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CM E

Long-term Psychological Consequences among Survivors of and their Current Relevance

CM E EDUCATIONAL OBJECTIVES 1. Describe the psychological, social, and cultural ramifi cations among World War I veterans of large-scale battlefi eld use of chemical ordnance. 2. Compare the similarities of that cohort to the experiences of recent victims of chemical warfare in Iran and elsewhere. 3. Discuss the nature of chemical at- tack threat as primarily a psycho- logical weapon.

Edgar Jones, PhD, is Professor of the History of Medicine and Psychiatry at the King’s Centre for Military Health Research, London. Neil Greenberg, MD, is Surgeon Commander, Royal Navy, and Senior Lecturer in Military Psychiatry, Academic Centre for Defence Mental Health. Address correspondence to: Professor Edgar Jones, King’s Centre for Military Research, Weston Education Centre, 10 Cutcombe Road, London SE5 9RJ; or e- mail [email protected]. In undertaking the research for this article, Professor Jones was supported by a grant from the Economic and Social Research Council and the Ministry of De- fence (RES-000-23-1057). The opinions and views expressed herein are those of the authors and do not refl ect the offi cial policy of the Royal Navy or the Ministry of Defence. Photograph by Captain Frank Hurley Dr. Jones and Dr. Greenberg disclosed no relevant fi nancial relationships. Edgar Jones, PhD; and Neil Greenberg, MD

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33711Jones.indd711Jones.indd 724724 111/2/20071/2/2007 11:11:2411:11:24 AMAM as was the truly novel ele- SIDEBAR 1. ment of World War I. A range Gof toxins were used (princi- The Experience of Soldiers Exposed to pally , , and mustard Private John Hall of the Machine Gun Corps about his service in France: gas), delivered by a variety of methods, “The enemy often sent over lachrymatory gas fi rst and then phosgene. I was terrifi ed of gas including cloud, shell and . Pro- to tell you the truth … I was more frightened with gas than I was with shell fi re.” duction of chemical weapons grew pro- Imperial War Museum Sound Archive, 14599, code A, reel 2 gressively and, as a result, increasing numbers of servicemen were exposed to Infantry soldiers fi rst exposed to chlorine in May 1915: gas as the war drew to a close. “As the gassing continued the men became excited, and could not be prevented from put- Although the box , introduced ting their to their mouths after each dip without squeezing them dry, the result from the summer of 1916, protected the was that the men could not breathe through the saturated respirators and thinking that windpipe and lungs from all toxins used they were being suffocated by the gas dipped them at shorter intervals, breathing hard between the dips instead of holding their breath, with the inevitable result that they were in the war, many suffered from the vesi- rendered unconscious by the gas.” cant effects of for which, in the absence of special clothing, there Report of Major General H.S.M. Wilson, May 31, 1915 was no adequate defense. Yet the num- bers killed by chemical weapons were relatively small as a percentage of total specifi c effects added to genuine anxi- by Douglas, a physiologist serving with deaths: an estimated 6,060 U.K. troops, eties. Soldiers traumatized or mentally the British Army, was that: which was about 1% of the total.1 For exhausted by the effects of prolonged “ … we have admittedly to deal with the U.S. Army, it was calculated that of warfare often misinterpreted the nature a large psychic element in very mild the 34,249 immediate deaths of soldiers of bombardments and assumed that they cases of gas poisoning, and this feature on the battlefi eld, only 200 (0.6%) were had been poisoned by gas. Powerful is naturally more prominent in the case from gas. However, of 70,552 U.S. ser- emotions inspired by chemical weapons of troops who have only a limited expe- vicemen exposed to chemical agents and not only had an impact on servicemen’s rience of gas shelling. Even with such admitted for treatment, 1,221 (1.7%) beliefs about damage to vital organs and experienced troops of our own, we have died in American Expeditionary Force long-term health but also infl uenced the to contend with this diffi culty — hence (AEF) medical units.2 number and range of symptoms that instructions to detain doubtful cases of Despite low mortality rates, gas ca- they reported. gas poisoning in medical units within the sualties were numerous, being the sec- army area until diagnosis is certain.”6 ond largest category (31.5%) of patients BATTLEFIELD RESPONSES Initial diagnosis was diffi cult because admitted to AEF after gunshot First, it is important to draw a distinc- the symptoms of anxiety often mimicked wounds (33.4%). In part, these fi gures tion between those who were severely the physical effects of mild exposure to refl ected the capacity of gas to trauma- gassed and suffered life-threatening gas.7 Charles Wilson, a medical offi cer tize soldiers. Indeed, some units exhib- physiological effects and those who working at a in Boulogne, ited outright panic when subjected to were minimally exposed and temporar- often found in newly admitted patients: chemical attack. Inexperienced troops ily incapacitated. One of the fi rst sys- “ … a nervous disorder — frequently were considered more vulnerable than tematic surveys of gassed servicemen hysteria — implanted on the physical units that had habituated to this new form showed that, where it occurred, death harm caused by the gas, which in itself of warfare. Clark showed, for example, was usually rapid and that the 95% who was often trivial. When after a few days that in July 1918 the U.S. 26th Division survived the initial went on to the bodily hurt had gone, there was left suffered four times as many gas casu- make a good recovery.4 With growing an emotional disturbance like a mild at- alties than the battle-hardened French clinical understanding, specialist physi- tack of shell shock … it was the mind 39th Division, although both units had cians recognized that non-severe cases that had suffered hurt.”8 been exposed to similar quantities of should recover within 6 to 8 weeks, al- By 1917, military doctors had de- chemical agent.3 Lack of knowledge lowing a soldier then to return to active vised a number of techniques designed about different types of toxins and their duty.5 A signifi cant diffi culty identifi ed to inhibit the accretion of symptoms

LEFT: Australian infantry wearing Small Box Respirators (SBR). The soldiers are from the 45th Battalion, Australian 4th Division at Garter Point, sector, 27 September 1917.

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33711Jones.indd711Jones.indd 725725 111/2/20071/2/2007 11:11:2511:11:25 AMAM 14 SIDEBAR 2. Pinard and Rendu, early in 1918. In the United States, a major government- Statements of Two U.K. Veterans Awarded a War Pension funded study by Gilchrist and Matz was for “the Effects of Gas” set up to “establish whether any or all of the several used during the “My condition came on in 1919 and has gradually got worse. I am unable to sleep properly at nights … I wake suddenly wet through with sweat and unable to get my breath. At World War left residua, either anatomi- the slightest excitement, or even from a noise, I am very often at a loss for speech, and cal or functional, after a of ap- trembling from head to foot. I am a clerk and on repeated occasions, I am unable to use my proximately eight to ten years.”15 Based pen for nerves. I may add that previous to the above occurrence [gassing], I was in perfect on 838 servicemen exposed to chlorine health and had very strong nerves.” and 1,016 exposed to mustard gas, they Private R.W. reported on September 22, 1922 concluded that gassed veterans were at heightened risk of chronic bronchitis, “While working in the mine I had constantly to cease work and rest owing to tightness of although Gilchrist and Matz were un- the chest and stomach pains which I attributed to gas. I tried to carry on but fi nally had to able to control for confounders such a leave the mine and obtain work in the open air. I have however been considerably worse, the smoking, industrial , and poor attacks being more frequent since working in the quarry. I have now come to the conclusion that instead of the effects of gas wearing off as hoped, it has gradually overpowered me.” quality living conditions. Evidence in the case of irritant-induced asthma, they Private E.D. reported on January 1, 1927 suggested, was unclear, and many cases were, in fact, misdiagnosed bronchitis.16 Retrospective study of U.K. World (including an insistence on activity, the servicemen who had recovered physi- War I veterans awarded a pension application of military discipline, and cally from the effects of phosgene and for the effects of gas found that many the removal of dark glasses as soon as mustard gas by Meakins and Walker gassed servicemen tended to interpret an ocular lesion was healed).9 However, found that one of symptoms “out- any post-war respiratory event in terms once a veteran was discharged from the numbered all others, both in frequency of their traumatic battlefi eld exposure.17 armed forces, the Royal Army Medical and severity, those of the condition New upper respiratory tract infections Corps was no longer responsible for his called disordered action of the heart or (URTI) served to reinforce beliefs about continuing care. Only if an ex-service- effort syndrome.”11 These were alterna- the harm caused by gas rather than pro- man had been awarded a war pension did tive labels for the disorder characterized vide a model of recovery and healing. responsibility for his treatment fall to the as soldier’s heart or irritable heart dur- In part, this related to fears associated government in the form of the Ministry ing the American Civil War. A major with chemical weapons but also their of Pensions. An inherent fl aw in the Brit- study of 4,575 British gas casualties systemic nature.18 It was believed that a ish war pension system was that pay- discharged from U.K. hospitals between toxin could be drawn deep into the lungs ments were based in large measure on May to August 1918 identifi ed a num- and spread through the viscera, akin to the number and severity of symptoms, ber of functional symptoms, including a pathogen from a plague.19 Likewise, a fact that probably undermined any in- photophobia, palpitations, and laryngi- blistering caused to skin and eyes by centive for recovery (see Sidebar 1, page tis, as responsible for prolonged inva- mustard gas offered tangible evidence 725, and Sidebar 2). lidity.12 By 1919, therefore, it was clear to a veteran of what damage a poison that mild exposure to gas could to might do inside the body. POST-WAR EFFECTS medically unexplained symptoms and A problem of mild gassing was that disability. Some physicians went so LONG-TERM EFFECTS enduring symptoms tended to be com- far as to suggest that such cases could For mild cases, long-term effects ap- mon and non-specifi c. A 4-year, fol- be re-interpreted as “gas neurosis syn- pear to be predominantly psychological low-up study of 188 servicemen who drome” because of their similarity “to rather than physical. For example, a 50- had been exposed to chlorine between the non-concussion type of so-called year, follow-up study of World War II April and May 1915 showed that many ‘shell shock’ or war neurosis.”13 naval veterans exposed to low levels of had the symptoms of irritable heart During the 1920s, it was popularly mustard gas found no increase in mor- (palpitations, chest pain, and shortness believed that gassing triggered latent tality rates.20 Furthermore, an investiga- of breath) without evidence of organic tuberculosis and asthma, an hypothesis tion of 111 U.K. veterans, who had vol- lesion.10 Similarly, an investigation of fi rst raised by two French physicians, unteered to take part in chemical agent

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33711Jones.indd711Jones.indd 726726 111/2/20071/2/2007 11:11:2511:11:25 AMAM trials at in the 1950s, re- of drawing sharp distinctions between the effects of poisonous gas.30 Other vealed no evidence of any long-term ad- physical and psychological symptoms. investigators have also reported that verse health effects or unusual patterns In addition, there are a number of seven Israeli civilians died as a result of disease.21 This fi nding was important contemporary examples to suggest that of improper use of an offi cial issue of as the subjects were a self-selected pop- the psychological consequences of po- atropine injections.31 Thus, the fear of ulation, who had presented to the Medi- tential exposure to chemical weapons cal Assessment Program at St. Thom- are far more extensive that can be ac- as’s Hospital in London, in the belief counted for by the effects of the poison that they had suffered enduring damage alone. The “terror” effects of poisonous to their health as a result of participa- gas are not limited to military popula- tion in medical trials. Another follow-up study of 24 U.S. males who had taken part in mustard gas tests during World Retrospective study of U.K. War II found that four (17%) had the World War I veterans awarded symptoms of posttraumatic stress disor- der (PTSD), which was attributed to the a pension for the effects of fears raised about 40 years earlier.22 gas found that many gassed RECENT EXPOSURES: IRAN AND servicemen tended to interpret Mustard gas was used by Saddam any post-war respiratory event Hussein not only against Iran (casualty estimates being as high as 45,000), but in terms of their traumatic also against the Kurds.23 Although many U.S. troops believe that they were ex- battlefi eld exposure. posed to chemical weapons during the 1991 Gulf War there is, to date, no fi rm tions. For instance, the release of a evidence to support this assertion.24 small quantity of gas in the Tokyo However, two studies have demon- subway system in 1995 by a terrorist strated that belief is almost as harmful organization killed 12 people but led gas attacks upon civilian populations to health as actual exposure. An investi- to the emergency rooms of local hospi- can cause death in the absence of any gation of 2,246 U.S. Gulf War veterans tals being swamped by more than 5,500 chemical agent, an important consider- who believed that they had been exposed people, of whom less than 20% were ation for emergency planners. to nerve or mustard gas found that they found to have suffered any identifi able had also reported more symptoms while physical effect.28 CONCLUSION serving in the Gulf, were more likely Anxiety about chemical weapons Since their fi rst large-scale deploy- to be diagnosed with a mental disorder, can also have substantial effects on ci- ment in World War I, chemical weap- and 10 years later reported poorer cur- vilians who, on investigation, are not ons have lost none of their power to rent health status.25 In other words, Gulf exposed to them. A study of the Israeli frighten.32 Like biological weapons, War veterans who believe that they had population, attacked by between 36 and chemical agents touch on a human been attacked by chemical weapons 40 missiles on 18 separate occasions concern about being destroyed by a were more likely to be symptomatic and during the 1991 Gulf War, looked at ef- potent force that enters the body and is disabled than colleagues who did not fects of equipping the population with drawn into vital organs where it is free hold these convictions.26 A similar fi nd- anti-gas countermeasures.29 The authors to cause signifi cant and lasting dam- ing emerged from a study of vaccines found that in spite of there being no evi- age.33 In the past, military personnel against possible biological weapons dence that any of the missiles contained were most likely to encounter noxious such as anthrax. Side effects have been toxins, six of the eight deaths caused by gases and to suffer as a consequence. shown to be linked not to the vaccine per Iraqi SCUD missiles were of individu- Although service personnel receive se but to the belief that an individual was als who, by failing to remove the plug training in how to protect themselves forced to have the injection.27 This also from the fi lter of their respirator, were against such weapons, the current ter- is powerful evidence of the diffi culty asphyxiated, misattributing anoxia to rorist threat has made civilians pos-

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33711Jones.indd711Jones.indd 727727 111/2/20071/2/2007 11:11:2511:11:25 AMAM sible targets without as yet resulting in (TNA, WO142/106, 28 March 1918). 21. Lee HA, Gabriel R, Bale AJ, Welch D. Clinical safeguards. During World 6. Douglas CG. Secret Report (TNA WO fi ndings in 111 ex-Porton Down volunteers. J 142/105, 12 March1918, 1). R Army Med Corps. 2004;150(1):14-19. War II, the entire U.K. population was 7. Newhouse P. Neuropsychiatric aspects of 22. Schnurr PP, Friedman MJ, Green BL. Post- issued with a respirator in 1938 and chemical warfare. In: G Belenky, ed. Con- traumatic stress disorder among World War received formal instruction in its use, temporary Studies in Combat Psychiatry. II mustard gas test participants. Mil Med. New York: Greenwood Press; 1987:185-202. 1996;161(3):131-136. while decontamination centers were 8. Moran. The Anatomy of Courage. London: 23. Romano JA, King JM. Chemical warfare set up in urban areas. It is suggested Constable; 1945:187. and : psychological that these public precautions and the 9. Cook T. No Place to Run: The Canadian and performance outcomes. Milit Psychol. Corps and Gas Warfare in the First World 2002;14(2): 85-92. threat of retaliation were important War. Vancouver: UBC Press; 1999:156. 24. Brown M. Toxicological assessments of Gulf factors in deterring Hitler from drop- 10. Meakins JC, Priestley JG. The after-effects of War veterans. Philos Trans R Soc Lond B Biol ping bombs fi lled with chemicals on . Canadian Med Assoc Sci. 2006;361(1468):649-679. British cities. However, because of the J. 1919;9:968. 25. Stuart JA, Ursano RJ, Fullerton CS, Norwood 11. Meakins JC, Walker TM. Changes Observed AE, Murray K. Belief in exposure to terrorist intense emotions often inspired by gas, in the Heart and Circulation and the General agents: reported exposure to nerve or mustard the introduction of protective measures After-effects of Irritant Gas Poisoning. Lon- gas by Gulf War veterans. J Nerv Ment Dis. alone is not suffi cient to address the is- don: Medical Research Committee, Report 2003;191(7):431-436. No. 7 of the Chemical Warfare Medical Com- 26. Riddle JR, Brown M, Smith T, Ritchie EC, sue. There remains little doubt that the mittee; 1918. Brix KA, Romano J. Chemical warfare and the release of a toxic agent upon a western 12. Meakins JC, Priestley JG. Report on the Length Gulf War: a review of the impact on Gulf veter- civil population would leave a signifi - of Stay in Hospital in the UK and Disposal of ans’ health. Mil Med. 2003;168(8):606-613. cant psychological legacy irrespective Gas Casualties. London: Medical Research 27. Murphy D, Dandeker C, Horn O, et al. UK Committee, Report No. 16 of the Chemical armed forces responses to an informed consent of the physical outcomes of those di- Warfare Medical Committee; 1918. policy for anthrax vaccination: a paradoxical rectly involved. However, history also 13. Hulbert HS. Gas neurosis syndrome. Am J effect? Vaccine. 2006;24(16):3109-3114. reveals that in spite of the ability to in- Insanity. 1920;77:213-216. 28. Ogawa Y, Yamamura Y, Ando A, et al. An at- 1 4. Anon. Poison gas and tuberculosis. Lancet. tack with sarin nerve gas on the Tokyo sub- duce fear and terror in those affected, 1918;1:272:852. way system and its effects on victims. ACS or those who think that they have been 15. Gilchrist HL, Matz PH. The Residual Ef- Symposium Series. 2000;745:333-355. affected, the use of poison gas as a fects of Warfare Gases, I. Chlorine and II. 29. Rivkind A, Barach P, Israeli A, Berdugo M, Mustard. Washington, D.C.: US Government Richter ED. Emergency preparedness and weapon is far from straightforward. Printing Offi ce; 1933. response in Israel during the Gulf War. Ann 16. Blanc PD. The legacy of war gas. Am J Med. Emerg Med. 1998;32(2):224-233. REFERENCES 1999;106(6):689-690. 30. Roff SR. Sitting it out in the sealed room: the 1. Douglas CG. Casualties caused in British 17. Jones E, Everitt B, Ironside S, Palmer I, Wes- Israeli response to the 1991 Gulf War. Med forces by gas warfare (The National Archives, sely S. Psychological effects of chemical Confl Surviv. 2001;17(4):348-354. hereafter referred to as TNA, WO142/109, weapons: a follow-up study of First World 31. Lorch N. The Arab-Israeli Wars. Israeli Ministry of 1918), and British Gas Casualties 1915 to War veterans. Psychol Med. In press. Foreign Affairs. http://www.mfa.gov.il/MFA/His- 1918 (The National Archives, WO158/123). 18. Jones E, Palmer I, Wessely S. This “atrocious tory/Modern+History/Centenary+of+Zionism/ 2. Heller CH. Chemical warfare in World War method of warfare”: enduring beliefs about The+Arab-Israeli+Wars.htm. Accessed on Au- I: the American experience. Leavenworth Pa- the effects of gassing. BMJ (in press). gust 10, 2007. pers. 1984;10:1-102,91. 19. Alexander DA, Klein S. Biochemical terror- 32. Stokes JW, Banderet LE. Psychological as- 3. Clark DK. Effectiveness of Chemical Weap- ism: too awful to contemplate, too serious to pects of chemical defense and warfare. Milit ons in World War I. Staff Paper ORO-SP-88, ignore — subjective literature review. Br J Psychol. 1997;9(4):395-415. Johns Hopkins University; 1959. Psychiatry. 2003;183:491-497. 33. Holloway HC, Norwood AE, Fullerton CS, 4. Black JE, Glenny, ET, McNee JW. Observa- 20. Bullman T, Kang H. A fi fty year mortality Engel CC, Ursano RJ. The threat of biologi- tions on 685 cases of poisoning by noxious follow-up study of veterans exposed to low cal weapons: prophylaxis and mitigation of gases used by the enemy. BMJ. 1915;2:165-67. level chemical warfare agent, mustard gas. psychological and social consequences. 5. Douglas CG. Letter to Colonel W. Pasteur Ann Epidemiol. 2000;10(5):333-338. JAMA. 1997;278(5):425-427.

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