medical aspects of chemical and biological warfare

i
MEDICAL ASPECTS OF CHEMICAL AND BIOLOGICAL WARFARE
ii
The Coat of Arms
1818
Medical Department of the Army
A 1976 etching by Vassil Ekimov of an
original color print that appeared in
The Military Surgeon, Vol XLI, No 2, 1917
iii
The first line of medical defense in wartime is the combat
medic. Although in ancient times medics carried the caduceus
into battle to signify the neutral, humanitarian nature of
their tasks, they have never been immune to the perils of
war. They have made the highest sacrifices to save the lives
of others, and their dedication to the wounded soldier is
the foundation of military medical care.
iv
Textbook of Military Medicine
Published by the
Office of The Surgeon General
Department of the Army, United States of America
Editor in Chief
Brigadier General Russ Zajtchuk, MC, U.S. Army
Director, Borden Institute
Commanding General
U.S. Army Medical Research and Materiel Command
Professor of Surgery
F. Edward Hébert School of Medicine
Uniformed Services University of the Health Sciences
Bethesda, Maryland

Managing Editor
Ronald F. Bellamy, M.D.
Colonel, MC, U.S. Army (Retired)
Borden Institute
Associate Professor of Military Medicine
Associate Professor of Surgery
F. Edward Hébert School of Medicine
Uniformed Services University of the Health Sciences
Bethesda, Maryland
v
The TMM Series
Part I. Warfare, Weaponry, and the Casualty
Medical Consequences of Nuclear Warfare
(1989)
Conventional Warfare: Ballistic, Blast, and Burn
Injuries (1991)
Military Psychiatry: Preparing in Peace for War
(1994)
War Psychiatry (1995)
Medical Aspects of Chemical and Biological
Warfare (1997)
Military Medical Ethics
Part II. Principles of Medical Command and Support
Military Medicine in Peace and War
Part III. Disease and the Environment
Occupational Health: The Soldier and the
Industrial Base (1993)
Military Dermatology (1994)
Military Preventive Medicine: Mobilization and
Deployment

Medical Aspects of Deployment to Harsh
Environments
Part IV. Surgical Combat Casualty Care
Anesthesia and Perioperative Care of the
Combat Casualty (1995)
Rehabilitation of the Injured Soldier
Military Surgery
vi
. . . .
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 . . .
Dim, through the misty panes and thick green light,
As under a green sea, I saw him drowning.
In all my dreams, before my helpless sight,
He plunges at me, guttering, choking, drowning.
1
. . . .
—Wilfred Owen
The poetry, excerpted from Dulce et Decorum Est, was written by Lieutenant Wilfred Owen of the Royal
Army, who was killed in action in France on 4 November 1918.
“Gassed,” the frontispiece painting, shows the horror of chemical warfare in World War I as perceived by
the artist, Gilbert Rogers.
2
As Keegan and Darracott observed, “Rogers was an officer of the Royal Army
Medical Corps commissioned to record medical work during the First World War. The subtitle to this
painting, “In Arduis Fidelis” (Faithful in Hardships), suggests the subject is a stretcher-bearer who has
succumbed to gas while transporting wounded.”
3

1. Excerpted from Wilfred Owen. Dulce et decorum est. In: The Collected Poems of Wilfred Owen. Copyright © 1963 by Chatto &
Windus, Ltd. Reprinted by permission of New Directions Publishing: New York, NY.
2. Painting: Printed with permission from Imperial War Museum, London, England.
3. Keegan J, Darracott J. The Nature of War. New York, NY: Holt, Rinehart and Winston; 1981: 222.
vii
MEDICAL ASPECTS OF CHEMICAL
AND
BIOLOGICAL WARFARE
Specialty Editors
FREDERICK R. SIDELL , M.D.
Chemical Casualty Consultant
ERNEST T. TAKAFUJI, M.D., M.P.H.
Colonel, Medical Corps, U.S. Army
DAVID R. FRANZ , D.V.M, PH.D.
Colonel, Veterinary Corps, U.S. Army
Borden Institute
Walter Reed Army Medical Center
Washington, D. C.
Office of The Surgeon General
United States Army
Falls Church, Virginia
United States Army Medical Department Center and School
Fort Sam Houston, Texas
United States Army Medical Research and Materiel Command
Fort Detrick, Frederick, Maryland
Uniformed Services University of the Health Sciences
Bethesda, Maryland
1997
viii
Editorial Staff: Lorraine B. Davis

Senior Editor
Colleen Mathews Quick
Associate Editor/Writer
This volume was prepared for military medical educational use. The focus of the information
is to foster discussion that may form the basis of doctrine and policy. The volume does not
constitute official policy of the United States Department of Defense.
Dosage Selection:
The authors and publisher have made every effort to ensure the accuracy of dosages cited herein.
However, it is the responsibility of every practitioner to consult appropriate information sources
to ascertain correct dosages for each clinical situation, especially for new or unfamiliar drugs and
procedures. The authors, editors, publisher, and the Department of Defense cannot be held
responsible for any errors found in this book.
Use of Trade or Brand Names:
Use of trade or brand names in this publication is for illustrative purposes only and does not
imply endorsement by the Department of Defense.
Neutral Language:
Unless this publication states otherwise, masculine nouns and pronouns do not refer exclusively
to men.
CERTAIN PARTS OF THIS PUBLICATION PERTAIN TO COPYRIGHT RESTRICTIONS.
ALL RIGHTS RESERVED.
NO COPYRIGHTED PARTS OF THIS PUBLICATION MAY BE REPRODUCED OR
TRANSMITTED IN ANY FORM OR BY ANY MEANS, ELECTRONIC OR MECHANICAL
(INCLUDING PHOTOCOPY, RECORDING, OR ANY INFORMATION STORAGE AND
RETRIEVAL SYSTEM), WITHOUT PERMISSION IN WRITING FROM THE PUBLISHER OR
COPYRIGHT OWNER
Published by the Office of The Surgeon General at TMM Publications
Borden Institute
Walter Reed Army Medical Center
Washington, DC 20307-5001
Library of Congress Cataloging–in–Publication Data

Medical aspects of chemical and biological warfare / specialty
editors, Frederick R. Sidell, Ernest T. Takafuji, David R. Franz.
p. cm. — (TMM series. Part I, Warfare, weaponry, and the
casualty)
Includes bibliographical references and index.
1. Medicine, Military. 2. Chemical warfare. 3. Biological
warfare. I. Sidell, Frederick R. II. Takafuji, Ernest T.
III. Franz, David R., D.V.M. IV. Series: Textbook of military
medicine. Part 1, Warfare, weaponry, and the casualty ; [v. 3].
[DNLM: 1. Chemical Warfare. 2. Biological Warfare. 3. Military
Medicine—methods. UH 390 T355 pt. 1 1997 v. 3]
RC971.T48 1989 vol 3
616.9 ’8023 s—dc21
[616.9’8023]
DNLM/DLC
for Library of Congress 97-22242
CIP
PRINTED IN THE UNITED STATES OF AMERICA
07, 06, 05, 04, 03, 02, 01, 00, 99, 98 5 4 3 2 1
ix
Contents
Foreword by The Surgeon General xi
Preface xiii
Patient Flow in a Theater of Operations xv
Medical Aftermath of the Persian Gulf War xvi
1. Overview: Defense Against the Effects of Chemical and Biological Warfare Agents 1
2. History of Chemical and Biological Warfare: An American Perspective 9
3. Historical Aspects of Medical Defense Against Chemical Warfare 87
4. The Chemical Warfare Threat and the Military Healthcare Provider 111
5. Nerve Agents 129

6. Pretreatment for Nerve Agent Exposure 181
7. Vesicants 197
8. Long-Term Health Effects of Nerve Agents and Mustard 229
9. Toxic Inhalational Injury 247
10. Cyanide Poisoning 271
11. Incapacitating Agents 287
12. Riot Control Agents 307
13. Field Management of Chemical Casualties 325
14. Triage of Chemical Casualties 337
15. Decontamination 351
16. Chemical Defense Equipment 361
17. Healthcare and the Chemical Surety Mission 397
18. Historical Overview of Biological Warfare 415
19. The U.S. Biological Warfare and Biological Defense Programs 425
20. Use of Biological Weapons 437
21. The Biological Warfare Threat 451
22. Anthrax 467
23. Plague 479
x
24. Tularemia 503
25. Brucellosis 513
26. Q Fever 523
27. Smallpox 539
28. Viral Encephalitides 561
29. Viral Hemorrhagic Fevers 591
30. Defense Against Toxin Weapons 603
31. Staphylococcal Enterotoxin B and Related Pyrogenic Toxins 621
32. Ricin Toxin 631
33. Botulinum Toxins 643
34. Trichothecene Mycotoxins 655

35. Medical Challenges in Chemical and Biological Defense for the 21st Century 677
Acronyms and Abbreviations 687
Index 691
To access USAMRIID’s contingency response and operational medicine and scientific consultation
capabilities, telephone 1-888-USA-RIID.
Interested readers can also find up-to-date information on the medical aspects of chemical and
biological warfare at the following internet locations:
The Medical NBC Information Server
Medical Research and Materiel Command
Medical Chemical Defense />Medical Biological Defense />Medical Research Institute of Chemical Defense
Medical Research Institute of Infectious Diseases
(numeric) http://140.139.42.105
xi
Foreword
The thought of chemical and biological warfare terrifies us. What is it in the
human psyche that makes being attacked with conventional weapons—that kill
and maim—more acceptable than being attacked with molecules that alter the
body chemistry or with organisms that cause disease? For some, the wearing of
chemical protective clothing seems to exemplify our fear of an unknown agent
that we cannot see, do not understand, and think must be immoral.
World events have conspired to increase the threat of the use of chemical and
biological weapons. The end of the Cold War brought not only the hoped-for
change of swords into plowshares but also political and economic turbulence in
the former Soviet Union, unemployed and disenchanted weapons specialists
and scientists, the rise of religious fundamentalism in southwest Asia, state-
sponsored terrorism, and blurring of the lines between terrorism and tradi-
tional warfare.
In addition, the nature of war is changing. We no longer expect a war to last
years, as World War II did, but rather days, as we saw with the Persian Gulf
War. Worse, the weapons of war have also changed. Many countries do or could

possess chemical and biological agents—bypassing the tremendous financial
outlay required to acquire conventional weapons.
Until this decade, our military forces had not faced chemical and biological
weapons since World War I, and the prevailing attitude has been “out of sight,
out of mind.” The Persian Gulf War changed all that. Just the threat that such
weapons would be used was itself an effective weapon, as it required us to
expend tremendous logistical resources to supply our troops in the desert. Now
we know that we must master all relevant aspects of defense against chemical
and biological warfare. The Biological Weapons Convention, ratified in 1975,
did not slow the massive Soviet program, which continued until early 1992, nor
did it prevent the buildup in Iraq between 1985 and 1990. At this time, experts
are severely questioning whether verification of compliance with the treaty can
be certain. Similar concerns delayed ratification of the Chemical Weapons
Convention by the U.S. Senate; nevertheless, the senate ratified the treaty on 24
April 1997.
A primary value of the Textbook of Military Medicine series is to preserve the
lessons of past wars and, by so doing, demonstrate how current doctrine is built
on knowledge that was gained at so high a cost. Medical officers should read
this volume, Medical Aspects of Chemical and Biological Warfare, and learn its
lessons well. Civilians expect that we in the military will know how to manage
chemical and biological casualties. Indeed, if we do not, then who will? The
nation expects us to be prepared to defend against all attacks and will be
unforgiving of any incapacity on our part.
Lieutenant General Ronald R. Blanck
The Surgeon General
U.S. Army
May 1997
Washington, D. C.
xii
xiii

Preface
Until recently, we in the United States have not given much thought to the
specter of chemical and biological warfare. Our fathers and grandfathers who
fought in World War I are almost all gone now, and the poet’s image of gassed
soldiers fumbling for their helmets has been considered merely a historical
footnote—if it is remembered at all. But forgetting is a luxury we can no longer
afford. In 1917, the Army War College stated:
The employment of poisonous gases as a means of offensive warfare has made it
imperative that medical officers should have some knowledge of the action of the
various gases that are likely to be met with and of rational lines of treatment which
may be adopted in cases of gas poisoning.
1(p5)
Nothing has changed except the increased availability of chemical and biologi-
cal weapons; now more than ever we must be able to both defend against attack
and manage chemical and biological casualties.
The good news is that the development of passive countermeasures for
chemical and biological defense (pretreatments, therapies, timely detectors,
effective protective equipment) has significantly reduced the threat to our
military forces. Although the biological defense countermeasures program is
not yet as advanced as its chemical counterpart, new developments in biotech-
nology have allowed us to take tremendous strides forward. In the meantime,
we can educate our healthcare providers now, at minimal cost and with great
potential benefit. One of the reasons that chemical and biological weapons are
considered so dangerous is that we medical officers, in our daily clinical
practice, hardly ever see patients whose conditions have any similarity to
casualties of chemical and some of the more exotic biological agents.
This textbook focuses on the management of casualties. Its publication may
be even more timely than we had expected, especially considering the increased
threat of terrorism—both foreign and domestic. Terrorist attacks at home and
abroad have heightened the interest of civilian healthcare providers and first-

responders, and of other governmental agencies such as the Federal Emergency
Management Agency and the Public Health Service that would be required to
respond in case of an attack on our own soil. These nonmilitary healthcare
providers will also find this textbook to be extremely useful.
The scientists who organized and are responsible for this textbook are
recognized worldwide as the foremost experts in the medical aspects of chemi-
cal and biological warfare. Their overriding goal is this: to produce a force that
understands the threats of chemical and biological weapons and how to re-
spond to them, and, by understanding the threats, sustains fewer casualties.
Brigadier General Russ Zajtchuk
Medical Corps, U.S. Army
May 1997
Washington, D. C.
1. Army War College. Memorandum on Gas Poisoning in Warfare, With Notes on its Pathology and
Treatment. Washington, DC: Government Printing Office; 1917: 5.
xiv
The current medical system to support the U.S. Army at war is a
continuum from the forward line of troops through the continen-
tal United States; it serves as a primary source of trained replace-
ments during the early stages of a major conflict. The system is
designed to optimize the return to duty of the maximum number
of trained combat soldiers at the lowest possible echelon. Far-
forward stabilization helps to maintain the physiology of injured
soldiers who are unlikely to return to duty and allows for their
rapid evacuation from the battlefield without needless sacrifice
of life or function.
xv
Medical Force 2000 (MF2K)
PATIENT FLOW IN A THEATER OF OPERATIONS
E: Echelon

EAC: Echelon Above Corps
FST: Forward Surgical Team
MASF: Mobile Aeromedical Staging Facility, USAF
Med Co: Medical Company
RTD: Return to Duty
ASF: Aeromedical Staging Facility, USAF
ASMB: Area Support Medical Battalion
ASMC: Area Support Medical Company
BAS: Battalion Aid Station
CM: Combat Medic
CONUS: Continental United States
CZ: Combat Zone
xvi
Medical Aftermath of the Persian Gulf War
The editors of the Textbook of Military Medicine are mindful that some veterans of
the Persian Gulf War (1990–1991) face continuing health problems. Although
readers might have hoped to find a discussion in this textbook devoted to the
illness known as Gulf War syndrome, the medical aftermath of that war is
incompletely understood. A formal academic treatment now would not only be
premature, it would soon be outdated.
One fact seems clear at this time (May 1997): the scientific community has not yet
reached a consensus on the medical consequences of serving in the Persian Gulf.
Most observers agree that some of the 697,000 U.S. soldiers who were deployed
there are sick and have wide-ranging symptoms, but the cause, or causes, have
not yet been established. Investigations into the etiology and epidemiology of
these illnesses have reached inconclusive and contradictory conclusions. Even
the popular name of the illness, Gulf War syndrome, is perhaps misleading
because the array of signs and symptoms does not fit the usual medical definition
of a syndrome: a set of symptoms that occur together; the sum of signs of any
morbid state; the aggregate of signs and symptoms associated with any morbid

process that constitute together the picture of the disease.
The level of scientific inquiry into the problem, already high, has increased in
recent months; we hope that these questions (particularly those pertaining to
etiology and epidemiology, and from there, treatment) can be answered soon.
Subsequent editions of this or other textbooks in this series will give the medical
aftermath of the Persian Gulf War the attention it deserves.
Overview: Defense Against the Effects of Chemical and Biological Warfare Agents
1
Chapter 1
OVERVIEW: DEFENSE AGAINST THE
EFFECTS OF CHEMICAL AND
BIOLOGICAL WARFARE AGENTS
FREDERICK R. SIDELL, M.D.
*
; AND DAVID R. FRANZ, D.V.M., PH.D.
†
INTRODUCTION
HISTORICAL PRECEDENTS
INTRODUCTION TO CHEMICAL AND BIOLOGICAL AGENTS
IMPLICATIONS FOR THE MILITARY MEDICAL DEPARTMENTS
*
Formerly, Chief, Chemical Casualty Care Office, and Director, Medical Management of Chemical Casualties Course, U.S. Army Medical
Research Institute of Chemical Defense, Aberdeen Proving Ground, Maryland 21010-5425; currently, Chemical Casualty Consultant, 14
Brooks Road, Bel Air, Maryland 21014
†
Colonel, Veterinary Corps, U.S. Army; Commander, U.S. Army Medical Research Institute of Infectious Diseases, Fort Detrick, Frederick,
Maryland 21702-5011
Medical Aspects of Chemical and Biological Warfare
2
INTRODUCTION

“Gas! Gas!” This warning cry, so common in
World War I, almost became real to U.S. forces again
as they prepared to liberate Kuwait in late 1990. The
threat of chemical, and even biological, warfare was
foremost in the minds of U.S. military personnel
during Operation Desert Shield, the preparation for
the Persian Gulf War. Iraq was known to have a
large stockpile of chemical weapons and had dem-
onstrated during its conflict with Iran that it would
use them. It was not until after the Persian Gulf War
that the U.N. Special Commission on Iraq confirmed
that Saddam Hussein also had biological agents
loaded in weapons. The chemical and biological
threats were major concerns to those in the mili-
tary medical departments who would be called on
to care for poisoned or infected casualties, possibly
in a chemically contaminated environment. Fortu-
nately the ground war of the Persian Gulf War
(Operation Desert Storm) was brief, and even more
fortunately, our adversary did not employ these
weapons.
In the desert, during the fall and winter of
1990–1991, the threat of chemical warfare be-
came very real to our military medical personnel.
The threat of biological warfare was no less feared.
The military medical departments realized that
medical personnel were not prepared to pro-
vide care to chemical or biological casualties
or to function in a contaminated environment. This
textbook should help accelerate the assimilation

of medical defense information in the next war;
in the past, such information has not been readi-
ly accessible. Two handbooks have also been pre-
pared: Medical Management of Chemical Casualties
Handbook, Chemical Casualty Care Office, Med-
ical Research Institute of Chemical Defense, Aber-
deen Proving Ground, Maryland (September 1994);
and Medical Management of Biological Casualties
Handbook, U.S. Army Medical Research Institute of
Infectious Diseases, Fort Detrick, Frederick, Mary-
land (March 1996).
Rapid and intense teaching programs help-
ed prepare our medical healthcare providers, so
that by the onset of Operation Desert Storm,
they were as ready as any military medical per-
sonnel might be to go to war. Hundreds of thou-
sands of troops were supplied with chemical
pretreatment and therapeutic agents and thou-
sands were immunized against anthrax and the
botulinum toxins, the two most likely biological
battlefield threats.
Two lessons were learned from this conflict,
lessons that should never be forgotten by those
in the military. The first was that there are coun-
tries that have chemical and biological weapons,
and there are other countries that might obtain
or produce them. The second was that the U.S.
military medical departments must be prepared
at all times to treat both types of casualties. As
long as potential adversaries exist, the U.S. mili-

tary might face a chemical or biological battle-
field.
Military medical personnel of the United States
have not treated a chemical casualty on the battle-
field for nearly 8 decades, and they have never
treated a biological casualty. Chemical agents have
not been used as weapons in a major war or in any
military conflict in which the United States has
been involved since World War I. Despite the re-
cent dissolution of the Warsaw Pact, the breakup
of the Soviet Union, and other events that have
seemingly reduced the conventional military threat
to the United States, a textbook for military medi-
cal personnel on the management of chemical and
biological agent casualties is still urgently needed.
The breakup of the Soviet Union, and the conse-
quent glut of biowarfare experts on the world em-
ployment market, may have actually increased the
threat of biological proliferation. In addition to the
recent experience in the Persian Gulf, a review of
other events of the past 2 decades bears out this con-
clusion (Exhibit 1-1).
EXHIBIT 1-1
RECENT TARGETS OF CHEMICAL OR
BIOLOGICAL AGENTS
Laos (mid to late 1970s; alleged)
Kampuchea (late 1970s and early 1980s; alleged)
Afghanistan (1980s; alleged)
Iran (1980s; Iran–Iraq War; confirmed)
Iraqi Kurds (1988; confirmed)

Overview: Defense Against the Effects of Chemical and Biological Warfare Agents
3
HISTORICAL PRECEDENTS
During the Arab–Israeli War (also called the Yom
Kippur War) of 1973, chemical weapons were not
used. While processing captured soldiers, however,
Israeli troops found that the Egyptians carried per-
sonal protective equipment, a decontamination kit
containing items unfamiliar to U.S. personnel, and
an antidote with which we were also unfamiliar.
This evidence suggested that the Egyptians were
prepared for a chemical battlefield, and the com-
ponents of the antidote suggested that they were
prepared for the use of the nerve agent soman. (The
antidote was a mixture of three compounds: atro-
pine, benactyzine, and the oxime, TMB4.) The U.S.
military soon issued the antidote to U.S. troops, only
to withdraw it about 5 years later.
In the mid to late 1970s, reports began to appear
that chemicals were being used against Hmong
tribesmen in Laos. The Hmong had been loyal to
the United States and had served this country
in many ways during the Vietnam War; it was
suggested that chemicals were being used against
the Hmong in retaliation. Investigations were
conducted by U.S. State Department personnel,
by a medical team sent by The U.S. Army Surgeon
General, and by international groups. Little defini-
tive evidence was discovered, primarily because the
alleged attacks took place deep in Laos. The

victims took weeks to travel to Thailand to be
examined, and outsiders could not enter Laos to
examine the attack sites. The Hmong who reached
Thailand provided graphic accounts of attacks
by sprays and bombs from airplanes and how these
“smokes,” which were of all colors, killed many
in their villages. One member of the medical team
brought back a sample of a yellow substance on
the outer (barklike) layers of a bamboo culm (ie,
stalk); the sample had been given to him by a
Hmong, who claimed that the material had killed
many of his fellow villagers. This yellow substance,
along with samples from many other locations, later
became known as “yellow rain” (see Chapter 34,
Trichothecene Mycotoxins, which discusses yellow
rain in greater detail).
Moreover, in the late 1970s and early 1980s, alle-
gations were made of chemical agent use against
refugees fleeing the barbaric conditions that existed
in Kampuchea at that time.
1
The clinical response
of the exposed humans did not fit what we under-
stood about the effects of classic chemical agents.
Tearing and itching looked like the effects of tear
gas. Convulsions suggested nerve agents. But the
occurrence of internal hemorrhage and skin lesions
could not be explained. Analysis of a leaf sample
collected in Kampuchea 24 hours after an attack
implicated trichothecene mycotoxins, a family of

toxins produced by fungi but having characteris-
tics more like chemical than biological agents.
In August 1981, based on limited physical evi-
dence, the U.S. government announced that
trichothecene mycotoxins had been used—but the
findings were less than convincing to some in the
scientific community and the issue became ex-
tremely contentious. This controversy was never
totally resolved, and the question of which, if any,
agents were used against civilians was not an-
swered. If mycotoxins were, in fact, used it was the
first recorded use of biological agents since before
World War II, when the Japanese used them against
the Chinese in the early 1940s.
2
In the 1980s, Soviet troops battled Afghan rebels
protesting the communist Afghan regime. During
this lengthy conflict, frequent allegations were
made of the use of chemical agents against the Af-
ghans. One of these chemicals, known as Blue-X,
was said to cause instant immobilization, the vic-
tim remaining in place for a number of hours be-
fore recovering. The use of other, more lethal agents
was also alleged, but again no definitive evidence
was found.
The most widespread and most open use of
chemical weapons on a battlefield in recent decades
was by Iraq in its conflict with Iran. This time the
evidence of chemical use was conclusive. Undeto-
nated shells were sampled and their contents were

analyzed by several laboratories in Europe. A vesi-
cant or blister agent (mustard) and a nerve agent
(tabun) were identified. About 100 Iranian soldiers
with chemical wounds were sent to European hos-
pitals for care; their wounds were consistent with
vesicant (mustard) injury. A team appointed by the
U.N. secretariat went to Iranian battlefields and
hospitals and found chemical shells and patients
with chemical injuries. The public outcry at the use
of these weapons was less than overwhelming. Ig-
noring protests from the world community, Iraq
continued to use these agents.
Evacuating wounded soldiers to Europe not only
lessened the burden on the medical facilities in Iran
(although the number sent was a small fraction of
the total) and provided soldiers with good medical
care, but it also provided the rest of the world with
evidence that Iraq was using these weapons. In gen-
Medical Aspects of Chemical and Biological Warfare
4
eral, the casualties were sent privately, not through
governmental connections. Physicians in Europe
accepted the patients and assumed responsibility
for their care, usually in private hospitals (a situa-
tion that made a retrospective analysis of the care
rendered and the effectiveness of different treat-
ment regimens difficult).
A similar situation enabled three physicians from
the U.S. Army medical community to examine sev-
eral casualties from Iraq’s use of chemical weap-

ons. On March 19, 1988, Iraqi airplanes bombed the
village of Halabja, in Iraq. The inhabitants were
Kurdish Iraqi citizens, a tribespeople who live in
the region where the borders of Turkey, Iran, and
Iraq meet. The casualties from this raid received
worldwide media attention. The chemical weapons
allegedly used were nerve agents, cyanide, and
mustard. The casualties were cared for by Iran, and
five of them (a man, a woman, and three young
children, all unrelated) were sent to the United
States for care by an Iranian physician living here.
On examination by three authors of chapters in this
textbook, the casualties were found to have skin
lesions and pulmonary pathological changes (as
determined by radiograph) consistent with mustard
exposure.
Other items in the news over the past decade
have suggested that the proliferation of chemical
and biological agents is greater than we might hope.
For example, numerous accounts claimed that Libya
had built a facility capable of chemical agent pro-
duction at Rabta—Libya’s protestation that this fa-
cility was a pharmaceutical plant notwithstanding.
One report even noted that monthly production was
about 30 tons of mustard.
In 1979, an accident at a previously undetected
biological weapons plant in Sverdlovsk, Russia, sur-
prised even the intelligence community.
3
At least

66 humans living or working downwind of the plant
died of pulmonary anthrax. Soviet troops quickly
attempted to decontaminate the facility and the city
following airborne release of anthrax spores, and
medical teams instituted preventive therapy, but the
message was clear. The Soviet biological warfare
program was thriving, more than 6 years after the
Soviet Union had signed the Biological Weapons
Convention.
In addition to their being used on the battlefield,
chemical and biological agents might also be used
in terrorist attacks. The nerve agent sarin was twice
used in Japan. The first incident, in Matsumoto in
June 1994, produced more than 200 casualties in-
cluding 7 fatalities. In the second incident—in the
Tokyo subway system on 20 March 1995—5,510
people were taken to medical facilities or sought
medical assistance. About 20% of these were hos-
pitalized, and 12 died. The cult that was accused of
both attacks was found to have a large facility for
manufacturing both chemical and biological agents.
In the face of overwhelming evidence, the Soviet
Union continued to officially deny having an offen-
sive biological weapons program until 1992, when
Russian President Boris Yeltsin admitted publicly
to having maintained a program until March of that
year. Since then, visits by teams from the United
States and the United Kingdom to former biologi-
cal warfare facilities under the Joint United States/
United Kingdom/Russia Trilateral Statement on

Biological Weapons have clearly documented the
capabilities to produce biological warfare agents in
massive quantities.
Verification of compliance with agreements such
as the Trilateral and with the chemical and biologi-
cal weapons conventions are plagued by the “dual-
use” nature of the facilities in which these agents
are developed and produced. A legitimate chemi-
cal facility can be converted fairly easily for the
manufacture of chemical agents. On threat of in-
spection by an international group, the facility can
readily be converted back to a legitimate use. The
dual-use nature of production facilities is even more
applicable to the production of biological agents.
Partly for this reason, chemical and biological weap-
ons have been called “the poor man’s atom bomb.”
It has also been said that agents can be made in a
bathtub, which may be true to a limited extent for a
skilled microbiologist or chemist. Production of
even tactical quantities of these agents and their
deployment on the battlefield, however, is not a
trivial undertaking.
INTRODUCTION TO CHEMICAL AND BIOLOGICAL AGENTS
Chemical and biological agents differ in several
important ways. Chemical agents are typically man-
made through the use of industrial chemical pro-
cesses. Biological agents are either replicating
agents (bacteria or viruses) or nonreplicating ma-
terials (toxins or physiologically active proteins or
peptides) that can be produced by living organisms.

Some of the nonreplicating biological agents can
also be produced through either chemical synthe-
sis, solid-phase protein synthesis, or recombinant
expression methods. Almost none of the biological
agents are dermally active (the mycotoxins are a
Overview: Defense Against the Effects of Chemical and Biological Warfare Agents
5
rare exception) and none are volatile. On the other
hand, most of the chemical agents are dermally ac-
tive, volatile, or both.
Therefore, while many of the dermally active or
volatile chemical agents can be disseminated as liq-
uids or aerosols, and the biological agents must be
dispersed as respirable aerosols (particles approxi-
mately 1–10 µm in diameter). Dispersing a respirable
aerosol on a battlefield requires a high-energy gen-
erating system to produce the small particle size,
appropriate weather conditions to assure that the
aerosol cloud stays near the ground, and adequate
infectivity or toxicity of the agent to produce the
desired effect. Except for infectivity, these are all
important practical requirements for the field use
of chemical, as well as biological, warfare agents.
In World War I, the use of chemical agents began
with the small-scale use of irritants (known today
as riot control agents). Chlorine, the first agent used
on a large scale, and phosgene caused large num-
bers of deaths. Cyanide was introduced in midwar,
but the agent that caused the greatest number of
casualties was the vesicant mustard, which was in-

troduced late in the war. Cyanide, phosgene, and
mustard are still potential chemical weapons today.
In the period before World War II, German sci-
entists synthesized the first nerve agents; during the
war, Germany had thousands of tons of nerve
agents stockpiled in munitions. The United States
and the Soviet Union captured the stockpiles and
manufacturing facilities late in the war, and they
began to manufacture and stockpile these agents.
Nerve agents are 15- to 100-fold more potent than
the chemical agents used in World War I. In the
1950s, the United States put the incapacitating com-
pound BZ into munitions (which have been de-
stroyed); late in that decade, the currently used riot
control agent CS was introduced for military use.
Military chemical agents are classified as “per-
sistent” and “nonpersistent.” Persistent agents are
those with low volatility or which evaporate slowly.
Since they do not readily evaporate, they stay on
terrain, materiel, or equipment for days, weeks, or
months, depending on the weather. Chief among
the persistent agents are the vesicant mustard and
the nerve agent VX. Nonpersistent agents are those
that are volatile and hence evaporate quickly; they
are not expected to be present for more than sev-
eral hours. The nonpersistent agents are phosgene,
cyanide, and the G series of nerve agents. Each type
has military advantages. Advancing troops might
disperse a nonpersistent agent ahead of their attack
to have the advantage of its effects on the enemy

and later to have uncontaminated terrain into which
to advance. A persistent agent might be used to con-
taminate terrain, supplies, and equipment, deny-
ing the enemy their use.
Biological weapons may contain either replicat-
ing or nonreplicating agents. Although hundreds
of naturally occurring bacteria, viruses, and toxins,
as well as “designer compounds,” could potentially
be considered agents by an aggressor, a finite num-
ber of these are actually useful as area weapons on
the battlefield. The agents’ utility is limited by ease
of production, stability, and infectivity (bacteria and
viruses), or toxicity/effectivity (toxins and other
physiologically active materials). Bacillus anthracis,
for example, is often touted as the best of bacterial
agents. Stability of the spore form and ease of pro-
duction are its greatest strengths as weapons mate-
rial. Among viral agents, Venezuelan equine en-
cephalitis virus is easily grown to extremely high
titers, making it a potential incapacitating agent.
The bacterial agents that cause tularemia, Q fever,
and brucellosis are infective at extremely low doses
(1–10 organisms per person). Finally, the extraordi-
nary toxicity (1,000- to 10,000-fold more toxic than
the classic nerve agents) of the staphylococcal en-
terotoxins as incapacitants and the botulinum tox-
ins as lethal agents makes them candidates for
weaponization.
Most of the chemical compounds noted above
have characteristics that make them uniquely suited

to warfare. Closely related chemical substances,
however, and some of the threat agents, are found
throughout the civilian community. Unlike the
chemical warfare agents, which are not found in
nature, essentially all of the biological agents de-
scribed are found in nature and cause the same or
very similar disease syndromes. Military medical
personnel might encounter persons exposed to the
organisms as endemic disease agents on remote
battlefields.
Similarly, civilians as well as military personnel
could be exposed during peacetime to commercial
chemicals closely related to chemical warfare
agents. Thousands of tons of cyanide, for example,
are manufactured annually for industrial use and
are shipped to users by truck and train throughout
the country. Phosgene is also manufactured in large
amounts and shipped cross-country. The nerve
agents are not available outside the military, but
they are closely related to most pesticides or insec-
ticides that are sprayed on orchards or used by the
backyard rose gardener. The effects of these agri-
cultural compounds are nearly identical to those of
nerve agents, and medical therapy is the same. The
incapacitating agent BZ (3-quinuclidinyl benzilate)
Medical Aspects of Chemical and Biological Warfare
6
is used in small amounts in research pharmacology
(where it is known as QNB). Also, BZ is pharmaco-
logically related to anticholinergic drugs, which are

present in many over-the-counter preparations,
such as sleeping medications.
Unlike the chemical warfare agents, essentially
all of the biological agents described cause syn-
dromes that mimic or are identical to naturally oc-
curring diseases. Outbreaks of disease caused by
bacteria or viruses or isolated intoxications caused
by toxins may result in syndromes similar to those
seen in biological warfare attacks. In the case of
these agents, the route of exposure—universally via
the airways on the battlefield—may cause slightly
or significantly different clinical presentations. Gen-
eral principles of prophylaxis and therapy pre-
sented in this text, however, often apply. Although
the reader may initially think that the information
presented in this textbook is needed only in war-
time, much of the contents will also be useful to the
physician in a busy emergency room.
On the battlefield, knowledge of the chemical or
biological agent threat and its medical and physi-
cal countermeasures can actually reduce the threat.
In World War I, the death rate for chemical casual-
ties was about 3%. Data are not available for the
Iran–Iraq War, but informal reports indicate that the
death rate for those chemical casualties who reached
medical care was probably less than 5%, despite the
use of the highly toxic nerve agents against rela-
tively unprotected troops. With well-trained troops
and well-prepared medical personnel, these figures
will be lower. For the chemical agents, real-time

detectors allow exploitation of the excellent indi-
vidual physical protective mask, effective pretreat-
ment, and therapy.
These countermeasures, in conjunction with
training of our forces, can make an enormous dif-
ference and actually serve as a deterrent to chemi-
cal agent use. A chemical attack on a battlefield will
not be the devastating event that some military
medical personnel fear. Soldiers will survive and
return to duty. For the biological agents, field detec-
tors are still not responsive enough to allow timely
warning of a cloud moving across the battlefield. Al-
though the mask is protective, adequate warning may
still be a problem. Knowledge of the meteorological
conditions necessary for effective deployment of bio-
logical and chemical agents can at least limit the time
during which a force must be on highest alert. In
addition, effective medical countermeasures (vac-
cines, drugs, and diagnostics) are available for many
of the agents of greatest concern. An integrated sys-
tem of countermeasures for the chemical and bio-
logical agents can significantly reduce the threat by
raising the cost/benefit ratio for the would-be ag-
gressor. If the agents are used, appropriate medical
care from well-informed medical care providers that
enables soldiers to survive could be the factor de-
termining whether a battle is won or lost.
IMPLICATIONS FOR THE MILITARY MEDICAL DEPARTMENTS
From 18 January to 28 February 1991, 39 Iraqi-
modified SCUD missiles reached Israel.

4
Although
many were off target or malfunctioned, some of
them landed in and around Tel Aviv. Approximately
1,000 people were treated as a result of missile attacks,
but only 2 died. Anxiety was listed as the reason for
admitting 544 patients and atropine overdose for hos-
pitalization of 230 patients. Clearly, these convention-
ally armed SCUDs were not effective mass casualty
weapons, yet they caused significant disruption to the
population of Tel Aviv. Approximately 75% of the ca-
sualties resulted from inappropriate actions or reac-
tions on the part of the victims. Had one of the war-
heads contained a chemical or biological agent that
killed or intoxicated a few people, the “terror ef-
fect” would have been even greater.
The likelihood of such a weapon causing panic
among military personnel decreases, however,
when the leaders and troops become better edu-
cated regarding these agents. As General John J.
Pershing wrote after World War I: “Whether or not
gas will be employed in future wars is a matter of
conjecture. But the effect is so deadly to the unpre-
pared that we can never afford to neglect the
question.”
5(p623)
The experience in the Persian Gulf War reinforced
General Pershing’s warning. Despite the improve-
ment in relations between the East and the West,
potential adversaries still exist—and potential ad-

versaries have chemical and biological agents.
These agents have been used in recent years, and
probably will be used again on the battlefield or in
small, regional conflicts. They might also be used
in acts of terrorism within the United States, in
which case, by authority of Presidential Decision
Directive 39 (1995), the military will assist civilian
authorities and medical personnel.
Fortunately, U.S. troops and medical personnel
have not been involved in these attacks; it is hoped
that they never will be. We must be prepared, how-
ever. The purpose of this textbook is to assist in that
preparation.
Overview: Defense Against the Effects of Chemical and Biological Warfare Agents
7
REFERENCES
1. McDermott J. The Killing Winds. New York, NY: Arbor House; 1987: 49–60.
2. Williams P, Wallace D. Unit 731: Japan’s Secret Biological Warfare in World War II. New York, NY: The Free Press
(Macmillan); 1989: 65–70.
3. Meselson M, Guillemin J, Hugh-Jones M, et al. The Sverdlovsk anthrax outbreak of 1979. Science. 1994;266:1202–
1208.
4. Karsenty E, Shemer J, Alshech I, et al. Medical aspects of the Iraqi missile attacks on Israel. Isr J Med Sci.
1991;27:603–607.
5. Pershing JJ. Final report of General John J. Pershing. Annual Report. Vol 1, Part 1; 1919. Quoted by: Brown FJ.
Chemical Warfare. A Study in Restraints. Princeton, NJ: Princeton University Press; 1968: 623.
History of Chemical and Biological Warfare: An American Perspective
9
Chapter 2
HISTORY OF CHEMICAL AND BIOLOGICAL
WARFARE: AN AMERICAN PERSPECTIVE

JEFFERY K. SMART, M.A.
*
INTRODUCTION
PRE–WORLD WAR I DEVELOPMENTS
WORLD WAR I
THE 1920S: THE LEAN YEARS
THE 1930S: THE GROWING THREAT OF CHEMICAL AND BIOLOGICAL
WARFARE
THE 1940S: WORLD WAR II AND THE NUCLEAR AGE
THE 1950S: HEYDAY OF THE CHEMICAL CORPS
THE 1960S: DECADE OF TURMOIL
THE 1970S: THE NEAR END OF THE CHEMICAL CORPS
THE 1980S: THE RETURN OF THE CHEMICAL CORPS
THE 1990S: THE THREAT MATERIALIZES
SUMMARY
*
Command Historian, U.S. Army Chemical and Biological Defense Command, Aberdeen Proving Ground, Maryland 21010-5423
Medical Aspects of Chemical and Biological Warfare
10
INTRODUCTION
Webster’s Ninth New Collegiate Dictionary defines
the term “chemical warfare,” first used in 1917,
as “tactical warfare using incendiary mixtures,
smokes, or irritant, burning, poisonous, or asphyx-
iating gases.” A working definition of a chem-
ical agent is “a chemical which is intended for
use in military operations to kill, seriously injure,
or incapacitate man because of its physiological
effects. Excluded from consideration are riot con-
trol agents, chemical herbicides and smoke

and flame materials.”
1(p1-1)
Chemical agents were
usually divided into five categories: nerve agents,
vesicants, choking agents, blood agents, and
incapacitants.
Webster’s dictionary likewise defines “biological
warfare” as “warfare involving the use of living
organisms (as disease germs) or their toxic prod-
ucts against men, animals, or plants.” A working
definition of a biological agent is “a microorgan-
ism (or a toxin derived from it) which causes dis-
ease in man, plants or animals or causes deteriora-
tion of material.”
2(p1-1)
Biological warfare agents
were normally divided into three categories: anti-
personnel, antianimal, and antiplant.
Prior to World War I, the United States had little
knowledge about the potential of chemical and bio-
logical warfare. Particularly in terms of preparing
soldiers for future wars, the possibility of chemical
or biological warfare went virtually unnoticed by
the U.S. Army. By the end of World War I, the situ-
ation had drastically changed. Chemical warfare
had been used against and by American soldiers
on the battlefield. Biological warfare had been used
covertly on several fronts. In an effort to determine
what had gone wrong with their planning and train-
ing, U.S. Army officers prepared a history of chemi-

cal and biological warfare. To their surprise, they
found numerous documented cases of chemical and
biological agents having been used or proposed to
influence the outcome of a battle or campaign. In
addition, they discovered that the technology to
protect against chemical and biological agents al-
ready existed, and, in some cases, was superior to
the equipment used during the war. In hindsight,
these officers realized that the army had failed to
recognize and prepare for these two already exist-
ing types of warfare.
[This chapter focuses primarily on the develop-
ment of chemical and biological weapons and coun-
termeasures to them, thus setting the stage for
Chapter 3, Historical Aspects of Medical Defense
Against Chemical Warfare, which concentrates on
medical aspects of chemical warfare. To avoid ex-
cessive duplication of material, protective equip-
ment of the modern era is illustrated in Chapter 16,
Chemical Defense Equipment.—Eds.]
PRE–WORLD WAR I DEVELOPMENTS
The chemical agents first used in combat during
World War I were, for the most part, not recent dis-
coveries. Most were 18th- and 19th-century discov-
eries. For example, Carl Scheele, a Swedish chem-
ist, was credited with the discovery of chlorine in
1774. He also determined the properties and com-
position of hydrogen cyanide in 1782. Comte
Claude Louis Berthollet, a French chemist, synthe-
sized cyanogen chloride in 1802. Sir Humphry

Davy, a British chemist, synthesized phosgene in
1812. Dichloroethylsulfide (commonly known as
mustard agent) was synthesized in 1822, again in
1854, and finally fully identified by Victor Meyer
in 1886. John Stenhouse, a Scotch chemist and in-
ventor, synthesized chloropicrin in 1848.
3
Many biological agents were naturally occurring
diseases thousands of years old. Others were gen-
erally discovered or recognized in the 19th and 20th
centuries. For example, plague was recognized
about 3,000 years ago. Smallpox was known in
China as early as 1122 BC. Yellow fever was first
described in the 1600s. Carlos Finlay, a Cuban
biologist, identified mosquitoes as the primary
carrier of yellow fever in 1881, while Walter Reed,
a U.S. Army physician, proved the agent to be a vi-
rus. Casimir-Joseph Davaine isolated the causative
organism of anthrax in 1863, followed by Robert
Koch, a German scientist, who obtained a pure cul-
ture of anthrax in 1876. Koch also discovered the
causative agent for cholera in 1883. Rocky Moun-
tain spotted fever was first recognized in 1873;
Howard T. Ricketts, an American pathologist,
discovered the causative agent in 1907. Ricketts
also identified the causative organism of typhus in
1909. F. Loffler and W. Schutz identified glanders
in 1882. Sir David Bruce, a British pathologist, dis-
covered the causative organism of brucellosis (it
was named after him) in 1887. Ricin toxin was iden-

tified in 1889. Tularemia was first described in
Tulare County, California (after which it was