drowned in oedema
+fluid.
+
+From the third day onwards the oedema fluid is reabsorbed or
+expectorated, and the lung soon resumes its functions. Bronchopneumonic
+complications may develop from secondary infections, but they are not
+very common.
+
+The recovery of the lung, even after severe gassing appears to be
+functionally good. In the earlier stages of convalescence there may
+still be signs of persisting oxygen want, so that tachycardia with
+excessively rapid respiration is the result of even slight physical
+effort. Later these disabilities vanish. The microscopic examination of
+lungs in these stages of recovery has not been made.
+
+[Illustration: PLATE I.]
+
+
+
+
+                              PLATE NO. II
+   Blue type of asphyxia from phosgene poisoning, with intense venous
+                              congestion.
+
+
+_History of case._ Drawing made early on second day after gassing; when
+there was copious frothy sputum, frequent cough, and hurried shallow
+respiration of 40 to 48 with temperature of 101° and pulse 100. The
+patient was bled 15 ozs. and oxygen added to the air that he breathed.
+He soon made a complete recovery.
+
+Such venous congestion was more frequent with chlorine poisoning than it
+now is with phosgene. It is associated with a full strong pulse at the
+outset, though later the pulse may fail and the asphyxia change to the
+pallid type shown in Plate III. The patient as a rule is fully conscious
+and complains chiefly of headache and pains in the chest; he turns
+restlessly to and fro in extreme general discomfort, and his hurried
+breathing is interrupted from time to time by short bursts of coughing
+and of expectoration. The lung is in the oedematous state shown in Plate
+I.
+
+Oxygen, when given by an efficient apparatus, will at once change the
+blue tint of the face to a full pink colour, showing that it can still
+be absorbed by the blood through the lungs. Venesection relieves the
+discomfort felt by the patient, and probably lessens the embarrassment
+of the circulation.
+
+[Illustration: PLATE II.]
+
+
+
+
+                             PLATE NO. III
+   Pallid type of asphyxia from phosgene poisoning, with circulatory
+                                failure.
+
+
+The cyanotic hue of the ears and lips, despite the general pallor caused
+by the failure of the circulation, indicates the intense want of oxygen
+from which the patient is suffering. Respiratory difficulty is shown in
+the strained effort of the muscles around the nostrils.
+
+_History of case._ Drawing made on second day after gassing, when there
+was profuse frothy expectoration, hurried shallow breathing of 50 a
+minute and a rapid running pulse of 132. The patient died two hours
+later.
+
+This pallid or leaden-hued type of asphyxia is characteristically
+frequent after phosgene, and it may either develop at once with a
+rapidly progressive failure of the circulation or follow a stage of
+venous congestion.
+
+The patient is restless, often semi-delirious, and his skin may be dry
+and hot, or cold in the final collapse, though it is not often damp with
+perspiration. The hurrying small pulse and the panting rapid shallow
+breathing, often with sounds of fluid in the trachea, are both
+characteristic. Examination of the chest finds physical signs very
+similar to those of the blue congested type, a little dulness on
+percussion and numerous fine râles and rhonchi, especially in the
+axillae and over the back. In both cases the intensity of the pulmonary
+oedema is hidden from physical examination by the presence everywhere in
+the lungs of scattered islets of emphysema.
+
+[Illustration: PLATE III.]
+
+
+
+
+                              PLATE NO. IV
+Gangrene of foot caused by vascular thrombosis from chlorine poisoning.
+
+
+_History of case._ Gassed by chlorine in 1915 under conditions which
+could not have induced frost-bite. Severe dyspnoea from pulmonary
+oedema.
+
+Drawing of foot made on fifth day. Both feet were then anaesthetic,
+stone cold, and no pulsation could be felt in the dorsalis pedis artery.
+The right hand also was mottled, cold, and painful. The circulation was
+restored in a few days with complete recovery, except that two toes
+became black and shrivelled.
+
+Such arterial thrombosis, of slowly progressive onset, is quite uncommon
+in the extremities, though it is occasionally seen with phosgene. The
+obstruction is very rarely so complete as to cause gangrene and death of
+the tissues. But this drawing of a visible condition is introduced in
+order to emphasize the fact that an unseen vascular thrombosis of
+smaller vessels in deeper organs of the body is frequently found with
+phosgene poisoning. Such thrombosis is revealed by the microscope in
+fatal cases in the smaller lung vessels, in the kidney, in the mucous
+membrane of the stomach, and in the brain. Indeed in deaths with
+prolonged asphyxia from gassing by phosgene the white matter of the
+brain is often seen to be thickly sown with brownish-red petechial spots
+around each tiny arterial thrombus. The obstruction to the lung
+circulation has already been referred to; the kidney thrombosis does not
+appear to have any serious results; and, except where larger
+haemorrhages have burst in the brain, the scattered cerebral thrombi do
+not appear to be of grave clinical import. The petechial areas within
+the stomach may occasionally become the seat of a superficial
+ulceration. Large thrombi are sometimes found within the heart, but they
+also are associated with rather than the cause of the other changes that
+lead to death.
+
+[Illustration: PLATE IV.]
+
+
+
+
+                              PLATE NO. V
+  Erythema of skin from general exposure to the vapour of yellow cross
+     substance. Dermatitis of this distribution and associated with
+   conjunctivitis forms a characteristic picture of poisoning by this
+                               vesicant.
+
+
+_History of case._ Exposed to ‘mustard gas’ at Ypres on July 12, 1917,
+when this substance was first employed by the enemy. Wore box respirator
+for only 30 minutes, so that he was exposed without any protection for
+nearly four hours. No symptoms were felt until some hours later, when
+severe vomiting commenced and conjunctivitis developed.
+
+Drawing made on the fifth day. The laryngitis and bronchitis were
+slight, so that the poisonous vapour must have acted only in low
+concentration. But the reddening of the skin was fairly intense because
+the man had been sweating freely when exposed to the gas, and he was not
+washed afterwards nor was his clothing changed. The erythema was
+succeeded by staining in the same areas of the skin.
+
+This reddening, as though the skin had been scorched or deeply
+sun-burned, is the first cutaneous reaction to mustard gas, though it
+sometimes may not appear until several days after exposure. It is
+accompanied by only a slight feeling of warmth and irritation. In
+addition to the face and arms which are directly exposed to the vapour
+in the air, the moist surfaces of the axillae, the flexures of the
+elbows, and the perineum and inner surfaces of the thighs are
+particularly affected, that is in the places where the skin is often
+sodden with fatty perspiration. This special distribution of the diffuse
+erythema characterizes the general dermatitis of mustard gas vapour; but
+the reaction may be limited to a smaller area in any part of the body,
+for example where the clothing may have chanced to be splashed by the
+liquid.
+
+The inflammatory reaction is chiefly superficial, and it is not
+accompanied by much oedema of the subcutaneous tissues except in the
+eyelids and over the penis and scrotum. Later the dusky red colour
+deepens, and patches of cyanotic or whitish oedema may arise amid it.
+Blisters then appear, and the cuticle becomes excoriated; or the skin
+may be retained while the erythema fades and a brown staining slowly
+darkens the original area of irritation.
+
+[Illustration: PLATE V.]
+
+
+
+
+                              PLATE NO. VI
+                 Blistering of buttocks by mustard gas.
+
+
+_History of case._ The man sat down on ground that was contaminated by
+the poison and the vapour passed through his clothing, causing
+inflammation of the buttocks and of the scrotum. A diffuse reddening
+appeared twenty-four hours after exposure, and this was followed by an
+outcrop of superficial blisters. On the eighth day the erythema began to
+be replaced by a brown staining, and the drawing was made on the
+eleventh day during this change of tints. Infection of the raw surface
+was avoided, and the healing was complete in three weeks.
+
+The blisters in this case were probably aggravated by pressure, for the
+inflamed skin becomes very fragile, so that the surface layer is readily
+loosened by pressure or careless rubbing. The blisters may be very tiny
+bullae, as on the eyelids, or they may coalesce into areas many inches
+across, covering a collection of serous fluid which perhaps itself
+contains enough of the irritant substance to injure other skin if it is
+allowed to flow over it.
+
+The blisters are usually quite superficial and almost painless in their
+development. But the raw surface that is left after the blister has
+burst becomes most acutely sensitive to all forms of mechanical
+irritation. Deeper destruction of the dermis may be caused by spreading
+necrosis where the substance attacks the skin locally in high
+concentration, or when secondary infections are implanted on the raw
+surface. Chronic and painful sores then result, and in this event the
+skin does not regenerate completely, so that thinly covered scars for a
+long time will mark the site of the burn.
+
+[Illustration: PLATE VI.]
+
+
+
+
+                             PLATE NO. VII
+              Burning of scrotum and penis by mustard gas.
+
+
+_History of case._ From the same incident as that described under Plate
+No. VI. Inflammation commenced at the close of the first day after
+exposure. Drawing made on the eleventh day when the red erythema had
+almost faded from the inner aspects of the thighs. The scrotum is
+oedematous and the raw surfaces have become the seat of a mild secondary
+eczematisation. The injuries were soon and completely healed.
+
+The perineum is peculiarly liable to be inflamed after exposure to the
+vapour of mustard gas, and the penis and scrotum become oedematous as
+well as reddened. Balanitis and pain with micturition may be
+troublesome. When the skin is excoriated, secondary infections of the
+raw surface are very likely to develop unless adequate precautions are
+taken to prevent sepsis. But with careful cleansing of the skin and
+clothes of a casualty after exposure to the vapour, inflammation of the
+perineum can be reduced to a comparatively trifling incidence.
+
+[Illustration: PLATE VII.]
+
+
+
+
+                             PLATE NO. VIII
+                    Brown staining from mustard gas.
+
+
+This purplish-brown, or brown, or brownish-black tint usually appears in
+areas that were first inflamed and red, but it may arise without such
+preceding erythema. Its distribution is in the same areas as those in
+which erythema occurs, that is over the exposed skin surfaces of the
+neck and hands, or on the sheltered moist flexures of the body. It may
+appear at any time from the fifth or sixth day onwards, and it persists
+for several weeks, until the stained cuticle desquamates. There is no
+deep pigmentation.
+
+The drawing was made from a case on the eighteenth day after exposure to
+gas, and the brown tint was present on the sixth day.
+
+[Illustration: PLATE VIII.]
+
+
+
+
+                              PLATE NO. IX
+                 Ulceration of trachea by mustard gas.
+
+
+The characteristic feature is the sloughing of the tracheal mucous
+membrane. The reddening of the base of the tongue and of the pharynx,
+with a sharp delimitation where the oesophagus has refused ingress to
+the toxic vapour, is seen also with chlorine and other irritant gasses.
+But the pharyngeal inflammation with mustard gas may proceed further to
+a local ulceration that will cause dysphagia for many days.
+
+The mucous membrane of the trachea and bronchi is affected by
+di-chlor-ethyl-sulphide in much the same way as is the skin. It reacts
+with an intense inflammation, and death of the surface layers soon
+results. The mass of necrotic tissue, exuded fibrin, and pus cells may
+form a yellowish-grey slough in which all manner of organisms flourish.
+Subsequently this false membrane comes away in patches or in entire
+casts from the raw surface of the bronchial wall.
+
+Meantime the infected débris and secretions tend to accumulate in the
+bronchial ramifications at the bases of the lungs, and infection may
+spread from them into the lung tissues and alveoli. Septic
+broncho-pneumonia, localised abscesses, superficial pleurisy, and even
+empyema or pyopneumothorax then develop and cause death.
+
+The drawing is of a trachea at the twelfth day after gassing. The base
+of the tongue and the pharynx show characteristic inflammation. Yellow
+necrotic sloughs lie on the larynx and at the bifurcation of the
+trachea. Between these the trachea is red and glistening, because it is
+now completely denuded of both mucous membrane and of slough. The dotted
+line points to a little group of ulcers on the posterior wall from which
+bleeding has occurred. The trachea and bronchi contained an abundance of
+thin yellow pus.
+
+[Illustration: PLATE IX.]
+
+
+
+
+                              PLATE NO. X
+Microscopic section of human lung from mustard gas poisoning, with death
+                    at end of second day (40 hours).
+
+
+The bronchiole is filled with fibrin and pus cells, and its lining
+epithelium has been completely destroyed. The inflammation has caused a
+characteristic ring of haemorrhage in the tissues around the bronchial
+tube, and infection is beginning to appear in the alveoli nearest to
+these inflamed tissues. But there is no generalised pulmonary oedema and
+no disruptive emphysema.
+
+Di-chlor-ethyl-sulphide may cause some catarrhal desquamation of the
+pulmonary endothelial cells, but it rarely excites an outpouring of
+oedema fluid from the pulmonary vessels. The pathological changes in the
+bronchioles and in the alveoli are therefore in the sharpest contrast
+with those caused by phosgene (see Plate No. I). As infection spreads
+into the lung tissues, patches of septic broncho-pneumonia and small
+abscesses develop, and these often excite an inflammatory oedema around
+them.
+
+If the patient lives, his bronchial mucous membrane is slowly
+regenerated; and during this time he is naturally subject to reflex
+spasms of coughing or even to a protracted bronchitis.
+
+[Illustration: PLATE X.]
+
+
+
+
+                             PLATE NO. XIA
+                Severely burned eye in the acute stage.
+
+
+Early in the second day after exposure to mustard gas vapour the eyelids
+and the external surface of the globe show an intense inflammatory
+reaction. Tears stream from between the closed oedematous eyelids, which
+may even be blistered, and there is often severe pain behind the eyes
+and in the forehead. The conjunctiva is swollen, oedematous, and bright
+red from injection of the blood vessels. The injury of the cornea, even
+when severe, is not so obvious, and careful examination is of great
+importance for its detection. Photophobia and blepharospasm render
+examination of the eye very difficult.
+
+The majority of gassed eyes exhibit inflammation of a general character
+that is not illustrated in this Atlas. But examples are continually
+occurring in which the eye is more severely burned, and these may be
+recognized by certain characteristic features that are depicted in the
+drawing, Plate No. XIA. Whenever a dead white band crosses the exposed
+area of the conjunctiva, while the parts of this membrane covered by the
+upper and lower lids are red and oedematous, serious injury from the
+burning is likely to have occurred.
+
+In the case illustrated, the caustic effect of the vapour is seen
+chiefly in the interpalpebral aperture. On each side of the cornea there
+is a dead white band due to coagulative oedema, which compresses the
+vessels, impairs the circulation, and thus acts as a menace to the
+nutrition of the cornea. The swelling in the region of this white band
+is slight, while the protected conjunctiva above and below it is greatly
+swollen and injected and may even bulge between the lids.
+
+The exposed portion of the cornea is grey and hazy; it has lost its
+lustre, and when viewed with a bright light and a magnifying glass it
+shows a blurred ‘window reflex’ and a typical ‘orange-skinned’ surface.
+The haze gradually fades off above in the region of the protected part
+of the cornea where the surface is usually bright and smooth. The pupil
+is at first contracted as the result of irritation and congestion. In
+this drawing it is shown as artificially dilated by atropine ointment,
+which should always be used early in severe cases or where there is much
+pain and blepharospasm.
+
+
+
+
+                             PLATE NO. XIB
+                 Slightly later stage of acute burning.
+
+
+The swelling in the conjunctiva above and below has subsided, but the
+vascular injection remains, and the solid white oedema in the palpebral
+aperture is still well marked. The cornea is grey in the exposed area.
+
+                 [_For_ History of the case _see page facing Plate XII_.
+
+[Illustration: PLATE XI.]
+
+_History of the case._ The casualty was caused by the bursting of a
+Yellow Cross shell close to the man when he was riding a restive mule,
+and his box respirator was momentarily displaced. A fine spray of the
+liquid must have splashed lightly over his right side, for cutaneous
+blisters developed on the neck, the cheek, and the forehead on this side
+only. The right eye showed serious burning with the central white band,
+while the left eye was only in the state of general red conjunctivitis.
+
+With the lowering of the nutrition of the corneal epithelium, secondary
+infection is liable to take place. In this case an infiltrated corneal
+ulcer is seen associated with a hypopyon. It is therefore important when
+there is conjunctival discharge, which indicates secondary infection,
+that in addition to the use of atropine the conjunctival sac should be
+cleansed by frequent bland irrigations and by the instillation of
+antiseptic drops so as to check infection of any corneal ulceration
+which may develop. Otherwise the infective progress which has led to
+hypopyon may progress till panophthalmitis supervenes.
+
+
+
+
+                             PLATE NO. XIIA
+               Stage of resolution after severe burning.
+
+
+The vascular injection is passing off, the solid oedema is becoming
+absorbed, and the corneal epithelium has regained its normal lustre. In
+this stage the use of atropine should be discontinued.
+
+
+
+
+                             PLATE NO. XIIB
+                       Late stage of resolution.
+
+
+The earlier vascular injection above and below the cornea has
+practically disappeared; the solid white oedema has been absorbed, and
+the conjunctiva in the palpebral aperture now shows definite injection,
+often of a bright violet tint. The entire picture has changed, so that
+the parts which were red in the acute stage are now white and the part
+which was formerly white is now red. This drawing would illustrate
+equally well the condition that may follow immediately on a very slight
+exposure to the irritant gas, when only a slight central band of red
+injection develops instead of the bloodless state of white oedema that
+is caused by the more severe burns.
+
+At this stage atropine and shades should be abandoned. Astringent drops
+should be instilled and photophobia combated with cold douching, &c.,
+while fresh air and occupation will help to restore the general health
+of the individual and mitigate any tendency to neurasthenia.
+
+[Illustration: PLATE XII.]
+
+
+
+
+                            PLATE NO. XIIIA
+      Drawing of the cornea in the acute stage of severe burning.
+
+
+This corresponds with Plate No. XIA. The exposed central area shows grey
+haze and loss of lustre on its stippled surface, which gradually fades
+off to the bright lustrous normal surface in the part above that has
+been protected by the eyelid. Injection of the conjunctival vessels is
+seen only in relation to this upper and less burned area.
+
+
+
+
+                            PLATE NO. XIIIB
+   Drawing of cornea in the stage of resolution after severe burning.
+
+
+The cornea is now smooth and bright with a clear light reflex on its
+surface. But some grey superficial nebulae are seen in the centre, and
+these may persist for several weeks. The injection of the conjunctival
+vessels is now limited to the central band.
+
+[Illustration: PLATE XIII.]
+
+------------------------------------------------------------------------
+
+
+
+
+                          TRANSCRIBER’S NOTES
+
+
+ ● Typos fixed; non-standard spelling and dialect retained.
+ ● Enclosed italics font in _underscores_.
+ ● Subscripts are shown using an underscore (_) with curly braces { },
+     as in H_{2}O.
+
+
+
+*** END OF THE PROJECT GUTENBERG EBOOK 76801 ***
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+    <title>An Atlas of Gas Poisoning | Project Gutenberg</title>
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+  </head>
+  <body>   
+<div style='text-align:center'>*** START OF THE PROJECT GUTENBERG EBOOK 76801 ***</div>
+
+<div class='tnotes covernote'>
+
+<p class='c000'><strong>Transcriber’s Note:</strong></p>
+
+<p class='c000'>New original cover art included with this eBook is granted to the public domain.</p>
+
+</div>
+
+<div class='titlepage'>
+
+<div class='lg-container-l c001'>
+  <div class='linegroup'>
+    <div class='group'>
+      <div class='line'><span class='under'>For official use only</span></div>
+    </div>
+  </div>
+</div>
+
+<div class='nf-center-c0'>
+  <div class='nf-center'>
+    <div>MEDICAL RESEARCH COMMITTEE</div>
+  </div>
+</div>
+
+<div>
+  <h1 class='c002'><span class='xlarge'>AN ATLAS</span><br> <span class='large'>OF</span><br> GAS POISONING</h1>
+</div>
+
+<div  class='figcenter id001'>
+<img src='images/i_title.jpg' alt='[Logo]' class='ig001'>
+</div>
+
+<div class='nf-center-c0'>
+<div class='nf-center c003'>
+    <div><span class='small'>1918</span></div>
+  </div>
+</div>
+
+</div>
+
+<p class='c004'>The Medical Research Committee have made the necessary arrangements
+for the preparation and reproduction of the drawings shown in
+this Atlas. The Atlas is printed for distribution in size uniform with
+the series of Reports issued by the Chemical Warfare Medical
+Committee with the sanction of the Director-General A.M.S. and of
+the Controller of the Chemical Warfare Department, Ministry of
+Munitions. The arrangements have been facilitated by the co-operation
+of the American Red Cross Society, who have undertaken to
+provide part of the present issue of this Atlas for official distribution
+in the American Army Medical Service.</p>
+
+<p class='c005'>The following Reports of the Chemical Warfare Medical Committee
+have already been issued:</p>
+
+<p class='c006'>No. 1. Notes on the Pathology and Treatment of the Effects of
+Pulmonary Irritant Gases. (<em>March</em>, 1918.)</p>
+
+<p class='c006'>No. 2. The Histological Effects produced by Gas Poisoning and
+their Significance. (<em>April</em>, 1918.)</p>
+
+<p class='c006'>No. 3. The Symptoms and Treatment of the Late Effects of Gas
+Poisoning. (<em>April</em>, 1918.)</p>
+
+<p class='c006'>No. 4. Polycythæmia after Gas Poisoning and the Effect of Oxygen
+Administration in the Treatment of Chronic Cases. (<em>April</em>, 1918.)</p>
+
+<p class='c006'>No. 5. The Reflex Restriction of Respiration after Gas Poisoning.
+(<em>April</em>, 1918.)</p>
+
+<p class='c006'>No. 6. Investigations into the Reaction of the Blood after Gas
+Poisoning, and the Results of the Administration of Saline and other
+Substances. The Effects of Bleeding and of the Injection of Calcium
+Chloride. (<em>April</em>, 1918.)</p>
+
+<p class='c006'>No. 7. Changes observed in the Heart and Circulation and the
+general After-Effects of Irritant Gas Poisoning. (<em>April</em>, 1918.)</p>
+
+<p class='c006'>No. 8. Reports on Fatal Cases of Poisoning. (i.) Ethyl iodoacetate.
+(<em>June</em>, 1918).</p>
+
+<div class='chapter ph1'>
+
+<div class='nf-center-c0'>
+<div class='nf-center c001'>
+    <div><span class='xlarge'>AN ATLAS</span></div>
+    <div class='c007'><span class='large'>OF</span></div>
+    <div class='c007'>GAS POISONING</div>
+  </div>
+</div>
+
+</div>
+
+<p class='c005'>These drawings have been reproduced by the permission
+of the Director-General of Medical Services,
+B. E. F., and they are presented as a supplement to the
+official memoranda on the Nature and Treatment of
+Gas Poisoning that have already been issued by
+General Headquarters to Medical Officers.</p>
+
+<p class='c006'>The drawings illustrate only the chief features in the
+pathology of the lesions produced by Enemy Gas, and
+the primary aim of their distribution is that of general
+instruction for Officers who are not already familiar
+with the subject by experience in the field.</p>
+
+<p class='c006'>The copyright of all these drawings is reserved and
+the contents of the Atlas must be regarded as confidential
+and not to be communicated to the press.</p>
+
+<div class='lg-container-l'>
+  <div class='linegroup'>
+    <div class='group'>
+      <div class='line'>B. E. F. <span class='sc'>France.</span></div>
+      <div class='line in4'><span class='sc'>August 1, 1918.</span></div>
+    </div>
+  </div>
+</div>
+
+<p class='c006'>Out of all the various substances used by the Enemy in Gas
+Warfare only two have been chosen for illustration of their
+effects in this Atlas. They are Phosgene (COCl<sub>2</sub>), and Di-chlorethyl-sulphide,
+(C<sub>2</sub>H<sub>4</sub>Cl)<sub>2</sub>S, or ‘Mustard Gas’.</p>
+
+<p class='c006'><strong>Phosgene</strong> is the chief of all the many gasses and liquids
+that are used for their effects as <em>pulmonary irritants</em>. Chlorine
+belongs to this group and was the first Poison Gas used by the
+Germans in April 1915, but it has long since been superseded
+by more effective chemical substances. The pulmonary irritants
+are inhaled as gasses or vapours. They may cause some watering
+of the eyes, but the chief effect noticed at once is a catching
+of the breath or a choking sensation so that the chest feels
+gripped and incapable of free respiration. Coughing and
+vomiting may follow, and then after a delay of time varying
+from a few minutes to several hours an inflammatory reaction
+appears in the lungs themselves, with the development of an
+acute oedema that may commence insidiously and yet progress
+so rapidly as soon to be an immediate menace to life itself.</p>
+
+<p class='c006'>The alveoli fill with oedema fluid, which then rises into the
+bronchial tubes and may appear in a most abundant expectoration
+of thin frothy fluid. Aeration of the blood is seriously interfered
+with, because the air sacs are either drowned with oedema fluid
+or burst by the efforts of coughing. Moreover the actual
+circulation through the lungs is embarrassed, both by the
+pressure of the oedema fluid on the capillary vessels and by
+the local thrombosis that occurs in many places in the smaller
+lung vessels. The blood itself is concentrated by the loss of serum
+so that the count may rise to even eight or nine million red
+corpuscles to the cu. mm. and this change probably adds to the
+difficulties of the circulation.</p>
+
+<p class='c006'>The gassed man can no longer get the oxygen that he wants,
+and he either dies in obvious asphyxia with progressive
+circulatory failure, or he collapses as the result of some muscular
+effort that suddenly makes a greater call for oxygen and so reveals
+the deficiency of the supply. Death is the result simply of this
+inflammatory oedema of the lung, and it occurs chiefly in the first
+and second day after exposure to Phosgene. A few cases may
+chance to develop secondary bacterial infections of the lungs
+and to succumb to a later broncho-pneumonia, but they are
+relatively rare.</p>
+
+<p class='c006'>The main clinical features of acute Phosgene poisoning may
+therefore be summarized as follows:</p>
+
+<p class='c005'>(i) Catching of the breath, choking, and coughing <em>immediately</em>
+on exposure to the gas.</p>
+
+<p class='c006'>(ii) Inability to expand the chest in a full breath after removal
+from the poisoned air.</p>
+
+<p class='c006'>(iii) Vomiting, hurried shallow respiration, and sometimes
+coughing with an abundant expectoration, follow. Pain is felt
+behind the sternum and across the lower part of the chest. Fine
+râles are heard in the axillae and over the back.</p>
+
+<p class='c006'>(iv) Cyanosis next appears, in association either with a full
+venous congestion or with the pallid face of circulatory failure.
+The development of these dangerous symptoms may occur after
+many hours’ delay, and sometimes with unexpected rapidity in
+an apparently slight case as the result of muscular effort.</p>
+
+<p class='c006'>(v) Death, which may or may not be preceded by mild delirium
+or unconsciousness, rarely occurs after the first or second day.</p>
+
+<p class='c005'><strong>Di-chlor-ethyl-sulphide</strong> is spoken of as being a <em>vesicant</em>. It
+may exert its irritant action either as a vapour in low concentration
+in the air or by direct contact from splashes of the liquid.
+The liquid or vapour clings to the clothing of men exposed to
+Yellow Cross shells, and thus slowly exerts its continuously
+irritant action on their bodies.</p>
+
+<p class='c006'>No irritant effect at all is felt on first exposure, whatever the
+concentration may be, but after a delay of about two to six hours
+the skin and mucous membranes begin to react with a progressive
+inflammation that may result in local necrosis and desquamation
+of these covering membranes. There is intense conjunctivitis;
+the skin turns an angry red, and this erythema is soon followed
+by skin blistering here and there over the face and body. The
+passage of the vapour down the respiratory tract may cause such
+severe injury to the lining mucous membranes of the trachea and
+bronchioles that they are eventually destroyed and sloughed away.
+Bacterial infection then seizes upon these raw surfaces, and the
+patient may die from secondary septic broncho-pneumonia.</p>
+
+<p class='c006'>Death is never the direct result of the action of the poisonous
+vapour. From the 2nd day onward through the first and second
+week severely affected men may die, but only as the result of
+secondary bacterial infection. This poison therefore differs
+entirely from the lung irritants such as Phosgene, which kill
+directly and speedily by flooding the lungs with oedema fluid.</p>
+
+<p class='c006'>The main features of poisoning from Mustard Gas may be
+resumed as follows:</p>
+
+<p class='c005'>(i) <em>Delay</em> of the irritant effect for at least two to three hours,
+and then a comparatively slow development of the various
+inflammatory reactions.</p>
+
+<p class='c006'>(ii) Vomiting, and a sense of burning in the eyes, with
+discomfort in the throat, hoarse cough, and some retro-sternal
+pain.</p>
+
+<p class='c006'>(iii) Intense conjunctivitis that temporarily ‘blinds’ the man.</p>
+
+<p class='c006'>(iv) Burning of the exposed skin surfaces and of the moist areas
+in the axillae and groin, followed by blistering, excoriation, and
+brown staining.</p>
+
+<p class='c006'>(v) Inflammatory necrosis of the mucous membrane of the
+trachea and bronchi, with the secondary development of infective
+bronchitis or septic broncho-pneumonia.</p>
+
+<p class='c006'>(vi) Death is relatively uncommon: it occurs later than the first
+day and only as the result of septic complications.</p>
+ <dl class='dl_1 c003'>
+    <dt>No.</dt>
+    <dd>&#160;
+    </dd>
+    <dt><a href='#I'>I</a>.</dt>
+    <dd>Microscopic section of human lung from phosgene shell poisoning. Death at the nineteenth 
+    hour after gassing.
+    </dd>
+    <dt><a href='#II'>II</a>.</dt>
+    <dd>Blue type of asphyxia from phosgene poisoning, with intense venous congestion.
+    </dd>
+    <dt><a href='#III'>III</a>.</dt>
+    <dd>Pallid type of asphyxia from phosgene poisoning, with circulatory failure.
+    </dd>
+    <dt><a href='#IV'>IV</a>.</dt>
+    <dd>Gangrene of foot caused by vascular thrombosis from chlorine poisoning.
+    </dd>
+    <dt><a href='#V'>V</a>.</dt>
+    <dd>Erythema of skin from general exposure to the vapour of Yellow Cross substance.
+    </dd>
+    <dt><a href='#VI'>VI</a>.</dt>
+    <dd>Blistering of buttocks by mustard gas.
+    </dd>
+    <dt><a href='#VII'>VII</a>.</dt>
+    <dd>Burning of scrotum and penis by mustard gas.
+    </dd>
+    <dt><a href='#VIII'>VIII</a>.</dt>
+    <dd>Brown staining from mustard gas.
+    </dd>
+    <dt><a href='#IX'>IX</a>.</dt>
+    <dd>Ulceration of trachea by mustard gas.
+    </dd>
+    <dt><a href='#X'>X</a>.</dt>
+    <dd>Microscopic section of human lung from mustard gas poisoning, with death at end of second 
+    day (40 hours).
+    </dd>
+    <dt><a href='#XI'>XI</a><span class='fss'>A</span>.</dt>
+    <dd>Severely burned eye in the acute stage.
+    </dd>
+    <dt><a href='#XI'>XI</a><span class='fss'>B</span>.</dt>
+    <dd>Slightly later stage of acute burning.
+    </dd>
+    <dt><a href='#XII'>XII</a><span class='fss'>A</span>.</dt>
+    <dd>Stage of resolution after severe burning.
+    </dd>
+    <dt><a href='#XII'>XII</a><span class='fss'>B</span>.</dt>
+    <dd>Late stage of resolution.
+    </dd>
+    <dt><a href='#XIII'>XIII</a><span class='fss'>A</span>.</dt>
+    <dd>Drawing of the cornea in the acute stage of severe burning.
+    </dd>
+    <dt><a href='#XIII'>XIII</a><span class='fss'>B</span>.</dt>
+    <dd>Drawing of cornea in the stage of resolution after severe burning.
+    </dd>
+    </dl>
+
+<div class='chapter'>
+  <h2 class='c008'>PLATE NO. I<br> <span class='c009'>Microscopic section of human lung from phosgene shell poisoning. Death at the nineteenth hour after gassing.</span></h2>
+</div>
+
+<p class='c005'>The piece of lung shown is almost entirely useless for aeration of
+the blood. Most of the pulmonary alveoli are filled with oedema
+fluid, and the walls of the air sacs are burst asunder in many places.
+The rounded edges of these torn walls can be recognized both in the
+areas of emphysema and in the parts that are flooded with oedema
+fluid. The bronchus also is filled with oedema fluid, but it should
+be noted that its lining epithelium is intact and pus cells have not
+accumulated in the secretion. The blood vessels of the alveolar network
+are congested; and intravascular thrombosis is frequently found
+in these smaller vessels, though it is not actually shown in the area of
+this section.</p>
+
+<p class='c006'>The main changes in the lung are:</p>
+
+<p class='c010'>Congestion, and occasional thrombosis, of the network of pulmonary
+blood vessels.</p>
+
+<p class='c010'>Abundant outpouring of inflammatory oedema fluid both into
+the tissues and into the air spaces of the alveoli and bronchi.</p>
+
+<p class='c010'>Disruptive emphysema of the weakened lung tissue.</p>
+
+<p class='c006'>The result of these changes is that the blood circulation through the
+lungs is impeded, and the respiratory exchange of gasses between the
+blood and the air in the lung is seriously diminished. The gassed
+man is in danger of death by asphyxia so long as his lung is drowned
+in oedema fluid.</p>
+
+<p class='c006'>From the third day onwards the oedema fluid is reabsorbed or
+expectorated, and the lung soon resumes its functions. Bronchopneumonic
+complications may develop from secondary infections, but
+they are not very common.</p>
+
+<p class='c006'>The recovery of the lung, even after severe gassing appears to be
+functionally good. In the earlier stages of convalescence there may
+still be signs of persisting oxygen want, so that tachycardia with
+excessively rapid respiration is the result of even slight physical effort.
+Later these disabilities vanish. The microscopic examination of lungs
+in these stages of recovery has not been made.</p>
+
+<div id='I'  class='figcenter id002'>
+<img src='images/i011.jpg' alt='' class='ig001'>
+<div class='ic002'>
+<p><span class='sc'>Plate I.</span></p>
+</div>
+</div>
+
+<div class='chapter'>
+  <h2 class='c008'>PLATE NO. II<br> <span class='c009'>Blue type of asphyxia from phosgene poisoning, with intense venous congestion.</span></h2>
+</div>
+
+<p class='c005'><em>History of case.</em> Drawing made early on second day after gassing;
+when there was copious frothy sputum, frequent cough, and hurried
+shallow respiration of 40 to 48 with temperature of 101° and pulse 100.
+The patient was bled 15 ozs. and oxygen added to the air that he
+breathed. He soon made a complete recovery.</p>
+
+<p class='c006'>Such venous congestion was more frequent with chlorine poisoning
+than it now is with phosgene. It is associated with a full strong pulse
+at the outset, though later the pulse may fail and the asphyxia change
+to the pallid type shown in Plate <a href='#III'>III</a>. The patient as a rule is fully
+conscious and complains chiefly of headache and pains in the chest; he
+turns restlessly to and fro in extreme general discomfort, and his
+hurried breathing is interrupted from time to time by short bursts of
+coughing and of expectoration. The lung is in the oedematous state
+shown in Plate <a href='#I'>I</a>.</p>
+
+<p class='c006'>Oxygen, when given by an efficient apparatus, will at once change
+the blue tint of the face to a full pink colour, showing that it can still
+be absorbed by the blood through the lungs. Venesection relieves the
+discomfort felt by the patient, and probably lessens the embarrassment
+of the circulation.</p>
+
+<div id='II'  class='figcenter id002'>
+<img src='images/i015.jpg' alt='' class='ig001'>
+<div class='ic002'>
+<p><span class='sc'>Plate II.</span></p>
+</div>
+</div>
+
+<div class='chapter'>
+  <h2 class='c008'>PLATE NO. III<br> <span class='c009'>Pallid type of asphyxia from phosgene poisoning, with circulatory failure.</span></h2>
+</div>
+
+<p class='c005'>The cyanotic hue of the ears and lips, despite the general pallor
+caused by the failure of the circulation, indicates the intense want of
+oxygen from which the patient is suffering. Respiratory difficulty is
+shown in the strained effort of the muscles around the nostrils.</p>
+
+<p class='c006'><em>History of case.</em> Drawing made on second day after gassing, when
+there was profuse frothy expectoration, hurried shallow breathing of
+50 a minute and a rapid running pulse of 132. The patient died two
+hours later.</p>
+
+<p class='c006'>This pallid or leaden-hued type of asphyxia is characteristically
+frequent after phosgene, and it may either develop at once with a
+rapidly progressive failure of the circulation or follow a stage of
+venous congestion.</p>
+
+<p class='c006'>The patient is restless, often semi-delirious, and his skin may be dry
+and hot, or cold in the final collapse, though it is not often damp
+with perspiration. The hurrying small pulse and the panting rapid
+shallow breathing, often with sounds of fluid in the trachea, are both
+characteristic. Examination of the chest finds physical signs very
+similar to those of the blue congested type, a little dulness on percussion
+and numerous fine râles and rhonchi, especially in the axillae
+and over the back. In both cases the intensity of the pulmonary
+oedema is hidden from physical examination by the presence everywhere
+in the lungs of scattered islets of emphysema.</p>
+
+<div id='III'  class='figcenter id002'>
+<img src='images/i019.jpg' alt='' class='ig001'>
+<div class='ic002'>
+<p><span class='sc'>Plate III.</span></p>
+</div>
+</div>
+
+<div class='chapter'>
+  <h2 class='c008'>PLATE NO. IV<br> <span class='c009'>Gangrene of foot caused by vascular thrombosis from chlorine poisoning.</span></h2>
+</div>
+
+<p class='c005'><em>History of case.</em> Gassed by chlorine in 1915 under conditions which
+could not have induced frost-bite. Severe dyspnoea from pulmonary
+oedema.</p>
+
+<p class='c006'>Drawing of foot made on fifth day. Both feet were then anaesthetic,
+stone cold, and no pulsation could be felt in the dorsalis pedis artery.
+The right hand also was mottled, cold, and painful. The circulation
+was restored in a few days with complete recovery, except that two
+toes became black and shrivelled.</p>
+
+<p class='c006'>Such arterial thrombosis, of slowly progressive onset, is quite
+uncommon in the extremities, though it is occasionally seen with
+phosgene. The obstruction is very rarely so complete as to cause
+gangrene and death of the tissues. But this drawing of a visible
+condition is introduced in order to emphasize the fact that an unseen
+vascular thrombosis of smaller vessels in deeper organs of the body is
+frequently found with phosgene poisoning. Such thrombosis is
+revealed by the microscope in fatal cases in the smaller lung vessels, in
+the kidney, in the mucous membrane of the stomach, and in the brain.
+Indeed in deaths with prolonged asphyxia from gassing by phosgene
+the white matter of the brain is often seen to be thickly sown with
+brownish-red petechial spots around each tiny arterial thrombus. The
+obstruction to the lung circulation has already been referred to; the
+kidney thrombosis does not appear to have any serious results; and,
+except where larger haemorrhages have burst in the brain, the scattered
+cerebral thrombi do not appear to be of grave clinical import. The
+petechial areas within the stomach may occasionally become the seat
+of a superficial ulceration. Large thrombi are sometimes found
+within the heart, but they also are associated with rather than the
+cause of the other changes that lead to death.</p>
+
+<div id='IV'  class='figcenter id002'>
+<img src='images/i023.jpg' alt='' class='ig001'>
+<div class='ic002'>
+<p><span class='sc'>Plate IV.</span></p>
+</div>
+</div>
+
+<div class='chapter'>
+  <h2 class='c008'>PLATE NO. V<br> <span class='c009'>Erythema of skin from general exposure to the vapour of yellow cross substance. Dermatitis of this distribution and associated with conjunctivitis forms a characteristic picture of poisoning by this vesicant.</span></h2>
+</div>
+
+<p class='c005'><em>History of case.</em> Exposed to ‘mustard gas’ at Ypres on July 12,
+1917, when this substance was first employed by the enemy. Wore
+box respirator for only 30 minutes, so that he was exposed without any
+protection for nearly four hours. No symptoms were felt until some
+hours later, when severe vomiting commenced and conjunctivitis
+developed.</p>
+
+<p class='c006'>Drawing made on the fifth day. The laryngitis and bronchitis were
+slight, so that the poisonous vapour must have acted only in low
+concentration. But the reddening of the skin was fairly intense
+because the man had been sweating freely when exposed to the gas,
+and he was not washed afterwards nor was his clothing changed. The
+erythema was succeeded by staining in the same areas of the skin.</p>
+
+<p class='c006'>This reddening, as though the skin had been scorched or deeply
+sun-burned, is the first cutaneous reaction to mustard gas, though it
+sometimes may not appear until several days after exposure. It is
+accompanied by only a slight feeling of warmth and irritation. In
+addition to the face and arms which are directly exposed to the vapour
+in the air, the moist surfaces of the axillae, the flexures of the elbows,
+and the perineum and inner surfaces of the thighs are particularly
+affected, that is in the places where the skin is often sodden with
+fatty perspiration. This special distribution of the diffuse erythema
+characterizes the general dermatitis of mustard gas vapour; but the
+reaction may be limited to a smaller area in any part of the body, for
+example where the clothing may have chanced to be splashed by the
+liquid.</p>
+
+<p class='c006'>The inflammatory reaction is chiefly superficial, and it is not
+accompanied by much oedema of the subcutaneous tissues except in
+the eyelids and over the penis and scrotum. Later the dusky red
+colour deepens, and patches of cyanotic or whitish oedema may arise
+amid it. Blisters then appear, and the cuticle becomes excoriated; or
+the skin may be retained while the erythema fades and a brown staining
+slowly darkens the original area of irritation.</p>
+
+<div id='V'  class='figcenter id002'>
+<img src='images/i027.jpg' alt='' class='ig001'>
+<div class='ic002'>
+<p><span class='sc'>Plate V.</span></p>
+</div>
+</div>
+
+<div class='chapter'>
+  <h2 class='c008'>PLATE NO. VI<br> <span class='c009'>Blistering of buttocks by mustard gas.</span></h2>
+</div>
+
+<p class='c005'><em>History of case.</em> The man sat down on ground that was contaminated
+by the poison and the vapour passed through his clothing, causing
+inflammation of the buttocks and of the scrotum. A diffuse reddening
+appeared twenty-four hours after exposure, and this was followed by an
+outcrop of superficial blisters. On the eighth day the erythema began
+to be replaced by a brown staining, and the drawing was made on the
+eleventh day during this change of tints. Infection of the raw surface
+was avoided, and the healing was complete in three weeks.</p>
+
+<p class='c006'>The blisters in this case were probably aggravated by pressure, for
+the inflamed skin becomes very fragile, so that the surface layer is
+readily loosened by pressure or careless rubbing. The blisters may be
+very tiny bullae, as on the eyelids, or they may coalesce into areas
+many inches across, covering a collection of serous fluid which perhaps
+itself contains enough of the irritant substance to injure other skin if it
+is allowed to flow over it.</p>
+
+<p class='c006'>The blisters are usually quite superficial and almost painless in their
+development. But the raw surface that is left after the blister has
+burst becomes most acutely sensitive to all forms of mechanical
+irritation. Deeper destruction of the dermis may be caused by spreading
+necrosis where the substance attacks the skin locally in high
+concentration, or when secondary infections are implanted on the raw
+surface. Chronic and painful sores then result, and in this event the
+skin does not regenerate completely, so that thinly covered scars for a
+long time will mark the site of the burn.</p>
+
+<div id='VI'  class='figcenter id002'>
+<img src='images/i031.jpg' alt='' class='ig001'>
+<div class='ic002'>
+<p><span class='sc'>Plate VI.</span></p>
+</div>
+</div>
+
+<div class='chapter'>
+  <h2 class='c008'>PLATE NO. VII<br> <span class='c009'>Burning of scrotum and penis by mustard gas.</span></h2>
+</div>
+
+<p class='c005'><em>History of case.</em> From the same incident as that described under
+Plate No. <a href='#VI'>VI</a>. Inflammation commenced at the close of the first day
+after exposure. Drawing made on the eleventh day when the red
+erythema had almost faded from the inner aspects of the thighs. The
+scrotum is oedematous and the raw surfaces have become the seat of a
+mild secondary eczematisation. The injuries were soon and completely
+healed.</p>
+
+<p class='c006'>The perineum is peculiarly liable to be inflamed after exposure to the
+vapour of mustard gas, and the penis and scrotum become oedematous
+as well as reddened. Balanitis and pain with micturition may be
+troublesome. When the skin is excoriated, secondary infections of the
+raw surface are very likely to develop unless adequate precautions are
+taken to prevent sepsis. But with careful cleansing of the skin and
+clothes of a casualty after exposure to the vapour, inflammation of the
+perineum can be reduced to a comparatively trifling incidence.</p>
+
+<div id='VII'  class='figcenter id002'>
+<img src='images/i035.jpg' alt='' class='ig001'>
+<div class='ic002'>
+<p><span class='sc'>Plate VII.</span></p>
+</div>
+</div>
+
+<div class='chapter'>
+  <h2 class='c008'>PLATE NO. VIII<br> <span class='c009'>Brown staining from mustard gas.</span></h2>
+</div>
+
+<p class='c005'>This purplish-brown, or brown, or brownish-black tint usually
+appears in areas that were first inflamed and red, but it may arise
+without such preceding erythema. Its distribution is in the same
+areas as those in which erythema occurs, that is over the exposed skin
+surfaces of the neck and hands, or on the sheltered moist flexures of
+the body. It may appear at any time from the fifth or sixth day
+onwards, and it persists for several weeks, until the stained cuticle
+desquamates. There is no deep pigmentation.</p>
+
+<p class='c006'>The drawing was made from a case on the eighteenth day after
+exposure to gas, and the brown tint was present on the sixth day.</p>
+
+<div id='VIII'  class='figcenter id002'>
+<img src='images/i039.jpg' alt='' class='ig001'>
+<div class='ic002'>
+<p><span class='sc'>Plate VIII.</span></p>
+</div>
+</div>
+
+<div class='chapter'>
+  <h2 class='c008'>PLATE NO. IX<br> <span class='c009'>Ulceration of trachea by mustard gas.</span></h2>
+</div>
+
+<p class='c005'>The characteristic feature is the sloughing of the tracheal mucous
+membrane. The reddening of the base of the tongue and of the pharynx,
+with a sharp delimitation where the oesophagus has refused ingress to
+the toxic vapour, is seen also with chlorine and other irritant gasses.
+But the pharyngeal inflammation with mustard gas may proceed
+further to a local ulceration that will cause dysphagia for many days.</p>
+
+<p class='c006'>The mucous membrane of the trachea and bronchi is affected by di-chlor-ethyl-sulphide
+in much the same way as is the skin. It reacts
+with an intense inflammation, and death of the surface layers soon
+results. The mass of necrotic tissue, exuded fibrin, and pus cells may
+form a yellowish-grey slough in which all manner of organisms
+flourish. Subsequently this false membrane comes away in patches
+or in entire casts from the raw surface of the bronchial wall.</p>
+
+<p class='c006'>Meantime the infected débris and secretions tend to accumulate in
+the bronchial ramifications at the bases of the lungs, and infection may
+spread from them into the lung tissues and alveoli. Septic broncho-pneumonia,
+localised abscesses, superficial pleurisy, and even
+empyema or pyopneumothorax then develop and cause death.</p>
+
+<p class='c006'>The drawing is of a trachea at the twelfth day after gassing. The
+base of the tongue and the pharynx show characteristic inflammation.
+Yellow necrotic sloughs lie on the larynx and at the bifurcation of the
+trachea. Between these the trachea is red and glistening, because it
+is now completely denuded of both mucous membrane and of slough.
+The dotted line points to a little group of ulcers on the posterior wall
+from which bleeding has occurred. The trachea and bronchi contained
+an abundance of thin yellow pus.</p>
+
+<div id='IX'  class='figcenter id002'>
+<img src='images/i043.jpg' alt='' class='ig001'>
+<div class='ic002'>
+<p><span class='sc'>Plate IX.</span></p>
+</div>
+</div>
+
+<div class='chapter'>
+  <h2 class='c008'>PLATE NO. X<br> <span class='c009'>Microscopic section of human lung from mustard gas poisoning, with death at end of second day (40 hours).</span></h2>
+</div>
+
+<p class='c005'>The bronchiole is filled with fibrin and pus cells, and its lining
+epithelium has been completely destroyed. The inflammation has
+caused a characteristic ring of haemorrhage in the tissues around the
+bronchial tube, and infection is beginning to appear in the alveoli
+nearest to these inflamed tissues. But there is no generalised
+pulmonary oedema and no disruptive emphysema.</p>
+
+<p class='c006'>Di-chlor-ethyl-sulphide may cause some catarrhal desquamation of
+the pulmonary endothelial cells, but it rarely excites an outpouring of
+oedema fluid from the pulmonary vessels. The pathological changes
+in the bronchioles and in the alveoli are therefore in the sharpest
+contrast with those caused by phosgene (see Plate No. <a href='#I'>I</a>). As
+infection spreads into the lung tissues, patches of septic broncho-pneumonia
+and small abscesses develop, and these often excite
+an inflammatory oedema around them.</p>
+
+<p class='c006'>If the patient lives, his bronchial mucous membrane is slowly
+regenerated; and during this time he is naturally subject to reflex
+spasms of coughing or even to a protracted bronchitis.</p>
+
+<div id='X'  class='figcenter id002'>
+<img src='images/i047.jpg' alt='' class='ig001'>
+<div class='ic002'>
+<p><span class='sc'>Plate X.</span></p>
+</div>
+</div>
+
+<div class='chapter'>
+  <h2 class='c008'>PLATE NO. <span class='sc'>XIa</span><br> <span class='c009'>Severely burned eye in the acute stage.</span></h2>
+</div>
+
+<p class='c005'>Early in the second day after exposure to mustard gas vapour the
+eyelids and the external surface of the globe show an intense inflammatory
+reaction. Tears stream from between the closed oedematous
+eyelids, which may even be blistered, and there is often severe
+pain behind the eyes and in the forehead. The conjunctiva is swollen,
+oedematous, and bright red from injection of the blood vessels. The
+injury of the cornea, even when severe, is not so obvious, and careful
+examination is of great importance for its detection. Photophobia and
+blepharospasm render examination of the eye very difficult.</p>
+
+<p class='c006'>The majority of gassed eyes exhibit inflammation of a general
+character that is not illustrated in this Atlas. But examples are
+continually occurring in which the eye is more severely burned, and
+these may be recognized by certain characteristic features that are
+depicted in the drawing, Plate No. <span class='sc'><a href='#XI'>XI</a>a</span>. Whenever a dead white
+band crosses the exposed area of the conjunctiva, while the parts of
+this membrane covered by the upper and lower lids are red and
+oedematous, serious injury from the burning is likely to have occurred.</p>
+
+<p class='c006'>In the case illustrated, the caustic effect of the vapour is seen chiefly
+in the interpalpebral aperture. On each side of the cornea there is a
+dead white band due to coagulative oedema, which compresses the
+vessels, impairs the circulation, and thus acts as a menace to the
+nutrition of the cornea. The swelling in the region of this white band
+is slight, while the protected conjunctiva above and below it is greatly
+swollen and injected and may even bulge between the lids.</p>
+
+<p class='c006'>The exposed portion of the cornea is grey and hazy; it has lost its
+lustre, and when viewed with a bright light and a magnifying glass it
+shows a blurred ‘window reflex’ and a typical ‘orange-skinned’ surface.
+The haze gradually fades off above in the region of the protected
+part of the cornea where the surface is usually bright and smooth.
+The pupil is at first contracted as the result of irritation and congestion.
+In this drawing it is shown as artificially dilated by atropine ointment,
+which should always be used early in severe cases or where there is
+much pain and blepharospasm.</p>
+
+<div class='chapter'>
+  <h2 class='c008'>PLATE NO. <span class='sc'>XIb</span><br> <span class='c009'>Slightly later stage of acute burning.</span></h2>
+</div>
+
+<p class='c005'>The swelling in the conjunctiva above and below has subsided, but the
+vascular injection remains, and the solid white oedema in the palpebral
+aperture is still well marked. The cornea is grey in the exposed
+area.</p>
+
+<div class='lg-container-r'>
+  <div class='linegroup'>
+    <div class='group'>
+      <div class='line'>[<em>For</em> History of the case <em>see page facing Plate <a href='#XII'>XII</a></em>.</div>
+    </div>
+  </div>
+</div>
+
+<div id='XI'  class='figcenter id002'>
+<img src='images/i051.jpg' alt='' class='ig001'>
+<div class='ic002'>
+<p><span class='sc'>Plate XI.</span></p>
+</div>
+</div>
+
+<p class='c006'><em>History of the case.</em> The casualty was caused by the bursting of a
+Yellow Cross shell close to the man when he was riding a restive mule,
+and his box respirator was momentarily displaced. A fine spray of
+the liquid must have splashed lightly over his right side, for cutaneous
+blisters developed on the neck, the cheek, and the forehead on this
+side only. The right eye showed serious burning with the central
+white band, while the left eye was only in the state of general red
+conjunctivitis.</p>
+
+<p class='c006'>With the lowering of the nutrition of the corneal epithelium,
+secondary infection is liable to take place. In this case an infiltrated
+corneal ulcer is seen associated with a hypopyon. It is therefore
+important when there is conjunctival discharge, which indicates
+secondary infection, that in addition to the use of atropine the
+conjunctival sac should be cleansed by frequent bland irrigations and
+by the instillation of antiseptic drops so as to check infection of any
+corneal ulceration which may develop. Otherwise the infective progress
+which has led to hypopyon may progress till panophthalmitis
+supervenes.</p>
+
+<div class='chapter'>
+  <h2 class='c008'>PLATE NO. <span class='sc'>XIIa</span><br> <span class='c009'>Stage of resolution after severe burning.</span></h2>
+</div>
+
+<p class='c005'>The vascular injection is passing off, the solid oedema is becoming
+absorbed, and the corneal epithelium has regained its normal lustre.
+In this stage the use of atropine should be discontinued.</p>
+
+<div class='chapter'>
+  <h2 class='c008'>PLATE NO. <span class='sc'>XIIb</span><br> <span class='c009'>Late stage of resolution.</span></h2>
+</div>
+
+<p class='c005'>The earlier vascular injection above and below the cornea has
+practically disappeared; the solid white oedema has been absorbed,
+and the conjunctiva in the palpebral aperture now shows definite
+injection, often of a bright violet tint. The entire picture has changed,
+so that the parts which were red in the acute stage are now white and
+the part which was formerly white is now red. This drawing would
+illustrate equally well the condition that may follow immediately on a
+very slight exposure to the irritant gas, when only a slight central band
+of red injection develops instead of the bloodless state of white oedema
+that is caused by the more severe burns.</p>
+
+<p class='c006'>At this stage atropine and shades should be abandoned. Astringent
+drops should be instilled and photophobia combated with cold douching,
+&#38;c., while fresh air and occupation will help to restore the general
+health of the individual and mitigate any tendency to neurasthenia.</p>
+
+<div id='XII'  class='figcenter id002'>
+<img src='images/i057.jpg' alt='' class='ig001'>
+<div class='ic002'>
+<p><span class='sc'>Plate XII.</span></p>
+</div>
+</div>
+
+<div class='chapter'>
+  <h2 class='c008'>PLATE NO. <span class='sc'>XIIIa</span><br> <span class='c009'>Drawing of the cornea in the acute stage of severe burning.</span></h2>
+</div>
+
+<p class='c005'>This corresponds with Plate No. <span class='sc'><a href='#XI'>XI</a>a</span>. The exposed central
+area shows grey haze and loss of lustre on its stippled surface, which
+gradually fades off to the bright lustrous normal surface in the part
+above that has been protected by the eyelid. Injection of the
+conjunctival vessels is seen only in relation to this upper and less
+burned area.</p>
+
+<div class='chapter'>
+  <h2 class='c008'>PLATE NO. <span class='sc'>XIIIb</span><br> <span class='c009'>Drawing of cornea in the stage of resolution after severe burning.</span></h2>
+</div>
+
+<p class='c005'>The cornea is now smooth and bright with a clear light reflex on
+its surface. But some grey superficial nebulae are seen in the centre,
+and these may persist for several weeks. The injection of the
+conjunctival vessels is now limited to the central band.</p>
+
+<div id='XIII'  class='figcenter id002'>
+<img src='images/i061.jpg' alt='' class='ig001'>
+<div class='ic002'>
+<p><span class='sc'>Plate XIII.</span></p>
+</div>
+</div>
+
+<div class='pbb'>
+ <hr class='pb c007'>
+</div>
+<div class='tnotes x-ebookmaker'>
+
+<div class='chapter ph2'>
+
+<div class='nf-center-c0'>
+<div class='nf-center c001'>
+    <div>TRANSCRIBER’S NOTES</div>
+  </div>
+</div>
+
+</div>
+
+ <ul class='ul_1 c003'>
+    <li>Typos fixed; non-standard spelling and dialect retained.
+    </li>
+  </ul>
+
+</div>
+
+<div style='text-align:center'>*** END OF THE PROJECT GUTENBERG EBOOK 76801 ***</div>
+  </body>
+  <!-- created with ppgen.py 3.57e (with regex) on 2025-09-02 20:37:34 GMT -->
+</html>
+
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+This eBook, including all associated images, markup, improvements,
+metadata, and any other content or labor, has been confirmed to be
+in the PUBLIC DOMAIN IN THE UNITED STATES.
+
+Procedures for determining public domain status are described in
+the "Copyright How-To" at https://www.gutenberg.org.
+
+No investigation has been made concerning possible copyrights in
+jurisdictions other than the United States. Anyone seeking to utilize
+this eBook outside of the United States should confirm copyright
+status under the laws that apply to them.
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+Project Gutenberg (https://www.gutenberg.org) public repository for eBook #76801
+(https://www.gutenberg.org/ebooks/76801)