Spotlight www.thelancet.com/respiratory Vol 2 July 2014 523 Gas! Gas! Quick, boys! – An ecstasy of fumbling, Fitting the clumsy helmets just in time; But someone still was yelling out and stumbling, And flound’ring like a man in fire or lime. . . Dulce et Decorum Est, Wilfred Owen (1893–1918) “Gas is heavier than air, and soon fills the trenches and dugouts”, explains Arthur Guy Empey in his 1917 memoir of World War 1, Over the Top. After the greenish cloud started drifting into the British lines—probably chlorine, or at least some combination containing chlorine, the other chemical agents are colourless—Empey and his fellow soldiers had to act quickly. “A company man on our right was too slow in getting on his helmet”, writes Empey. “He sank to the ground, clutching at his throat, and after a few spasmodic twistings, went West [died]. It was horrible to see him die, but we were powerless to help him. In the corner of a traverse, a little, muddy cur dog, one of the company’s pets, was lying dead, with his two paws over his nose.” The helmets would keep you safe for 5 h or so, but you could hardly say they were comfortable; “a vile-smelling thing, and it was not long before one gets a violent headache from wearing it”, complains Empey. Still, the alternative was far worse. “I wish those people who talk about going on with this war whatever it costs could see the soldiers suffering from mustard gas poisoning”, wrote Vera Brittain, who served as a field nurse for the British forces during the war. “Great mustard-coloured blisters, blind eyes, all sticky and stuck together, always fighting for breath, with voices a mere whisper, saying that their throats are closing and they know they will choke.” The first large-scale deployment of chlorine occurred on the Western Front, during the Second Battle of Ypres. At daybreak on April 22, 1915, German forces released 168 tonnes of the choking agent, contained in over 5700 canisters. The toxic mist settled over 4 miles of Allied positions, filling the lungs of 10 000 or so soldiers, around 800 of whom died within minutes. Victims suffered severe respiratory distress, coughing and vomiting without respite. When chlorine dissolves in water, it produces hydrochloric and hypochlorous acids; it causes severe cellular damage, and fluid starts leaking into the lungs. General von Deimling, a German commander at Ypres, expressed qualms over the new weapon. “I must confess that the commission for poisoning the enemy, just as one poisons rats, struck me as it must any straightforward soldier: it was repulsive to me”, he commented. But this was war; “personal susceptibilities had to be silent”, affirmed the general. Von Deimling’s ambivalence was shared by many in the military. “Chemical weapons were really seen as something The fog of war that were unchivalrous”, Leeds University’s Alastair Hay told The Lancet Respiratory Medicine. “They were unseen agents that disabled and killed, rather than someone standing face-to-face with a bayonet, for example.” In fact, chemical weapons had already been banned under the strictures of the 1899 Hague Convention (“the prohibition of the use of projectiles with the sole object to spread asphyxiating poisonous gases”), but the Germans were undeterred. They cited a French statement admitting that “shells with stupefying gases” were being manufactured in furtherance of the country’s war effort. “The vapours spread by means of the shells with asphyxiating gases are not deadly, at least when small quantities are used and their effect is only momentary”, the French Ministry of War had offered, in a strikingly inadequate assurance. “What hypocrisy when the same people grow ‘indignant’ because the Germans much later followed them on the path they had pointed out!”, scoffed Germany. Regardless, soon enough the Allies had relinquished any lingering claim to the moral high ground. At the Battle of Loos in September 1915, the British forces unleashed 140 tonnes of chlorine. But things did not go according to plan. In places, the gas blew back into the British trenches, causing more than 2600 casualties, perhaps more than those suffered by the intended target. It had become very clear that releasing gas from cylinders and hoping that the winds were favourable was far from ideal. Phosgene, another choking agent, was much easier to deliver. Its effects could take up to 3 days to appear, but when they did, there could be no mistaking their severity. After inhalation, phosgene combines with water in the respiratory tract. Hydrochloric acid begins to eat away at the lung membranes and, as with chlorine, victims begin to Science Photo Library Soldiers repairing telephone wire during a gas attack For more on Syria see Country in Focus Lancet Respir Med 2013; 1: 439
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Spotlight
www.thelancet.com/respiratory Vol 2 July 2014 523
Gas! Gas! Quick, boys! – An ecstasy of fumbling,Fitting the clumsy helmets just in time;But someone still was yelling out and stumbling,And fl ound’ring like a man in fi re or lime. . .
Dulce et Decorum Est, Wilfred Owen (1893–1918)
“Gas is heavier than air, and soon fi lls the trenches and dugouts”, explains Arthur Guy Empey in his 1917 memoir of World War 1, Over the Top. After the greenish cloud started drifting into the British lines—probably chlorine, or at least some combination containing chlorine, the other chemical agents are colourless—Empey and his fellow soldiers had to act quickly. “A company man on our right was too slow in getting on his helmet”, writes Empey. “He sank to the ground, clutching at his throat, and after a few spasmodic twistings, went West [died]. It was horrible to see him die, but we were powerless to help him. In the corner of a traverse, a little, muddy cur dog, one of the company’s pets, was lying dead, with his two paws over his nose.”
The helmets would keep you safe for 5 h or so, but you could hardly say they were comfortable; “a vile-smelling thing, and it was not long before one gets a violent headache from wearing it”, complains Empey. Still, the alternative was far worse. “I wish those people who talk about going on with this war whatever it costs could see the soldiers suff ering from mustard gas poisoning”, wrote Vera Brittain, who served as a fi eld nurse for the British forces during the war. “Great mustard-coloured blisters, blind eyes, all sticky and stuck together, always fi ghting for breath, with voices a mere whisper, saying that their throats are closing and they know they will choke.”
The fi rst large-scale deployment of chlorine occurred on the Western Front, during the Second Battle of Ypres. At daybreak on April 22, 1915, German forces released 168 tonnes of the choking agent, contained in over 5700 canisters. The toxic mist settled over 4 miles of Allied positions, fi lling the lungs of 10 000 or so soldiers, around 800 of whom died within minutes. Victims suff ered severe respiratory distress, coughing and vomiting without respite. When chlorine dissolves in water, it produces hydrochloric and hypochlorous acids; it causes severe cellular damage, and fl uid starts leaking into the lungs. General von Deimling, a German commander at Ypres, expressed qualms over the new weapon. “I must confess that the commission for poisoning the enemy, just as one poisons rats, struck me as it must any straightforward soldier: it was repulsive to me”, he commented. But this was war; “personal susceptibilities had to be silent”, affi rmed the general.
Von Deimling’s ambivalence was shared by many in the military. “Chemical weapons were really seen as something
The fog of warthat were unchivalrous”, Leeds University’s Alastair Hay told The Lancet Respiratory Medicine. “They were unseen agents that disabled and killed, rather than someone standing face-to-face with a bayonet, for example.” In fact, chemical weapons had already been banned under the strictures of the 1899 Hague Convention (“the prohibition of the use of projectiles with the sole object to spread asphyxiating poisonous gases”), but the Germans were undeterred. They cited a French statement admitting that “shells with stupefying gases” were being manufactured in furtherance of the country’s war eff ort. “The vapours spread by means of the shells with asphyxiating gases are not deadly, at least when small quantities are used and their eff ect is only momentary”, the French Ministry of War had off ered, in a strikingly inadequate assurance. “What hypocrisy when the same people grow ‘indignant’ because the Germans much later followed them on the path they had pointed out!”, scoff ed Germany.
Regardless, soon enough the Allies had relinquished any lingering claim to the moral high ground. At the Battle of Loos in September 1915, the British forces unleashed 140 tonnes of chlorine. But things did not go according to plan. In places, the gas blew back into the British trenches, causing more than 2600 casualties, perhaps more than those suff ered by the intended target. It had become very clear that releasing gas from cylinders and hoping that the winds were favourable was far from ideal. Phosgene, another choking agent, was much easier to deliver. Its eff ects could take up to 3 days to appear, but when they did, there could be no mistaking their severity. After inhalation, phosgene combines with water in the respiratory tract. Hydrochloric acid begins to eat away at the lung membranes and, as with chlorine, victims begin to
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Soldiers repairing telephone wire during a gas attack
For more on Syria see Country in Focus Lancet Respir Med 2013; 1: 439
Spotlight
524 www.thelancet.com/respiratory Vol 2 July 2014
drown as fl uid accumulates in the lungs. A combination of phosgene and chlorine known as white star was deployed by the Allies during the Battle of the Somme; its bland name is an early example of the kind of doublespeak that today characterises the rhetoric of war—“collateral damage”, “enhanced interrogation”, and so forth. The British referred to their gas canisters as “accessories”.
By the end of World War 1, 124 000 tonnes of chemical agents had been dispersed. More than 90 000 soldiers had died as a result and more than 1 million had been injured. Chemical weapons had not been restricted to the Western Front. The British used them against the Ottoman forces in Palestine, and during the early days of the Russian Revolution, in support of the White Russians. Two decades later, the Japanese would deploy an array of agents against the Chinese, and the Italians would attack Abyssinia (now Ethiopia) with mustard gas. In the 1960s, Egyptian forces unleashed a combination of phosgene and mustard gas during their intervention in the North Yemen Civil War.
Later came the atrocities of Saddam Hussein, fi rst against Iran and then, in 1988, against Kurdish civilians in the town of Halabja. “I saw people lying on the ground, vomiting a green-coloured liquid, while others became hysterical and began laughing loudly before falling motionless onto the ground”, a survivor of the Halabja attack told a correspondent from Radio Free Iraq in 2008. Iraqi air forces had used a concoction composed of mustard gas and a nerve agent. “It is a situation that cannot be described”, the survivor added. “Birds began falling from their nests; then other animals, then humans. It was total annihilation. Whoever was able to walk out of the town, left on foot. Whoever had a car, left by car. But whoever had too many children to carry on their shoulders, they stayed in the town and succumbed to the gas.”
The brutal and indiscriminate attack on Halabja excited widespread revulsion. It confi rmed that those who lacked protection—civilians, in short—were the most vulnerable to chemical attacks. “It really helped set the seal on chemical weapons”, explains Hay. “It led to the negotiation of the treaty that we have now, the Chemical Weapons Convention [CWC], which forbids anyone using weapons or hoarding them or helping anybody else to acquire them.” 5000 people died in Halabja, but the eff ects on the survivors are unclear. “At the moment we really don’t know enough about the long-term eff ect of chemical weapons”, said Hay. “For the survivors of Halabja, most symptoms seem to be linked to the chronic eff ects of exposure to mustard gas—there has been no real separate attempt to assess the eff ects of exposure to nerve agents.”
Finally there is Syria, and the four attacks last year, possibly with the nerve agent sarin, that eventually led to President Assad’s commitment to give up his chemical weapons. Human Rights Watch recently alleged that the Syrian regime had dropped barrel bombs embedded with cylinders of chlorine gas on towns in northern Syria in April of this year. Among others, they quoted a doctor in Keferzita who claimed to have treated over 100 patients suff ering from symptoms consistent with chlorine poisoning.
As for the future, Jerry Smith of the Organisation for the Prohibition of Chemical Weapons (OPCW), which is charged with implementing the CWC, believes that the chances of a state-on-state attack is low (although he adds that several countries have yet to sign up to the convention). “But you can’t exclude the possibility of a non-state actor, a terrorist group, or a so-called lone wolf, from using a chemical weapon”, he noted. The Japanese doomsday cult Aum Shinrikyo, for example, carried out a handful of sarin attacks, including one on the Tokyo subway, in the 1990s. “On the other hand, these weapons are quite hard to make”, said Smith. He points out that Aum Shinrikyo spent millions of dollars on manufacturing sarin; they established a factory and used expertise from highly educated followers. Yet the sarin they produced was of inferior quality. “If you look at the money they spent to kill a couple of dozen people, from a cost-benefi t angle, it would make more sense to achieve your terror aims another way”, said Smith. Moreover, collecting the equipment and chemicals required to orchestrate any potential attack will probably attract the attention of the intelligence services. It is far simpler to try to cobble together an improvised explosive device using “kitchen chemistry”. In the end, the actions in Syria notwithstanding, chemical weapons might fall out of use entirely because for states they are not worth the condemnation, and for others, they are not worth the eff ort.
