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Veterans at Risk

The Health Effects of Mustard Gas and Lewisite

Constance M. Pechura and David P. Rall, Editors

Committee to Survey the Health Effects of Mustard Gas and Lewisite

Division of Health Promotion and Disease Prevention

Institute of Medicine

National Academy Press
Washington, D.C.
1993



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Veterans at Risk: The Health Effects of Mustard Gas and Lewisite Veterans at Risk The Health Effects of Mustard Gas and Lewisite Constance M. Pechura and David P. Rall, Editors Committee to Survey the Health Effects of Mustard Gas and Lewisite Division of Health Promotion and Disease Prevention Institute of Medicine National Academy Press Washington, D.C. 1993

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Veterans at Risk: The Health Effects of Mustard Gas and Lewisite NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for this report were chosen for their special competences and with regard for the appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an advisor to the federal government and its own initiative in identifying issues of medical care, research, and education. The work on which this publication is based was performed pursuant to Contract No. V101(93)P-1326 with the Department of Veterans Affairs. Funds for this contract were provided by the Department of Veterans Affairs. Library of Congress Cataloging-in-Publication Data Institute of Medicine (U.S.). Committee to Survey the Health Effects of Mustard Gas and Lewisite. Veterans at Risk : the health effects of mustard gas and Lewisite / Constance M. Pechura and David P. Rall, editors. p. cm. "Committee to Survey the Health Effects of Mustard Gas and Lewisite. Division of Health Promotion and Disease Prevention. Institute of Medicine, National Academy of Sciences." Includes bibliographical references and index. ISBN 0-309-04832-X 1. Mustard gas—Toxicology. 2. Lewisite (Poison gas)—Toxicology. I. Pechura, Constance M. II. Rall, David P. III. Title. RA1247.M8158 1993 615.9'1—dc20 92-40735 CIP Copyright 1993 by the National Academy of Sciences. All rights reserved. No part of this book may be reproduced by any mechanical, photographic, or electronic process, or in the form of a phonographic recording, nor may it be stored in a retrieval system, transmitted, or otherwise copied for public or private use, without written permission from the publisher, except for the purpose of official use by the United States Government. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.

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Veterans at Risk: The Health Effects of Mustard Gas and Lewisite Committee To Survey the Health Effects of Mustard Gas and Lewisite DAVID P. RALL (Chair),* Director (Retired), National Institute of Environmental Health Sciences, Washington, D.C. O. MICHAEL COLVIN, Professor of Oncology and Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland. ELLEN EISEN, Associate Professor, Department of Work Environment, College of Engineering, University of Massachusetts, Lowell. WILLIAM EDWARD HALPERIN, Associate Director for Surveillance, Division of Surveillance, Hazard Evaluations and Field Studies, National Institute for Occupational Safety and Health, Cincinnati, Ohio. CHARLES H. HOBBS, Assistant Director, Inhalation Toxicology Research Institute, Lovelace Biomedical and Environmental Research Institute, Albuquerque, New Mexico. DAVID G. HOEL,* Director, Biometry and Risk Assessment Division, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina. KARL KELSEY, Associate Professor of Occupational Medicine and Radiobiology, Harvard School of Public Health, Occupational Health Program, Boston, Massachusetts. CHARLES J. McDONALD, Professor and Director, Division of Dermatology, Brown University, Physician in Charge, Division of Dermatology, Roger Williams Medical Center and Rhode Island Hospital, Providence. JAMES MALCOLM MELIUS, Director, Division of Occupational Health and Environmental Epidemiology, State of New York Department of Health, Albany. JOHN A. MONTGOMERY, Distinguished Scientist, Southern Research Institute, Birmingham, Alabama. WILLIAM  NICHOLSON, Professor of Community Medicine, Mount Sinai School of Medicine, New York, New York. ROSWELL ROBERT PFISTER, Past Chairman, Department of Ophthalmology, University of Alabama, Director, Brookwood Eye Research Lab, Birmingham, Alabama. MARGARET SINGER, Emeritus Adjunct Professor, Department of Psychology, University of California, Berkeley. BAILUS WALKER,* Dean, College of Public Health, University of Oklahoma, Health Sciences Center, Oklahoma City. ANNETTA P. WATSON, Research Staff Member, Health and Safety Research Division, Oak Ridge National Laboratory, Oak Ridge, Tennessee. Former Members VINCENT MARCHESI,** Director, Boyer Center for Molecular Medicine, Professor of Pathology, Biology, and Cell Biology, Yale University School of Medicine, New Haven, Connecticut. LINDA ROSENSTOCK, Director of Occupational Medicine and Associate Professor, Department of Medicine and Environmental Health, University of Washington, Seattle.

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Veterans at Risk: The Health Effects of Mustard Gas and Lewisite Institute of Medicine Staff Constance M. Pechura, Study Director Catharyn T. Liverman, Research Associate Jennifer Hope Streit, Project Assistant Gerri Kennedo, Project Assistant Gary B. Ellis, Director, Division of Health Promotion and Disease Prevention *   IOM member **   IOM and NAS member

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Veterans at Risk: The Health Effects of Mustard Gas and Lewisite Preface So vivid were the memories of the first use of "mustard gas" (sulfur mustard) by the Germans in World War I that the United States government began to prepare for chemical warfare even before the Japanese attacked Pearl Harbor in 1941. This work was also spurred by the fury of war in Europe and reports of Japanese use of sulfur mustard against the Chinese. The U.S. preparations included the establishment of war-related research programs organized by President Roosevelt under the White House Office of Scientific Research and Development (OSRD). Two groups under the OSRD became involved in secret testing programs concerned with mustard agents (sulfur and nitrogen mustard) and Lewisite:  The Committee on Medical Research This group studied protective ointments and other treatments through the National Research Council's Committee on Treatment of Gas Casualties.  The National Defense Research Committee This group studied protective clothing and gas masks through military units such as the Chemical Warfare Service. These testing programs involved the use of close to 60,000 military personnel as human experimental subjects. It was this use of human subjects more than 50 years ago that provided the impetus for the study reported in this volume. The initiation of this study in 1991 was finally prompted by long-delayed official admissions that human subjects had been used and the recognition that these subjects may have suffered

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Veterans at Risk: The Health Effects of Mustard Gas and Lewisite adverse, long-term, health consequences as a result of their exposure to mustard agents or Lewisite. The committee, convened to produce this report by the Institute of Medicine in response to a request by the Department of Veterans Affairs, was comprised of experts in the fields of toxicology, epidemiology, occupational and environmental medicine, ophthalmology, dermatology, oncology, chemistry, and psychology. Its task was to survey the medical and scientific literature on mustard agents and Lewisite, assess the strength of association between exposure to these agents and the development of specific diseases, identify the gaps in the literature, and recommend strategies and approaches to deal with any gaps found. To accomplish this task, the committee met four times, examined nearly 2,000 scientific and medical reports in English and a number of foreign languages, and considered input from 13 military and civilian experts and over 250 affected veterans, including public testimony from 20 veterans. Although this task may have seemed straightforward in the beginning of the study, closer examination of the literature and the World War II (WWII) experimental protocols presented numerous scientific and ethical challenges. The major scientific challenges were the meager literature on long-term health effects of exposure to these agents and the lack of quantitative exposure data for the veterans who served as human test subjects. The vast majority of the scientific and medical literature was concerned with the short-term, acute effects of mustard agents and Lewisite, because the research priorities of most countries had been placed on treatment of battlefield injuries and the fact that most investigations of mustard agents and Lewisite have been conducted throughout this century under the control of military establishments. Particularly distressing was the essential lack of information regarding the toxicology of Lewisite. Assessing the long-term health effects of mustard agents and Lewisite thus required the committee to integrate many types of data, from studies using laboratory animals to single human case studies, and to examine and compare closely the known biological mechanisms of injury from these agents with agents with similar properties for which more data were available. The lack of exposure data for the WWII human subjects caused the committee to attempt to gather as much information as possible about the experimental protocols, the equipment used, and any injuries from official reports of the testing programs. The committee found that an atmosphere of lingering secrecy still existed in the Department of Defense regarding some of the testing programs. Reports of the specific experimental protocols were not always easy to obtain; in some cases, reports were not available or were obtained as the study was almost complete. Fortunately, enough information was gathered to allow

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Veterans at Risk: The Health Effects of Mustard Gas and Lewisite reasonable estimates of the exposures to human subjects, who were repeatedly exposed to mustard agents and Lewisite in gas chamber tests or under so-called field conditions. As the full scope of the WWII testing protocols was revealed, compelling ethical questions emerged. At times, it seemed as if every new discovery only posed more questions. As the study progressed, the bits and pieces of information finally coalesced into a picture of abuse and neglect that was impossible for the committee to ignore. One of the first discoveries was that the end point of all the WWII mustard agent and Lewisite experiments was tissue injury—from mild skin burns to severe, and widespread, skin burns that took more than a month to heal. The chamber and field tests were actually called "man-break" tests. Both veteran self-reports and official documents revealed that some subjects suffered damaging injuries to the lungs and upper respiratory system from inhalation of the agents. Committee analysis of expected gas mask efficiencies further showed that projected normal mask leakage under the hot, humid conditions of the gas chambers would have, in some cases, resulted in exposure levels as high as those reported on World War I battlefields. The first response of many of the committee members to these discoveries was to try to understand the actions of the investigators in historical context—it was a war and the experiments were conducted before the Nuremberg Code of 1947 established formal principles to govern the proper treatment of human subjects. However, examination of the treatment and care of WWII chemical warfare production workers, and the conduct of later military experiments with human subjects from 1950 to 1975, demonstrated a well-ingrained pattern of abuse and neglect. Although the human subjects were called "volunteers," it was clear from the official reports that recruitment of the WWII human subjects, as well as many of those in later experiments, was accomplished through lies and half-truths. Most appalling was the fact that no formal long-term follow-up medical care or monitoring was provided for any of the WWII human subjects, other exposed military personnel, or chemical warfare production workers, despite knowledge available by 1933 that mustard agents and Lewisite could produce long-term debilitating health problems, particularly in those people suffering severe burns and inhalation injuries. There was not even adequate short-term follow-up of the human subjects by the Department of Defense. Subjects in the chamber tests were sworn to secrecy and simply released on leave at the conclusion of the experiments. Some of these men still had blisters or evidence of skin burns upon release, but were not given any instructions about how to obtain knowledgeable medical care if they had needed it.

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Veterans at Risk: The Health Effects of Mustard Gas and Lewisite Although the experiments began in a wartime climate of urgency and secrecy, it was clearly a mistake in this case to continue the secrecy after the conclusion of the war. Follow-up of the exposed human subjects could have provided a wealth of information on the effects of these war gases and could have served as a basis for legitimate disability claims by injured subjects. By the end of the war, the use of nitrogen mustard as a chemotherapeutic agent (developed as part of the WWII testing program) clearly showed the serious health effects that the previous "volunteers" might be expected to experience. In the face of the abuses uncovered, the committee members nevertheless sought to maintain an appropriate balance of their scientific responsibilities in assessing the available literature and their ethical responsibilities as physicians and scientists. In this effort, the committee members were guided by their stated task and their own individual judgments of the scientific and historical information examined. Thus, the committee believes that the findings and recommendations contained in this report are entirely justified by the scientific, medical, and historical evidence examined. There are, however, specific statements the committee wishes to offer as commentary on its findings. First, the committee believes that each veteran who served as a human subject in the WWII experiments deserves honor for his sacrifice. 1 These men risked their health and safety to help develop better means of protection against chemical warfare. Yet, in most cases, their participation in these experiments was not even acknowledged in their service records and was, in fact, officially denied for decades. Further, these men were ordered to keep their participation secret. They did so for nearly 50 years, in some cases despite serious, disabling diseases that they believed were caused by their exposures. There can be no question that some veterans, who served our country with honor and at great personal cost were mistreated twice—first, in the secret testing and second, by the official denials that lasted for decades. They deserve recognition. Second, the committee believes that any future military research with human subjects should be conducted according to publicly established ethical principles similar to those that apply to civilian research. The Department of Defense should consider including civilian medical experts in reviews of all proposed military research protocols involving human subjects. As was shown in the examination and evaluation by the Department of the Army Inspector General's report of the military drug and chemical testing programs from 1950 to 1975 (see Appendix F), a climate of secrecy provides a permissive environment for the neglect of 1   According to all available reports, all the human subjects were males.

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Veterans at Risk: The Health Effects of Mustard Gas and Lewisite established rules of conduct. Such neglect should never be allowed to occur when human experimentation is involved. Beyond the immense personal costs of the mistakes and failures of the United States government during and after the WWII testing programs, there are societal costs as well. The lack of available biological data concerning these chemical warfare agents also slowed the important fields of toxicology and cancer chemotherapy. Much would have been gained by careful observation after the end of WWII; instead much was lost. The primary reason to identify and follow-up veterans exposed to mustard agents or Lewisite is to provide needed medical care. In addition, follow-up of these individuals now may also benefit our understanding of carcinogenesis. For example, recent advances in molecular biology have linked some chemical exposures in laboratory animals to specific changes in tumor cells; for example, activated oncogenes with unusual mutations or suppressor genes (and/or their protein products), or chromosome damage. In addition, it is well known that nitrogen mustard cancer chemotherapy can result in second tumors, which show unusual genetic changes. Therefore, study of any sulfur mustard-associated tumors should be explored, because the results could shed light on laboratory animal and human responses to carcinogens. The committee wishes to acknowledge that this study could not have been done without the assistance of a number of people, many of whom are listed in the acknowledgments section of this report. Before this report was completed, the report draft was reviewed by experts in appropriate fields under the rules of the National Research Council's Report Review Committee. These individuals provided helpful commentary on the draft manuscript and the committee greatly appreciates the care and expertise that the reviewers brought to their task. The work of the committee's Institute of Medicine staff deserves the highest praise. The committee is especially grateful for the thoughtful input, advice, and support given by Gary Ellis, the Director of the Division of Health Promotion and Disease Prevention. Thanks are also extended to Jennifer Streit, the study's project assistant responsible for planning travel and other meeting arrangements, who also translated some of the French papers requested by the committee. The massive job of finding, organizing, and procuring the hundreds of scientific papers and technical reports was accomplished with great skill by Catharyn Liverman, the study's research associate and medical librarian. The committee is truly indebted to Ms. Liverman—she always knew where something was, kept a thousand details straight, and did a wonderful job tracking down obscure references. Finally, the committee wishes to recognize the major contributions of the study director, Constance

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Veterans at Risk: The Health Effects of Mustard Gas and Lewisite Pechura. She knew and understood the literature, she worked tirelessly to obtain information from reluctant sources, and she organized the study plan, the meetings, the special presentations, and this final report. She clearly foresaw the major problems that this committee faced as it moved from the safe, but complex, problems of risk assessment to the thornier issue of human ethics. This Preface is somewhat unusual in that it is signed by the entire committee, rather than by the chairman alone. However, the report itself is unusual because it tells a story about veterans involved in a long-secret wartime research program in the United States—a story that the committee and its staff hope will never have to be told again. David P. Rall, Chairman O. Michael Colvin Ellen Eisen William Halperin Charles H. Hobbs David G. Hoel Karl Kelsey Charles J. McDonald James M. Melius John A. Montgomery William Nicholson Roswell R. Pfister Margaret Singer Bailus Walker Annetta P. Watson

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Veterans at Risk: The Health Effects of Mustard Gas and Lewisite Acknowledgments The committee wishes to acknowledge the valuable help and assistance it received from a number of individuals. First, the committee wishes to thank and honor the more than 250 veterans who participated in the public hearing process. The veterans' openness about their health problems and their understanding of the committee's role was of great value (see Appendix G). The committee is also very grateful for the input of the 13 civilian and military experts, who gave their time to make important presentations before the committee (see Appendix A). Maria Lloyd and James Gately from the Naval Research Laboratory were tremendously helpful in sending technical reports of the World War II testing projects from their institution. In addition, they have worked diligently to provide documentation of participation to affected veterans. The assistance of Marjorie Ciarlante of the National Archives and Janice Goldblum of the National Academy of Sciences' Office of Archives and Information Services was also of great help in locating and obtaining historically relevant materials. Susan Mather, Han Kang, and Robert Allen of the Department of Veterans Affairs aided the committee in many ways, but most especially by the determination of the feasibility of identifying the veterans who had served as subjects in the chamber and field tests (see Appendix E). Richard Patterson from the Disabled American Veterans and Richard Christian from the American Legion were valuable resources to the committee and their assistance in publicizing the public hearing process is greatly appreciated. The committee also wishes to thank Sanford Leffingwell of the Centers for Disease Control for sending an early bibliography and helping the committee to locate helpful toxicological

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Veterans at Risk: The Health Effects of Mustard Gas and Lewisite reports. Jeffery K. Smart, Historian at the U.S. Army Chemical and Biological Defense Agency, aided the committee by sending technical reports and photographs from work done at the Edgewood Arsenal in Maryland. The committee appreciates the able editorial work of Paul Phelps, Florence Poillon, and Barbara Bodling. The committee is also indebted to the efforts of the Institute of Medicine's (IOM) managing editor, Michael Edington, and the sponsoring editor from the National Academy Press, Sally Stanfield. Laura Baird, the IOM librarian, provided helpful support and input in the literature search, and Susan Turner-Lowe, from the Office of News and Public Information, provided expert advice on the public hearing and interactions with the press. Gerri Kennedo, a project assistant who stepped in to help produce some of the final drafts of the report, deserves much thanks for her very competent handling of difficult assignments.

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Veterans at Risk: The Health Effects of Mustard Gas and Lewisite Contents     LIST OF BOXES, FIGURES, AND TABLES   xvi     EXECUTIVE SUMMARY   1     Background   1     General Conclusions   3     Specific Findings   4     Recommendations   5 1   INTRODUCTION   9     References   13 2   METHODS OF LITERATURE COLLECTION AND SURVEY   14     Online Databases   14     Other Sources   15     Supplemental World War II Military Reports   17     Literature Translation, Dissemination, and Analysis   18     References   19 3   HISTORY AND ANALYSIS OF MUSTARD AGENT AND LEWISITE RESEARCH PROGRAMS IN THE UNITED STATES   21     Introduction   22

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Veterans at Risk: The Health Effects of Mustard Gas and Lewisite     Research Programs of World War I and the Postwar Period   26     Testing Programs and Chemical Warfare Production in World War II   29     Research, Use, and Disposal of Chemical Weapons After World War II   45     Conclusions and Further Analysis   50     References   55 4   FINDINGS FROM THE PUBLIC HEARING PROCESS   61     Results and Findings   63     Treatment of Human Subjects   67     Conclusions and Actions Taken   69     References   70 5   CHEMISTRY OF SULFUR MUSTARD AND LEWISITE   71     Sulfur Mustard   71     Lewisite   78     References   80 6   RELATIONSHIP OF MUSTARD AGENT AND LEWISITE EXPOSURE TO CARCINOGENESIS   81     Acute Effects and Biological Mechanisms   82     Evidence of Long-Term Health Effects   87     Summary   103     References   105 7   NONMALIGNANT RESPIRATORY EFFECTS OF MUSTARD AGENTS AND LEWISITE   112     Physiology and Anatomy   113     Acute Effects and Biological Mechanisms   115     Evidence of Long-Term Health Effects   118     Relationship Between Acute and Chronic Effects Caused by Exposures to Other Respiratory Hazards   123     Summary   126     References   127 8   OCULAR EFFECTS OF MUSTARD AGENTS AND LEWISITE   131     Physiology and Anatomy of the Eye   131     Acute Effects and Biological Mechanisms   133     Evidence of Long-Term Health Effects   139     Summary   142     Conclusions   144     References   145

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Veterans at Risk: The Health Effects of Mustard Gas and Lewisite 9   DERMATOLOGICAL EFFECTS OF MUSTARD AGENTS AND LEWISITE   148     Anatomy and Physiology of Skin,   148     Acute Effects and Biological Mechanisms,   157     Evidence of Long-Term Health Effects of Mustard Agents   167     Evidence of Long-Term Health Effects of Lewisite   171     Summary   174     References   175 10   OTHER PHYSIOLOGICAL EFFECTS OF MUSTARD AGENTS AND LEWISITE   179     Effects on the Immune System   179     Effects on Systems Other than the Immune System   187     Reproductive Risks   189     References   195 11   RELATIONSHIP OF MUSTARD AGENT AND LEWISITE EXPOSURE TO PSYCHOLOGICAL DYSFUNCTION   199     Historical Development of the Concept of PTSD   202     Current Research in PTSD   204     Evidence from Studies of Military Personnel and Veterans   204     Evidence from Studies of the Psychological Effects of Environmental Contaminations   209     Conclusions   210     References   211 12   SUMMARY OF FINDINGS AND RECOMMENDATIONS   214     General Conclusions   214     Conclusions Regarding the Causal Relationships of Exposure to the Development of Specific Diseases   216     Gaps in the Literature Regarding Mustard Agents and Lewisite   221     Recommendations   224     BIBLIOGRAPHY   227     APPENDIXES         A Scientific and Background Presentations Made to the Committee   333

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Veterans at Risk: The Health Effects of Mustard Gas and Lewisite     B Excerpt from The Residual Effects of Warfare Gases   335     C Involvement of the National Academy of Sciences Complex in World War II Research Programs: A Summary   338     D Excerpts from Chamber Tests with Human Subjects I, II, and IX. Naval Research Laboratory Reports Nos. P-2208 and P-2579   340     E Interim Report and Addendum: Feasibility of Developing a Cohort of Veterans Exposed to Mustard Gas During WWII Testing Programs   370     F Summary of the Department of the Army Report: Use of Volunteers in Chemical Agent Research   378     Key Elements of the Nuremberg Code of 1947   380     G Public Hearing Announcement   382     Veterans Who Appeared at the Public Hearing   383     Summary of Health Problems Reported by Veterans   384     H Letter from Dr. Jay Katz to Dr. David P. Rall   386     I Risk Assessment Considerations for Sulfur Mustard   390     J Examination of the Effects of Certain Acute Environmental Exposures on Future Respiratory Health Consequences   399     LIST OF ACRONYMS AND ABBREVIATIONS   417     INDEX   421 BOXES 3-1   Odor Threshold for Sulfur Mustard and Lewisite: Comparison with Tissue Damage Thresholds   53 11-1   Diagnostic Criteria for Post-Traumatic Stress Disorders   201 FIGURES 3-1   Vesicle formation on an Iranian patient   23 3-2   Organization of World War II civilian scientific research and testing programs,   30 3-3   U.S. naval personnel dressed for World War II sulfur mustard experiments   37

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Veterans at Risk: The Health Effects of Mustard Gas and Lewisite 3-4a   Naval Research Laboratory gas chamber   38 3-4b   Interior of the Edgewood Arsenal gas chamber   38 7-1   Structure of the respiratory tract   113 7-2   Illustration of the various types of cellular arrangements of epithelium that line internal body passages   114 8-1   Anatomy of the eye   132 8-2   Course of mustard gas lesions of rabbit cornea   136 9-1   Anatomy of human skin   149 9-2   Layers of the epidermis   150 9-3   Epidermal-dermal junction   152 9-4a   Epidermal melanin unit   155 9-4b   Summary of major events in melanocyte development   155 10-1   Model of the competent immune system   181 I-1   Relative carcinogenic potency of three nitrogen mustard derivative antineoplastic agents   394 TABLES 2-1   Bibliographic Databases Searched   16 2-2   Factual Databases Searched   17 2-3   Foreign Language Citations   18 3-1   Chemical and Physical Data   24 3-2   Known Gas Testing Facilities and Test Types   32 3-3   Concentration Versus Cumulative Exposure Level   32 3-4   Summary of Major Biological End Points Characterizing Sulfur Mustard Exposure to Humans   34 6-1   Pulmonary Tumors in Strain A Mice Injected Intravenously with Nitrogen Mustard and Sulfur Mustard   90 6-2   Pulmonary Tumors in Strain A Mice Injected Intravenously with Nitrogen Mustard and/or Exposed to X-Radiation   91 6-3   Tumors from Subcutaneous Injection of Sulfur and Nitrogen Mustard into C3H Mice and Sulfur Mustard into C3Hf Mice,   92 6-4   Tumors from Subcutaneous Injection of Sulfur Mustard into Strain A Mice   93 6-5   Number of Rats Developing Tumors Following Exposures to HD (Toxicity Study)   94 6-6   Number of Rats Developing Tumors Following Exposures to HD (Carcinogenicity Study)   95 6-7   Tumors Observed in Rat Carcinogenicity and Toxicity Studies, 96   96 6-8   Percentage of Female RF Mice with Neoplasms from Exposure to HN2 or X-Rays   96 7-1   Effects of Acute Sulfur Mustard Vapor Exposure on the Human Respiratory Tract   116 7-2   Antitumor Drugs That Produce Pulmonary Fibrosis   123

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Veterans at Risk: The Health Effects of Mustard Gas and Lewisite 8-1   Effects of Acute Sulfur Mustard Exposure on the Human Eye   134 8-2   Effects of Acute Lewisite Exposure on the Mammalian Eye   135 8-3   Characteristics of Sulfur Mustard and Lewisite Ocular Lesions   138 12-1   Summary of Findings Regarding Specific Health Problems   217 I-1   Comparative Carcinogenicity of Selected Agents in Strain A Mice   393

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Veterans at Risk: The Health Effects of Mustard Gas and Lewisite Veterans at Risk

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