DEPARTMENT OF THE ARMYU.S. ARMoY MEDICAL INTELLIGENCE AND INFORMATION AGENCY ( 'I

WASHIJINGTON. D.C. 2031A

USAMNIA TRANqIATION

_- Number: USAIIIA-K-5943

Date Completed: 31 Oct 75

Language: Serbo-Croatian

Geographic Area: Yugoslavia

•, English Titles: 1. Contribution to the Doctine Governing Ilospitalization inNationwide Defensive Warfare.

, c2. Wartime Military Medical Equipment for Care of the Sicl.3. Present-day Trends in the Development of Chemical Weapons.4. Pharmacological and Toxicological Properties of Present-DayCombat Poisons Which Cause Malaise (CS, CR).5. Clinical Aspects and Care of Patients 'of Acute Poisoningwith Present-Day Poisons That Cause Malaise (CS, CR).

4iForeign Titles: i. Prilop dcýke'ini hospitalizaciie u omceuarodnom obrambernom ratu. . .

2. Ratna sanitetska oprema za zbrinjavanje obolelih.'.3 Savromene t-endencile u razvoJu he,,ijskog oruzia.4. Farmakoloske i toksikoloskt, osobine savremenih vojnih otrova"za uenemiravanje (tipa CS, CR).5. Klinicka slika i zbrinjavanje akutnib trovanja savremeuimotrovinma za uznemiravanje (Tipa C.3, CR).

Authors: 1. Ivo Kralj.2. Aleksander lBranilovic at al.3. Nedeljko Resic.4. Nedeljko Rosic et al.5. Radivoje Kusic et al.

Source Document: VOINOSANITETSKI PREGLEI), Vol 31, No 5.

S Pages Translated: Pp. 304-310; 339-349.27

Pub Ibi•ier Federal Secretariat for National Defense

Date/Place Publication: September-October, 1974, Belgrade, Yugoslavia.

Distribution Statement:

Approved ior public jLLease; L • .. .Distribution unlimited

NAFIONAL TECHN'ICALINFORMATION SERVIC.E

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[PP 305-31-01 UDc 61.ooi:355.01:362°:.11:355 .45 :351.86_

S• CONTRIBUTION TO THE DOCTRINE GOVERNING H01SPITALIZATION-S• IN NATIONWIDE DEFENSIVE, WARFARE

S~Medical Lieutenant ColonelSGeneral lvr. KralJ, doctor

SFactors exerting an essential effect on the d~biens-JLons,strutcture and ter'ritorial placement of -the hospital net-work %uder the conditions of a nation:i..de defensive war

r• • are discussed. 'Iypes of hospital institutions are pro-Sno -ed - There "•o - c,•ounced, nee fo-" via-- 10• ' 1-- ... - 1

- •izal'.ion lx).licy -to b•e def.ined in peacetime because of 'theinevitability of conisiderabl•e r'estrictions in quotas aondi i standards of the hospital service. 'The taL'ticle presents

certain problems and solutions regarding the movement and• housing of hospital institutions in wartime and alsoS~views and special procedures regarding protection of hos-•Jpitalized members of ithe a~niid :forces and in connection

S• ~with• tlhe tanctioning of the hospital service on portionsS• ~of territory tem~porarily occupied by th~e aggressor.

SCriter'ia of thle D"imensions and Territorial Distribution of -the Hospital•_•Net~orkA

S• The basic problem~s standing in the way of working out a system ofho spi tali zation and of establishing a hospital service under" the conditionsof naltionwide defenose a.rizsc, first, fr'om t-he necessi-ty for a, considlerableenl~argement of h~ospital capaci~ty and *the maintaining of acceptable stand-ards of treatment 9-nd care and adaptation of the structure of the hospital.network to the population's wartime pathology, second, from the positionanIP requirement that all major forms of hospital ".reatnent &.ways be avail-

able to the population and th~e ann•ed forces on all port[ions of the terri-Stc-r thanks to appropriate geogra,•-i 11sobton 11 -ai facilities,_ and -third, :from -the special eircinnstanees of hospitalization of members ofSthe anmlod forces.A

TIlie atetp to fix the ,,,:!Ye of tihe milit-ary hospital, netw~ork if threspect to hospitalizatLioni criteria that -fpply In peacetime wou~ld. resultin an enormous enlargement of- hlospital capacity, but since there is nopossibility whatever of increasing professional medical forces as I-cll, adra~stic degradation oP all standards of hiospitalt care and tr.eatmejlnt wouldinevitably ensue. it is therefore necessary to make certain changes iiistandards applied to hospitalization, and those changes esseiltial~y comledoml to making criteria stricter, that is, to narrowing the indication,, of

FIR ~hospitt1ilzation -and to br~inging the standard of the hospital oervice intoline with the real capabilities of the health service.

We are dealing, then, irith the nec~tsity of restrictions In the do-main of' hospital treatinent, rest-rictions which are cuctomary practice in

*wartimne and are implemented in various forms, such as the following: pos3t-Aponement of the .iospita~lization of the chronicall~y ill, Weduction of thetime of hospital treatment, stronger orientation toward outpatient treat-mientG, e~c. Analogous tLendencies and procedlures are mianifesting themnselve.9with increasing strength even today in peacetime, and ce~rtain stu.dies cbowthat certain categories of patients occupy~ing 50 percent or evenl more ofhospital capacityr could be successifully cared for Iin a systein of out-of-hospitLal sorviceY through out-patient treatmriet and home care [6]. in viewof the great hiuman casualties in a possible war, such a course would hav-eto be given exeettional, eiimhasis In policy govern~ing hosnitalizaIt-ion, con-Lddert:bly miore p~roc;o~ly, thlan ever before in previous wars. 'Th~is make.s awell organized seirvice for homne treatment and care anid a solid imedical vis-iti.ng service ha"ve cosenitial. importance, and cornpreehensi~ve p~reparat.,ions inthat. direction aro decisive to success of this concept of treatmllent.

Therefozre it follows that one of the things that comes before thedimensions of wartimie hiosp~ital capacity are determiined :Is the defin~it~ionof wartime Criteria of h-ospitaLization. Medical experts in various fieldsshould coluiwit themlselves to this task. once we have these cr' iteria and anestimlate of tile nulliber of injured and sick, it is possible to exanine andcompuy~te the necessary ininimlim of hospital capacity. A comparison of -thecapacity deteniined in this way width avalaMble personnel and ninds makesit possible to deteimine the wartime s~btandard levels of service of the hos-pital. serv~ice and the standards t~hat call be achieved in hospital treatment.

A3arting fromi the realisti~c assý111Umpt ion that; even a~ftcr m~ajor re-s-Lri etions in indications of hospi ta:Vl.zation wart1;.imle hospit-al capacity wil Ahave to be considerabl~y larger than peacetime capacity, it I~s obvious thatquotas concerning personnel and equipmjent (wjartime form7ations) and conse-quently standard treatment and care must be adapted to these circumstancesand must undergo correoponding restrictions. Wut th-is adaptation and thoserestrxictions iiust not be riewed as a task call-ing for indivi~dual. "resource-fulniess" of' mnedical personnel during, a war, but it should be an elemlenit oft~he wartiime poiygvring hospitalizat! oi thai; i-L.-> l~ she.,d in peace-.timei and which is bui:Lt on a, knowledge of both wartimie needs and also war-timei capaebili1ty.

2

All measures which con ribute to optinalmi uti.1 zation of capacity andto ra:L• ing the "L evel of utilization" of c.npacity, such as the maneuverabil-ity of Che system and institutions, the level of training and drilling ofPersonnel, good orgaui.zation of work, etc., also have imporLance for ra-tiena, arrmigements in this field. On the other hand, when "they have beenadopted the standard levels of hospitalization should not be regarded asuinchanging categories, but one should constantly look for ways and means ofsoftening the re.*e*t,'etions and the severity of their consequences. ,

The necessary enlargements in hospital capacity should be made ac-cording to an established plan of geographic distribution, and it is obvi-ous that there will be different relations in that distribution than thosethat exist in peacetQio. Whia't are those relctionships and what are thecriteria for establishing them?

The plan governing the general enlargement and territorial distribu-tion of hospital capacity should be an appropriate reflection of the func-tions of the wuartij regional organization of the health service and shouldbe in line with the wartime role that has been defined for :individual re-gions in the domain of hospitalization. The regional system for the orga-nization of the health service insures every region a proper degree of in.-dependence in protecting the health of the population and also insureshealth support of the armed services along every ope.iational direction andin every region of national terri-tory [4]. Il the p•rocess of ada-ptationof the organizational structure and dimensions of the hospital network towartime needs, then, the following iiteasures must be carried out in everyregion: I. All major types of hospital treatment must be establishIed,2. capacity imst be developed in accordance with the estimated needs forhospitalization of the population and members of tthe aimed forces on thatterritory, and 3. specific needs and requirements must be met with regardto hospitalizing members of the arned forces.

One of the bases for establ.ishing the necessaiw hospital capacity ,:

in a region is the assessment of the wartime niorbidity rate of the popula-tion, which in turn is based both on peacetime pathology and its possiblewartime evolution, especially in the field of infectious diseases, and alsothe character of the threat iom mi].:i.ta•r act:i.ons. The needs of the armned

forces, as one of the factors in detennirting the dbimensions and distribu-t,.Lon o(I hospitAl aacxtit'y, should be viewed from two standpoints. On theone hand, there is -the desire for the total capacl:i.'y necossary for hospi-talization of members of the armed forces to be so distributed that mostof tbixs will be within range of the major operational directions and re-gions where the most serious battles and highest losses are expected, andon the other hand there is a need for hospitalized members of the anmedforces to be protected f•rom capture, and therefore that distribution offacilities for their hospitaolization is most favqrable which will put themout of the range of the aggressor and will offer themu maxnimIu secutrity.In view of the character of contemporary military actions, the sIXecificfeatures of our theater, and our defense doctrine, it seems that the most

favorable solittion to this problem lies in a combination of disperzjion ofthe injured and sick over the- entire territony wid evacuation to relativelymore secure roeions in the inlcrrior of the couit.y. :In "the contexth of t'h.srwrangement the armied forces would have hospital su]pport for .bheir I:nj•wedand sick in every region, but there would be stronger orientation towardregions thought to be more securoe. -

Not a single rq-rlon is, altoget-.her ue¢\ure 4Wint the• punc~rution of = •the aggressor's units, and therefore one imst not create excessive.y large

concentrations of hospitalized members of the armed forces a¢nwhere, on aitlyrestricted space, since in case of an inmuediate threat to that space itwould be very difficult or imipossible to remove all the injured and siciO from that space in good time. o region, then, should be excessively bur-doened, but at the somne timae none of themu ought to be completely relievedfrom the obligation of hospitali.zing memibers of the armed forces, just as Iit would not be correct to set quantitatively equal obligations on all .re-gions. The coipetent goverinient agencies evaluate the conditions cnd capa-bilities for hospitalization of members of the awmed forces and in thatmanner establ.sis 'the obligations of each individual, region%. 't. :i~s cer'taj.i - -

that those reglons which are in the deeper interior and which are away fromthe main operational routes should have greater capabilities and accord-ing•y greater obligations.

Consequently, the principal criterion govewring the diW-trli.ution of0hos!ital_ capacity. i.'s the e'tabLished rcle of each in, d ividual reg.ion in theoverall plan for hospitalization, and this should be based on all estimate,of the needs of the population and the conveniences each region offers asa base for hospitalization of mcmbers of the a-rmed forces. Achievement ofthe distribution of hospital capacity that confoxmvs 'to theis criterion will.require a corresponding redistribution of medical personnel, above all tothe advantage of regions whose role in hospitalization is being essentiall.yincreased. However, the movement of personnel fron certain "richer" re-gions nnist in no cases be of such size 9s to put the health servvdce of thoseregions in a position which is below the level of t1he role intended forthewiI and which they can perfonr :in v-iew of objective evalubtions of theircapabilities and the strategic conditions of hospitalizabi,,n.

The Structure of the_ I ital Network and. T•Iype _ o osfitL!. s

In its internal stuniture the wartime hospital netWork should cor-respond to the characteristics of wartime pathology, and peaecetine propor-tions in that strlcture canners be taken as the principal orientation for,wartime develop•iint. Certain types of hospitals, for example, varlow; -1fields of surger-y, will experience anl extraordinarj Jincrease in theirshare in the total. nwmber of beds, whibl certain others (pediatrics, ob•stetrics, etc.) may remain at the peacetime level. in quantitatiive tcrilis oreven decrease.

Th2iis qucstion will always be om urgent on-truhwtt3gnAa

tdonal formro mid w-1-bivh wht, kinds, of h031)r'-taj. -iniioitutioim i.ý A beot tocreatLe the iiece.Stnry dixieiirsloi.onn of' hospital um acity Lso thaot the Uj.%ne..im3.

proport onso that ckatyworld be appropriately related to the Struc-kirt n' 'arti'iie Dt. liy

lie houitld bear In iind lud tepoemo ai eretAlnothe hospital. networlk tovfar vortim taolco anld the rapid trannition to awrtiLmo footing, which Lv, posed as an impertit~w mrnder conditions of sur-

prise aggrevmionn, is frau2ght vith a serious danger of' an organizationulcriuis with coasiderable disruptiono or eveii Intorrixption of the £tuictionaof the hospital enerAice At a very, sensitive mnoment. Precisely for thbatreaon it is aL just-i-fled position that in 0-l .1 essentia~l. organizationalfetuesthe mwArtilme hospital. qcrvi ce shou:ld be as clmo se pas 1xab)e to

the pceactinic system and the poecctiiuc Fituations, so that major Chanigesdo not have to be made in the structure, at least at first, which wouldjeopoxidize its function, so that the necessary adaptations to 'wartime

neeodo and. condi~tIons would be carried out in the course of time, call.

Proceedinig. then, oii the basis thaxt the poacetitmo - tructure should.be respocted as imich as possible in the transition to the imvtime footing,

Itis liogical. to conclude that with regard to the organizational. forml ofrwartime hosp~ita~ls it la most correct, t~o orienrt oneaelf towar-d the syotemA

ot' general on fumll t i rm.'W;ioaJv mn at As, Is.s dojidnwtium-bie strtiaetxi ( o7f our country' ooptn e'vvice, aud tbi s type of hoitlalis fAvorized in developmient of the ooervi cc. whi le tAi.e t~otatl, oare of apa-cilIized hoiopitals and so-c Cllod nonfioosp~it.l. i~iP~m.':s ga; ndlmlly de-creasinig [2] . lIt is f:tthat thsline ol' delopuciiiin has every juotif'i-cati on from both, the nwodioti. tind ecoonomle( s'tandpoin't; there is a1 saving -oni per~sonnol. adequipment, and more fmorable conditions-. are abi.Cvod forI

comroiosio reanin-k;ofpntient.- ol a"Ll. tyesOvConsistent with thi~s, then, this typ~e of inatitution shall be domii-Iki li~anit in1 the wartime structure of the hosspital s'erv-ice. flve , this does

not mwanlta i~t Would beifse ;for thie eni;:idre hospitA.U. network to be. b~ivl 4.up, 4my, of severaj.l hxuxtaed general ho..pitalo of' approximately the sonic£ormurhi~on, -with all. iiajort pci~l.~e dep),art(mentso in t-he stritreture of er-~cry Sirngleý hospit'al. :iFt is obvious, that is, that because of the crisis'.

ofprsnel inl Certain IledI.c11l d"Isej.1p..i~nes it oudot be possible todevel~op alli the major Speciali.zed de3part-mniit:: Jn ealch of llu,ýso gonce-VI..hospitals we7 have rl~suaiz.l.ed in such number, and because of: the expectedlfrequtency of cert~ain types, of pxactiels, the veryj needo fo~r certain ope-cialIized fields oarc nto reat. tha~t they would all. have to bc providedfor In every one of thio large number of ho.spitals. ft is therefore juj-4tin.i'd to think in -Um-mr of. tuo or more vnr~iatmt of 6he geiierI.ta hiosp:1itnl,rathliu.. thani Just one, saidhey ivoulo. (U £.er froali oneC IIIwxth'r Jin the .1ovci0$of (Iew"ve~k4miet of spe~cia:lizeda servi c~is. -

which varianixt:,. Aho00A be provid1_ed for. wilatd 'Aoilld be0 the pi~y.9iOC-11011 Of' the 1:I~fd~vivd'.u1i Vai.(;- 0a uw101-ot I 1..Cg nfiohii 'be ?~e~0roooatatioll0. 'L -h lie idi-vjhidUI. var~Lant;u In tWe toteal iuliber of' ,geuiraA hospitrialo?

IY1 'vi.ew of' the prob~tble Co11MMonti oil or wo.1Imienorbi.dit-y i t .Inoh-LIviloutu that a. hos"pita:'. 14th a gonora1 aurgical aind geiiertCL interniStb Ser-vice thcvt, to c0lso eqUipped for iolo~tion of 11nflectious dhiseases ~uP1d be -;hue most rouitable tor broado-t. use. Thisiiu igqtitutýion would he the prhi-7

F a ciptc1. faeli~ty for tiviely gene~ra. ~jurgicalI tui.d genert'lL illtel'fl1t sCe~rv:.00for hoapita).i-ýaU1;.on1 to mQC't the needu of tho popiWvUion and territorial do-fense uxifts, and also for support of tho mi:U.1;ary mnedlLca sexrvice of theax'niied forcews with ý.qegard to an appropriate M,0.1O of hiosp-ital treatmlent. 1twould ha-ve to be higliy tLccensible fv'cm a,11 arntz.s of thec countnry, whichmeans tha~t they would be nunierowl enough so as ýo in11sure the nece ssar~ydensity of their placement in t-he cowntry, and the distributi.on and each

F ~inciv-idua2. location would have to be auch as to make them as naccessible aspolbie. to P~ticnltu :U1 the areat they serve-.

Thio hospitul- Shoukd 110NO a. ))ore hlighlly (IoVolope(l -variant of' thegeniera. ospital. to re~lv on; tho latter, ill additi;ion -to the servloef3 the

F firut varianit wouild have, would also have all other maj or npeciklties,above all neuropsyCeh4atry, ear,, nose and throat, ophthlutiuuology, gyneco:logyanad obstetrics, pedia triLc s, in.aausI egU0,,,n also( -a g.00( pnyaj e.lI.

T.1-il. Svaln aid. foulld be to eX1.ied unola)at. to genieral1 ho.-p-J.zi:. t of' the. irstkind within the-1r corea of' Imedical. serv".1ce and t~o expandc the. Antict~iot-w; of 5

ho:-P~i~tnil. enre IPor "0.).. oithel. Majorspclte

~Calcral konspiIn:lo deve:I.ol edi t e tVO Vprji antsr Would.( 1b( theColundation of' hos ia. -o)' for the genera~l. public anid the airmed :Coroo.;a~t thc levceL of spoe~J,0Jk-oLd mfeditQL caservice.

Th lie to Oct up a 'iys-tei of' highly spec~tialized Iiospital11s. thaitif' th lled to iffereliti.Ute hospital Itre~atmeirt infto 5i.)cua,11.0Zd and

hig~bly opecializedl, derives Prcmi the saijc Lreawons ao, inl peCCCteclic., zandtoereasooiu; hune to do0 wit. t differlences ill the llature of the patho'Logi- Sk

4z al non(di fi~on tuind A nl the 11"ituirc of the saC0 rL~ m'edlical 5CI'VICv. Nev0er-~tlxe:Le~sý IL aoonido Jtha ill War:iu th11isa or pronounuced nood Cor tino Maiatll na1 dir~L.O han in poticetime, the -reasotn being that- inr( iz~ioa ii I-tt 1..1

time ~ ~ ~ ~ ) theý toa Uue fhs'tCb; is. eos:detbI grenter, whJ.1.e tlic inun-

U(,r of their subdAY wi ioni, for highly spudJaLi~zed treatment caniiot increaso.1athe stuie prpotonbcause of' tie shox-ttigo of' pcrnonucl. t sthere-

for'o mno.-t fsuitb3.e and rationt:I. to concenut~rate the wncace perol)'50110 alldequi.-ionnt Cor high~ly opecia]J.zCd trAtln01t '.t Vui th lIIIu 1'hglspec~inl.izecl :i,10.nst.Ltiows that CUin be not up w uith the av,.lab0 ic onlpo~rcrIand~ equipmient, ofsea ± their being scattered crownd and 1ost- i~n -(he.very nu~ieousncrv. tisituJIV Onof the geealiype. We nro ta~k~ing tibolithighle1y speceit.aLized ii otitlU~ons. ( clinlics ilmtitutes, oetnltearo 'zlld 11Os"P:I-.tal.s) for lneuro-urtgery," plantic awd conzervwtivo u~ricry , orAothopei,,

6

A

~inotiitationt; for chcist itnjiiri~es, bmm..W eyh) ~rv~j~iiL'~~~l

HTowever, there vtouldt be. carttiln &kU _eru~ in ustulisim;an a~ ý!iyjtumi O1'fWeor flO'1fyI(T 2flCC)eia.2.ed 1 'tAituti~onus: L.Inlce colmIrnu:1 teniit, (of I.~Lleb

auid tho exc3.usivya orliotaL~on of higlilty (juuJ:i'Ied specialisto towaird car-talpn Iuarrow :L1i of wmirh coald. bý; one of the rua.ýonn 1'oi ' t11icir ndercm"-ploymtLeft wid irrctionml, unio from~ the AituldU1(iV~t of tiio pif'or'ity tCUokn of'

Sthe Iiout-I(i aervo1vI~O n wtmn1110 "I'hetae qI()q ru(illire thvti 00e conuOpt Of'-thesoc inot:Ltationuw role be clear,; they oxught not to be ireduoud to Lheztamaw of ho06pi1tale for' speceil. cases, but stoch~ nhimild be talekn of thel rcap)oabil.LtLion -- tind prx-fu~t-Ae hias conNt'ivnod the cuvroctnoss of thi ivwi'or eman-ngohivi~tfln (Iwhelnevev mid Ito whMtvcv c. 4en th'K t~i~'1 Ucsft~liow) to tile golneral -,17iea3. cuid 6*eiera. Niterniust :Le.veL of' medicle: .90r-vice, whioli in it~ealt would be a cont~ribution to the gemoralI t~ieccmm in

coxing f'or the wouded and sick, but at the same timm thaso Usin btutioilswouldA not havo bo glvo u.1 Itho;lr C~Wl pks-:1.ognoomy. moreOvor, the(ý i'rairiedI1?orsoflnc. ofV theae ].notitutionn sithoul~d nal.'o be, i'o'dy -to work olrtnido thAe

Iii adcit~i~o) to thotso Irfins oe Ilospi tals, the structure of 'lihe wax-

tbiuieos~pital noirvlee would Caer1t.0.n3y al.oo 111cluda, tiiout'l -itr e~on "A denWzy -igious~ dhiseasesn for ve1;.hin of uJOvere irrad1iation, for vi ct:Uni,; ol' colibat.

- ~~poiso~ifsý for itl l wL1:t J-11 aidV. bietitaill defcctivxe, tAc.2 s citn. of' whi cha3}o =10~ lU u peaneetiae. tidllc o Lhelrz wovld be, not up only in wart!±ue zaL;

t ~ ~ -;:u.I~t of need;;.

IT.[.cn- be Judged that 1)II.Id0ing a hosplt-31 ew 11101 - 'lan t'eIiiirioria (ij. n.Iriibuitfion Conformed to'LhL i ýolhcqpL 'ad MoidolILe-would provide the pot~einLial. for ii).. ~euseti-0. ~oimn o~f hoapitt.C! treat~nICII;in ECU. nreas or ingionst. However., the hIdg-h mmbljdity rate in iartinmehwhen1 -there Iin a (Žrit.MtCal oshortage o1, special.O3.4it, ;;rio yj eoparndi~./en,the po;3ibillty of achieving, evren minjinulum standtards off hospitta. treataeticlwith the ttvailablo putuntial. if all paim-cidtti for whom ikolpital. U-0atil~ietIn :indi cated wemr lo:~~~t J.11c the 1 in'-J~d ~hio we have kdcxvib:I~b . I t.ini not difficult- to iumagi~ne 1hn when t-ere iao Ia (~rcat. in:lkut Of' J~injref.in)n ~iJek t1)e sp~ecJ~iaized serv~icen wauwtd Wi.I:y-ni.: :i havor to perfo'orm t.'nrIkrtiuu work- t-bat womiLd puid; O-t~en'I-iftC1 lm , oil perfo:011aucc oft their bn.,3c

fliic1;itoi;; ProcitLcly why it; L~; just'i ftiahje and. iece iniry to sut up1

poJ1,ta3.:L:'~Aton at thQ goncra.l Ic u. lovel ini a lar'ger' I-QJ.~L ; :~l~itted to j1 ziititutLifJ.ono, mmh an henIth enici' an ht .h I.C net"It-i ont7,i *e.., ('ganlizflt~iOf in 1 iI:Ich oiIuoi hen0t1) ac~re ts'v'ices3 Ml the gpeIIO1):.

WHO~cn level are Kno IMEvc:Opr. Thieoie health care Intttit are Ll iomImOt accessible n~ Wasoo-t A~ . s pop~.th Lion mnid to tLer :! (;orim &Ind ni

and they woul.d meeot a, lareu~ po±iUohi oif the*cd for to'ha1h ~'

Llu:1Aldil(: w, aCOhidi-VOIdcaeb 1porIlom o Wc.; ICtxotcv of' bcd patllb11 11o,14 li IP1 -i-xny and 1lumi.g1 t ii11c, ~iA of' troamowld~! ; 1id- m) . I ithr-11

wo~rp. 01, toteri ~cI hor,.:1'-3r in "VC"0 mi ro ~d Prpe0rY, tlhnU n'c.o~)i '

1t101A Of 1110 i 1I4~o would, 1A;'kO phluteG rigid Ulvli~ I~ev)'~L. ThIOL' woit;bring husp1itbL i' 1lJouht)lL ~w to ph no(to Wto fI''ld 44'4idii,11 W *tO1W0

tbtlt~o '111 p :Lii~zaL facilitiorl of the CaorG 1100uopita:L18 W-OWAc bO .loft more-eo -~t bio. 1ir prj~tltllwy pll'pomili, whiolh It, W-Gathiioi. al I. ho lv&.or (.)to IIw-d-

tirowC littLve ioted!lc!J 11II-:1i'iu-1vco ge(Ž)i(Ylt. Itorij).1t~naJ 01l the i' r n Uand second typeo, highJly " pecializod contors and apeoiaI1 honpit~ltn) wuuidconta~in 01lJ the c~smntai'i. GI~rkmontl of' wwr-timm honp4ti.1_itjio, P..nr it wnOu3.hot. d'tlier claont-vally fl~raB the ponotixo atr"Gture. 1xcept vor a illmunlbC' of' special. houpitalmj. thn slaxc-tizi'- 1, no Inztitutiom.a that wouild. =U

nobcx1it ii cae~inc ~i e1, nio that the trawiltion to a wItrLtic fuotln6~Icould 'be EaonW haod without urujn:U&.ly dli~ruptina ir.th existing~ iytaLom,and hI~ho cont'Id.mity ofl t. s, moti1oniLng ooul.d be f1ilnwtrodl

Tkl EtJ jiUtrutu doea n to 1. JAI. I 1..a 11 hi CXQ..0( Q II1UI)CW.J' 01' 1tYpOeV alldvarval.mln" of.,~t i(Aoi Itoi In u-I trt.I r I ,i11.P1 r1 Aon rl tlw ntlerr ~bald convoquoneoo of a :Axieutura~ conýýoit thatL wo~.d favor C ny ciLoui oi in-

OU'tiionaclona-il UOtO'to a IAngle~1 orgwilsoationCl 1)Iatterfl, It wotI1d tCloo re-

(. i. ni.*whi. (-I, w.L.L~ wn;iAG i hers vt~i- i Lintot wtVI IO IO i-mOWn u-o

ofelw it 1T I tIl q~'ywpvrii..e ,umtmeica'l. abar. e , 1n tilo vtmtki'U ure of' eraiei rc.giO11'13 hospital iet-work. Certainl of the highl" ,'Pcia3J.iod Ino.WtiluLoitoand a eoiaj hom);xi.ttA. COuLd nlot m nd wou.ld nxot need -to tic ;at u-p ccpnxatijeyibv oeell rogi~.oii, but would b)~eLU lat I iwt 1.11I.)tt (Mti niI blt 1l ;inii-tevlegi.'jonntl. Jms n;LW-. tuiLoii wo'u]d flave 11-t~£;i~An ~~ i h vari~ovilli~:

the pare'nI; Iuli'I;i tutdonl The. rcgi onftlL oo)o;ptnL w.tLnp. ouldf be Lthw ro-.*poll 31)bi.'Ly o.C the opatit ao (lotmi eollbmm I;I eý wou~l zkihýo pa-OApt) )hand Cach of 0111C111 1%YOuil.( hiaw LA do t.1 1i t.:h~ Icct~piu h nthu

13Y w~akdig ft~ 11iire tho~rottth .ty; of' 1\mV'tftiO nccd.;( uind wn:tioCon-.

tu;ouOne call c:Iatl1'ho s~i have w' (711Vh CyTpi o' hO~P JDi. 0 ITi.eJl2

totko. capac .1 Ly and theL r'proooln n~Lal~onl 111 .Ath tota 1111111(n ot(,'e Uor thetT i'i on1tnp~ti '~And thelln theo &9me 1woul. I be dolne for the Capac:itLy -l( aid nubcer of.'

bO,;PJ*1taJ.,z. :1ill thte Cc.10ib.I.A ol itd :1ill i;Iie FCedcriat .on1

Uo ~ t2.C 1 :0111,41.. (JCiic t i. ii~ tn.1 t:' n3~ri.d q.C.Inied oic olq.Ilvt e t-13 o d'(Col, Cri'on(al.C-C1101t:! l (w 11'stitI..... ....

bctl .OiL~ I'll L4.1 t11ugjCa umAIUm U!. ov, tudsti~OlT'iiA fUYPVI wi ordinclW)p-JIii I~loA.; (1~ IfA v r~rto~i movl mtX it'.II ino.h).1NŽW.L.1 JJA 0,'12y b

V .. ý vfje v j' U ht i " '. c h o_ p i -c t ~ v ~ ( i i K ~ d2 1 4 1

U.ho outi~~oL ill tL3l nxo.w; !.d writi;in rwigG Wo. U al. outct;. ud whc 1Ll-ir c a -paci -t,; itn ivindcqu~atc at puaictdtuIai i they eml b velit rliforat-A

mwt In -e 1'oxwis oi' Inoh;Llo tamic, *It £Lv UeLo tw.utijucu d f0o1 hou-piL0a.01we ill the diomai~n of tho flaxrowLV alic~it&1.i.-ad f-ioldi o 1-.)U bagwk Oil LeUZ-

0 r CLIy no~U.xtýkorns v caibndh~itl~,wa mozru pmsmana%1, o~~l-Ga.IzaL:I.ona2. fcI'on~ jx'x'? (.1digf, thtuI. (!v COt.-C ~nfl' kdt thif t'he rei:L0.11t. uyectoim.

H~ot ieor,. 010 mimt not %X0.111d. ultogetlir tha ponvibility or organi-Eaam prodie fc smr nu-,vow twurpoivawy upeiaiIutioul or Uot&aili

geaevrL hotiplbato or, ritCy mi~daLW a orLdyt nuulibor of' djillrzU hlW0spUA1i or'

(hospita.1 tow~ w, vmgica1 VQOiIn, atc.) which lnave becri prowv-Idcc f'or in Ithei

cCioM amL atru~cturo of IndivIdua1 inotitutiona or au~ rosjarveai -- iodoait intaii4ir n t~.Ut raz ,mw oqiptnt. ol We,- oUia~v hanld v~jry Iauilorottj -

cou:L(1 bo th'o bcodia for in~i2~tý, ( mai.-.vor by'ixenzk in Lho~ Ioyntcml of' thehiotpil W1i rs.WtFv~jA ao3t. wp~ sil 11mi a{hpi.it 0, Llvt) ooucop; of WaIoth coxc J-1 lut.

Uiomfido defeime. 'khoy would s~o ouLnide thuli i.nri-ot ijlwtiLutj.on-3 (.o cu-rryx~Iitd13 be :trO.rat0toa.1 Eculd boyond Our rotlhi itic copoW L.4tics'i to bImso thtit 111-

(o kI 'ont iC Mnlielivor~in Al.

Tfhe cQ11(1It lkj Jq jjfVo orc)o~e i t~w:, .1tr~c;1Ii)on awtrritCoro 1i r-tributliol of iioai~iLa:L Awd:IAIi Liu woucld In Q'illuipA1 c'.ijQo3.vd 1Uhu ql;.d.icnl

:iOd anld ftiNI.Iy iq)OUik.U.ý:0d :LoVFc:1P W44 Uhao t.he i oo1 n opl vilt- OF 11i~c

Voi~l.1~antt~~ witr,: ofa "x'oal thetli; IWO d~ VC1.tfile w-3,11 ni1.t

t~i,:t on ri ln adaping OPP~~eu fnn ture o "rs II. cd rnd d -'c i , incvi xorI of. ho~[. piýLnd fcilitico, to the nituat~ion ns it devvtlopu.

[- In pr(e(A_10 y f'or Uthot roaarm thwa; 01-m Q.-uinoln~i; 011 n1j.ww1y.1

110cddo atinizhtcn~ ;ii tia.' j-..'rn 1. ho'p.tu3.Ua euin be Cx(I.'1opekl ille : (lA.Itermei~nHL vuI'AAUitti and "'he .loca.z ho,1iO 01~ ta. an a21 G0 klýVcc.O)p oII 't; oei,

jIce Lb e 1 iCo~i I' Li v i cnih n-Iaud ;Jch %-.I133 1 I 1)(. bt1. Pzll~cll aI1ouk.

T-1

E~19

jda~cc.:- wlm;rmc .c ha nianoou" grotkciy. 1-1'l in why Unr I :z-ync

the twvlcu .Thu ciu.cUoii of mlaQ'ivol- Iq. iilwvpI tll counici f.y call hr~ ront-Ovyd

A~ n!t (toD~ 01a t L.A.x-.L I e3(2nVO includet- Jn 'Lhe tioipit-til. ArucLuv-: kflnobtLeU_ hot'spJ. luaA LectWW that would be paii-1; of the ntriuclt.-ar of the inol'o WA,,l deI-

a. ~id r:c1luri.JQ h1oSJpi-t~UG) m~ild alo by clooliti oil ruducitig curtlabit f"'el -

kof twqU1ovaLW oceitpettlan of 1luru'r or mtnalcropixt-ts OC~1h til--Lcrit Ltrv 'wngvennor.. In this connection um s1hou:d rofor to Car1.nii ponitions £onviu-

IF~di t~l GwiUAolinan for' Pe2mnIe of' the e11vi.)1et F' Rnl ia'm1IcYligoo'1avi.* AgIntAnint Agtg~n181 o0: "Mier~ rc' no part'" Of t~c, tc'vrll-t)1y 1int.woulid bo .IQL' W.. kkii UdhgrCluLQn Wi1J' tt f £i1ht. noa' arc t here parts of theLarritox'y whichi am tiggrocmov would4 tmvnporu-il occu~py find Where combaitwouI~d not -be wtiflad and mrhorc Lha . --opla oiWOld not o-rrer man~niv revi tittuicp ,

Tt i-oviu hn h popUlftitioui and units of the . ili~ct f'oci onc

LAioci Loi.Wit-LoA<.1a titia't be prowl ded d(k'Y.1 tr owt IA on'01 for I1'(0~.1i Cýtca .III

I1Ž~~~~~~~~~4~ t~o ii'iuJ. U~ OU 31Iu F0 U. ittffflt IA oll o. I. f' i ~mu pt

thiat. An tLho npoW'Ulwouia Coltruec of' event'a atoiic mted-I pnJ r,;onn1 Would.1ti dLo1 ( .1. ,vack.!(-.c "ut' tie~c2 ott L:L1i UI IIC ag~gvce;i $0 I' h$ i i~h a Ii I-ue" wi l I 0'

o Lhrra nn~u3dtny ! n Gcup ctd. piak'- S e ,.o i.F' ý:z A ~~U ~

SuTiUIC ent&l2y fIlr.xIbj~c alld atat-1I;ble to i~CIi'btayC.1 1c1Iii::tItaflc: mald to A.1eCiit,11"'cLai tuict Oderec 01 cotit~rolt (if Ulai .'.,iiriloiy by the tgtgŽotnor rso 1l.: tohIý .tb)o1 to uItai u ki -il J! LUCIF lkndk ift1~Ioii con CInuiLo1.J',. Ili ('at1. evury i-u-

11ti out AtU L o havute Uic rul-eVAIII. tial.h alI$ limWllj41ill 11i "On')tIi t. ,~din:;t'ic 1. kt)p ýni1i n n\'M Wiit oil i t b rri t o.vy 11'. sIX -t tict ;Alkl 4.11C: nv~~ ~~ iz'c.

III~~~~~~~~g cIL~ F~t'C O 1 I~ L IL i'U hu) t.! nI.; fiuA i hed ,p ua~I 4 I tw t~work ý(. ', kil to0Q.,.,t L 'tI isC of the c.Z trc HO)~ dI~.Io~~wowl- there"'t 1ni't' Vvce i c- I.-

et'l.-t1 -L& I. :ltcs i..-: tha. Ilito r zm f'3 himp v m 1-o )L f t hc :u vn'.I i'o'8 Cti k) 1) '1t

pi.orU v.1piot ityh ' L~iIl14ti.I.s of'ni ~t I it, i ;- u a CQIunl i'J V'.unco, kfor i'c 10! ho 'a. --

Cor t'"utl 1-cond-mou at honw Idji 1.1te CouX beC~ I . I.1'o-' fueI 1~Lor'i

%V11

* would be centers for lighit wounds and lighyt ca-ses of illness and. for con-valescents; they woul.d have a. soundly orgauized ser-etce for p1ljsica1. ther-apy and rehabilitatLion so it; -to enable patlienlt-s `Go re~turn t'Uo t6heir -units as

fast as possible.

Thle problem of -the pms-sica:l protection of these wounded and -.;ich isnever~heless -the maost difficult one. W4ithout neglecting prL-eparations to -

take advantage of' i~nternaiional conventions concerning protection ofwounded wil~itary personnixel and wilita-ry medical institution there is

tIl a necessity for AuU prepaxredneso -to protect -the 'wounded &nd sickshould the aggressor tramp~le on -those conventbions.

Seciret hospitals and secret underground she:lters were one of thepincipaZL means of protecting immobile wounided and siLck in the. RationalLberation Struggle. it is realistj -to assume -that in a possible waxtere would be considerably more casualties than in the National Liberation

Strugleand. only a small. portion of -the wolunded and sick couLLd. be f"con-cealed" in ,'. manner like that. On 'the other hand, it lqouj~d not be ifise toconcentratUe all -the wounded q., .1 si'ck in -the depths of liberated territ-ory,

n4fle th:! sectmrityr of even p~rztý of tha't territory is onlyr relative.IIn the Guidelines for Defense of -the Socialist Federall Republic ofV7 Yuigoslavia Against Aggression we also find the following. view's, which have

i~l~ir +n~ ___i _u,+n-"h ~~afi toc hold andcnrlspace, :in~cludirng V-the spic-e which the aggres.sor has temnpor.arl4Uy oc-

cupiedJ., is, a (CII4nstnt task. ofL oi'Lv ax~id combat and of aLl other formns ofAi'e~i.stxie " 1 ice "the creation and holding of liberated territory in tern-

poo~il ocuicd regions ;*-roul d have exceptlonal military and political iri-portance, " and this presupposeas comubat o-ver -the entire -territory of Yugo-slavia and the holding and creatbion of several liberated zones or. tempo-[ ~ rrilyocciapied poarts of the terit.-or~y." [I]

[IAs w-e have already emphasized, it combinat-ion of dispersing thewoiunded and sick over the entire tUerxitor, i with e-vacuation into -the inte-rior is one of the founda.tions for protectang them. This presupposes es-t-ablisInrien"V of si.zable ffic:lL:ties fcr hospitali'aiItion in the more secureareas in the interior, beut one would not allow the -wounded and s~ick. to beexcessi'vely concentrdited in these areas, which mraies it necessary 'thatd con-ditions also be found and created for hospitalization of memibers of the

arm'c forc-ý3 in all other: partis oi* tiie tor'ritoyy, including those -which are-in Ute rear of 'the ag'ggrc - sore s forces. tWit-h regard. to the use of the setcz'-ritories the concept of defense set forth i~n the passages of t~he Guide-jlines we have quoted suggests certain f~airly concretLe procedures.

Thc system of dispersion would also 'be applied as broadly as po~ss..ble ort territory 'ý ' the rear of -the enemy forces, using~ in parlticular areasli-berated and areas utnder wcak. control by -the aggressor, bearing in mindthant the acggrc:ssor is not capabole of constvantly maintaining every settle-ment., every house ord eversy foot of teritot-.Ly uncle-t' hbs effective control..

11A

MI

-4

In case of an immediate threat, the wounded and sick -would be gathered upand. moved about5 on this territory, might possibl1y be housed in secret shel-ters, and if necessary territb:orial and other units would be cornniitted totheir protection.

On whatever paart of the territory they are located, in the deep in-terl.or or on tuerritory- temporarily occupied by the alressor, hospitalizedmembers of the armed forces should always be in an- appropriate state of'-readiness and should -lways have a plan of measures ad procedures shouldthey be exposed to an imnediate threat. So that these measures can be car- .tied out more easily, wounded and sick military personnel should if' neces-sary be placed in separate hospitals or in separate departments withinjoint hospitals.

Buildings Used to House Hospitals

Because of the considerably greater need for hospitalization andbecause of wartime devastation, wh~i.ch unquestionably would also affect hos-pitals, it is obvious that only a minor por-ion of the facilities neededcould be pro•ided for in the rertaining peacetibne hospital structures. Forthat reason a major portion of hospitalization would have to be organizedin v-rious pubML n buildings and also apartment houses. Sizable settlements •and cities offer considerable conveniences in this regard with their ho-tels, -arr5 iS-ns, schools and other struct•res, but there i s a questionwhether it is wise to have major hospital facilities in cities in view ofthe threat to thcan and their exposure to air attacks. Certainly the citiesshould not be deprived of their own hospital service. On the con-bra", theneeds of the veiy population of the mn'jor settlements wnd cities and the T

large number of casualties because of bombing and active defense would re-quire that there be appropriate hospital facilities within reach. La-rge

building structures in cities, various tunderground structures, shelters,and so on, offer considerable possibilities for developing infirnarieswith the necessary hospital operattions under relatively good conditions ofprotection and security.

Nevertheless, even assuming that sizable hospital facilities willbe developed in cities, there wizll still be a need to take advantagge ofother possibilities, such as, say, hotels in tourist areas and also nlumer-ous villages; incident+•11yv during the Na.tional Iaber-aton Striggle thclatter welre in many reegi ons of the countiy the basic foundation for theorgaaization of partisan hospitals. In certain regions that have a short-ape of suitable public buildings it w-rill not be possible to achieve thep:Laxned capacity without making extensive use of villages. In spite ofthe objective difficulties in finding buildings for housing hooi'ta.s, thevillage also offers cer tain unquest:ionable advantages, such as, for exam-ple, the use of local manpower and local resources to meet various needs.In World vlar II it was not uncoaiaton for even the regular armed forces tos;et up hospital facilities that were based on the local population and itsdwel.lings [5], and in North Vietnam in the ears of A-,erican aggresoionthe principal hospital Cacilities were developed in rural villages [3].

12

Moreover, the use of the village has special importance from thestandpoint of the protection and security of hospitalized members of thearmed forces. 'Te basis of this protection would be evacuation to the in-Stc.rior of the territory, acc anodation4i in relatim.ly secure areas awayL ~ from major military directions and coiwani ca:Uion routes, and in dispersionover the entire territory. It is precisely this dispersion and evacuationto more secure areas swtay from the major militnry directions and routes

that come down in practice to quartering the wounded and sick in numerousv-il.lages.

The use of the village for this pttrpose would be considerably easierif at. least minimal preparations were made in peacetime: for exatnple,sketches as to the housing of parts of an infirmary and an inventory ofwhat could be procured from local sources would be prepared in every vil-lage where there are basic conditions for setting up infiiaries (suitablelocation, good housing conditions, enough water, favorable circumstancesas to food s- ply, and so on); a certain nxmber of persons would be desig-nated and tra'.ned fc- work in the infirmary; prefabricated structural ele-Sments would be rep. d at various points so that certain structures could

be rapidly set up, etc. On a site prepared in this way the appropriateteown (a hospital tevim -- the core of the fature hospital) might set up ahospital for the needs of the armed forces and the local population in arelatively short time, relying or local manpower and materials. If thesepreparations were made in the *' of general social. campaigns in lo-,4l

+.o •. h citiz.e• .uld shmo vol.untary initiative and the 'RedCross, young people and wom- i.d have a particular shar there would beno doubt whatsoever of the" .aplete success.

Bibliographg

1. "Guidelines for the Socia-ist Federal Republic of Yugosla-via Against ^A: DBRANA I ZASTITU (Defense and Protection),•No 6, 1972.

2. "Statisticki godisnjak o narodnom zdravlju i zdravstvenoj zastiti uSFRJ" (Statistical Yearbook on Pufblic Health and Health Care in Yugo-slavia), Federal Bu~reau of Health Care, 1973.

3. Kelch, K., ZEITSCHIIFT FUER MILITAER MEDIZIN, No 3, 1969.

4. K•alj, I., VOJNOSANIT. PREGL., No 12, 1971.

5. Shematikov, M. D., VOYEO-MEDITSINSKIY Z.ERJNAL, No i 1972, pp 10-13.

6. Sk jxic, S., et al., unpublishea report on a research study conductedfor the Committee for Medical BJ ,gical Sciences of the Council forScientific Work in the Yugosla'- :Led Forces, 1972.

Submi-tted 9 September 1974

13

[pp 339-3421] UDC 61 5 .4"36411 :355-.3:362.191

WARTIME NIUITARY MEDICAL EQUIPMENT FOR CARBE OF THE SICK

Medical Colonel Aleksanderlhranilovic, docent and graduatepharmacist, and Medical ColonelIvan Palmar, docent and doctor

The process of earing for the sick encompasses two basic actions:diagnosis and breatiment. Diagnosis is a precondition for expedient treat-ment, and when there are large numbers of sick people, especially in war-time, it is also a precondition for professional triage. It is character-is'tic of preserit-day medicine that diagnostic methods are experiencing un-heard of develolauents and new means of treatment are constantly being dis-covered and produced, especially drugs. Very complicated equipment (arti-£VLcial kidney, electronic devices for monitoring vital functions, and soon) is being used in the process of treatment. Present-day diagnosis fre-quently requires cmplicated apparatus that requires special operatingconditions and the help of highly qualified collaborators: chemists, bio-chemists, physicists, pathophysiologists, pathologists, and so on. Underwartime conditions it will be the exceptional case to have these highlyqualified collaborators in various fiel.ds and also to have the complicatedequipment and opportunities to use it. It is quite clear that this kindof equipment and also mnny drugs maiufactured abroad are being omitted fromiartime military medical equipment, since their use under wartime condi-tions would be brief, uncertain and uneconomical. In wartime, then, thedmilitary medical service and the health service use in principle '•hose di-agnostic asids which yield the maximum results, which can be used with theavailable personnel and which are generally recognized and reliable. ITheassortment of dxugs is also being limited and includes drugs whose reliableeffect has been verified, primarily 'those which the domestic industry cansupply.

Wartime military medical equipment for the care of the sick is usu-all, divided into the following:

014

n.. equipuient for dUagnosis;

b. equipment for the treatment and care of the sick.

Equirment for Diagnosis

The equipment and supplies (aids) used in diagnosis are to be foundin militaxy medical kits which are part of individual and group medicalequipment, and some are classified as individual articles, sinco in view oftheir size and purpose they cannot be made part oi the content of a medicalkit. The t-rpes and quantities of these aids which arc issued to individualmedical personnel or the medical institution depend on the types of medicalservice being rendered to the sick, on the professional competence of the JZ;medical person, on the specialization and capacity of the medical institu-tion, etc. For enxample, in wartime every physician would possess the basicmedical supplies for conducting a ,mkedical examination within the limits ofgeneral medical aervice (thermometer, stethoscope, blood pressure apjara-tus, tongue depressor, etc.). These aids in diagnosis are to be found inthe medical kits for this medical station which are in the po:•.nession ofthe physician (see VOJNOSANITETSKI PREGLED, Vol 31, No 3, 1974, pp 186-190).At higher medical stalions of the armed forces and in ho.Spitals diagnosticaids are usually grouped by specialties or branches of medicine, and sub-units anid inctitutions are equipped with speciUlized medical kits which

..... 1.. ,&......... &vfr broader diag•noais and fu•jl , -enudeoý.*ii•. a U!r[hi I ̂017--1L

of medical aid. Since the principle of ti ctionality is applied in makingup these medical kits, the desired capabilities are created for a rArticu-lar branch of medicine by comibining military medical kits aud .indI.vidui alarticles.

The basic medical kit for this purpose .i the "Outfit for -00,1o :and Work With Outpatients," which is intbended for the work of tihe intenMistor specialist in general, medicine. This kit is also adequate for the workof an ophth m)ologist, ear, nose and "hroat specialist, deimatologist ,n'(specialist for infectious diseases; that is, it makes it possible for aphysician in one specialty to conduct a basic examination in these otherspeciaLties. '•'

This kit contains diverse medical supplies, instriments, gear and -irubber articles, and because of the capabilities it affords, it is issuedt11o all specialized outpatient clinics and those hospital ,diepawrtm1ents orsubdivisions of highcr military medical stations of the regular arnedforces where a medical specialist is working.

The medical kit labeled. "Drugs and Outfits for NetutopsychiatricWork" is intended for the diagnosis and treatment of the sick by a neuro-psychiatrist, above all. under field conditions. The contl;ents of tVi s kitmake it possible to conduct a neuropsychiatric examination ard basic diag-nosis, aa.d the drugs are used to treat light n.qbulant cases of mentaltrauma in the sense of tranquilization and psychotherapy. Since the

.15

purpose of this medical kit is limited, it contains tranquilizers, basicsupplies and gear, syringes, a sterilizer for instruments, a percussionharmer, an apparatus for measuring blood pressure, etc.

Even in wartime present-day diagnosis cannot be imagined without re-liance on a laboratory whether the physician is workIng in a clinic or inthe field. It is certain that laboratories in hospitals and medical Insti- -

tutions in the area will have a larger volume and broader scope of clinical

and chemical work than will be the case in the military medical stations of6 the armed forces. This difference results not only from the division of

labor agreed upon, but is also an inevitable reflection of the conditionsunder which the relevant specialist will work in the very mobile miliatarymedical station by contrast with those under which biochemists will perform 'their professional activity in health centers, medical centers and hosni-tals. Therefore the methods, laboratory gear, reagents and equipment usedfor clinical chemistry under field conditions are adapted as much as pos-sible to those conditions and represent simple, rapid and satisfactory so-lutions with regard to the accuracy of the standard methods used.

Two medical kits have been developed for work under field condi-tions: "Biochemical Laboratories, Basic" and "Biochemical Laboratories,Supplemental," the first of which also contains a section called "Instru-ments for the Work of the Microscopist," which can also be taken as a sepa-rate medical kit.

The basic biochemical laboratory is a medical kit used to determinethe number of leukocytes in the blood, the leukocyte index, to detect pro-tein, stgar and urobilinogen in the urine, and also for conducting certainspecific reactions in the blood related to the organism'ls reaction to com-bat poisons.

The supplemental biochemical laboratory is used to carry out theit following analyses:

a. in the urine: detection of protein, sugar, acetone, urobilino-gen and bilirubin, and also to differentiate the sediment of the urine;

t b. in the blood: determination of the number of leukocytes anderythrocytes, the leukocyte formula, sedimentation, hemoglobin, urea and

sugar;

c. in the spinal fluid: determination of protein and the numberof elements;

d. in punctate: determination of protein.

The laboratory methods are adapted to the working conditions andthe professional level of the laboratory person, the medical technician.Most of the reagents used in peacetime in the form of solutions are in the

a.6

T,

f'orm of' tablets or paper ostrips ,I n thejSe kijt, So htwr a edn

- ~quicktly and with idnimwn gear, nevertheless retaining adequate accuracy.

Thepricipesof the chemical reactions are in principle adaptedto standard methods taken from medical biology, and the only difference iE;In the form of' the reagents and the manner in which the procedure is car-ried out.

.... .....

#14I

Figure 21. The Medical Kit Labeled "Outfit for Diagnosis and Work With Out-patients."

Mhe "Field X-Ray Apparatus" is a piece of military medical equipmentconsisting of' X-ray apparatus, a photolaboratory and an electric generator.The X-ray apparatus cant be used f'or either roentgenography or fluloros copy,which develops 30 MA and 835 KV, and it can be connected to the regular2,v_ supply or can be used with Its own generator. it is packed ;incrates, and it takes about half an hour to set up the equipment for work.It also has a table on wheels so that the patient can also be examinedwith a D~ucky diaphragm.

This medical kit makes it possible to perform the following diag-nostic procedures:

-A

man&A AIL-

Figure 2. The Medi cal Kit Labeled "Biocheniical Laboratory Bwsic"t and '13io0-chemical LA~boratory qutpplementftl.e"

a, fluoroscopy of lungs and heart;

b. roentgenograply of the :kull, bones aid jointa;

c. fluoroscopy of the stomach and duodentm using barium nllfate;

d. natural photography of the abdoien and urinary tract.

Equipment for Teatment of the Sick

In addition to the medical kits already described, the "Phyasician'sLAM-," "Drugs for General Medical Aid," "Drugs and Gear for Neuroprychi-

atric Work," etc., several. types of medical kits containing medi.cal sup-plies and drugs oad kits intended for Care of the patient are used intreatment of the sick.

The medical kits "Pharmacy, Mield" and "Pha•mtacy, Basic" contain

- - drugs and chemicals and instriuents mnd equipment for preparing drugs.

The field phoamacy is issued -o those idlitary med cal stations andhealth institutions where general medical service is offe) ad, since it con-tains drugs intended for the work of a general practitioner, This kit ishandled by a pharmaceutical teclnician, mid the contents includc antibiot-.cs, miLfonordipde , anai1Feqics,, 'ronczioudtoi fd uhear drug-

for emergency aid and treatment of the most coninon illnosse s.

The militarjy medictl kit referred to as "Pbarmacy, l•l;aic" is hai-i-dled by a phaimacist, the content of drugs is more diverse, it makes itpossible to meet needs whd.ch arie out. of the work of a inddi.ea1, specialist,and it also makes it possible to prepare certain basi c magnistral drugs(eyedrops, powlers, ointmrents, solutions, etc.).

The military medical kit referred to as "Drugs for the Sick" is in-tended for 'treatment of a certain nwmber of patients in medical instltu-tions and milLtary medical stations where an internist is working. Theassortment of drus is broader, and in combination with the militaly medi-cal kit referred to as "Pharmacy, Bas:1.c" :i.t can meet the Wartime need- ofmost medical institutions where specialized aid hia- been given to the sick.

The military medical kit referred to as "Drugs for Infectious D)is-eases" has been made up in a similar way; it contftins a broader specificassortment of antibiotics, sulfonamides and other drugs used in treatingthe most conmion infectious diseases in Yugoslavia.

The militai-j medical kit referred to as "Ouitfit for Care of the:3ick" and "Hospit-l Equipment" are indispensable for the care and atten-dance of patients under field conditions, and they contain articles suchas bedpans of various types, garbage buckets, cans for washing the h-nmds,a (eicy-te for hea',ing v:ater, pots, brushls, glasses, etc.

19

aeA -1

Ver11y klp-to-drtte cpxi.1miceiit; for O~ing113.ano t'.nd treatdilent, 1=10I.3y 1.1the forat of portuble apparatxttxc.. a~re Ial.o iuved :inx wurtive inedictmt ingitj -tutitono wnd mil-it-tr mxedical gjAti-ona.: elcctrocart.log~raphu~, de:0,bri.LL-torn, px~cemko~kr, oet. The typooi tnd iinu~ibrr of these appftratkul~es cepundnot only on the pliyaiognoiiwi-ad capteity of the henl~th -institut~ions, butalso on the condi tions lunder which It w.Ut11 be operatiAng hi wurtinic. Thaisi. it' I:eration- 'mdcr stationary conditionn J.- provided -or With L uuai

kj teed source of electric Ipower, the available peacetine equilment cani beused without limitations. on the other litnd, operation %Wdel! fie:ld Oondi-tiLonii, and in movement affbet the selection ot the -type or apparat~us so muchthat the correct orientation in exeiusively toward por tabl.e &ppfratusen.

~itch use batteries or storage batterles for thecir opern.ti.onl. The experi-ence front the peacetime ema rency mnedic.alni~d .icx'ice vi.D. certain~ly he3lpev~ry medical inatitution to fiind the appropriae n1olution for its owni conl-

AA

Fiur 3 M WrevaX-ayApart.1: itheM1.1&yMilcl i tl

"X-111y Macine, ield.

It ppas itjh i:t crc oreiat11 J.' IfrIII(II) it

andJoiiv~lul mdial .arile eecrcrdU.,rth d'bilao, t.Ineuipngwrtm ieleO I miu ion an d1tr uil.

y~ ~ ~ ete * o~

20 -- ~ ~A

-to cti'i'y out jo'tuid prprto'1 MorI.I al auppillum atid d~inigu. Cor troenting.tio culck oxro p~jrexc-d :Iin the tfoin o-f med~ical kitiu, midl thuy roproumont, Lh8tnbjaeflt alld efujivit&"t *o0:.I.tiollin . the Prepai~d.owiv o~f the hctilthb tjei.vica, a -

tn1though evcry mudical. bistitut~loin, aldyivg.yv :1ta own capa1.1;LtL1oc -, njuodtatnd wartime arxignmxnt. mtky~ &18o formI raeryervu of tiloue supplies ar prtoit~ phtixuu~y or te ,ubdiv nio~ of the moidioul inatitutiora, ma~fin thoO1)1)1oprinte l1ovlimiud ulmortarnttit, of i~to pec~cetric Inventorian.q

Whbzitited 9 Sieptembrnb 19'Jh

Pj

fF

?iW18FJIP-DAY TREND8 IN DMEILO]?M.1' oF CIW~MICAL WF.APONS

MenilC-.', TdaiLtc-dieuin ColonelNodJ.ljki 11001a. doetor,

r~octor for Mara~noclogv andToxicology of the Tin~titute

fo~r 001invlCO:i. anld MMIOrtc..i?"rotection, MIogruda

Tho use of poisonous cixondca.ln as woapona datea fromu ancient tiiie.Ilwoirver, the Itioderil h:L1.vtory. of cht-id.ml~. -40tqoinj begbia with World W~kr 'I,

Lime , 411 techn1o13.0e atnd. oljeanmi. clicill.j..:y 11i',c dcVcI.opi.od Chemnical. Wcaj)c;:have alobo t-xo~g nbprat1)letoiv'1 tbi ev~JAI1i a

the laboratoricai of 1. 0. * Ic'ben (;liun).Te &LuacoW1Wr o1., tllo~IC (cm- Apowds ared no ý,tzgein tho biodOeki la~tory of cliendictd. weapouio, and

ther ar soic ho et-ardAipil *01 (when imsao productioni aid -ttockpll. ngthere~ ~ the 4.2vlolvciO ohf~~dA.ri.1

of tabim begaii) an: parlin.p.; a miore i~m.1ortwit dth' e In tedvIo1ct01chcikicl WOopolc)OknI th JnIy 1~917, when mota~~trd gaa im use td a.- a combat1)1 sloil Oil the fot

III tile% fiJrst, TpOA14twr Lem hort'! :~ .~ i A. -wkou lchom...ca):.wcrofliprobabl~y bui nusct1.ho vro'rjd Wasti;i . greatly .impiiancc by thec d0-.

dI;'netivu powtr of imloarIQt wetapo1Ia. Thcuilmnk to the bivte-nve pro~gaaaw ofU techn1uology, Imiprovvziaent ini tho syixt~hoteticapab1b1..ttea of. organid chjemistry.

miud t'he t'Ixnida re V_5Lutdozi in f, lerC. * -Vil oU:; tý o fbilg(Milly aot"Ive maoQ11A.Id; haxve boont ayntheaizeci. Nan of' tOieu have driawni the

-tetl-BtOXI of rni:I11.1"ry renaenrceT.1r I)eCftoc of thc on:lbiJity of thcir use

-ac.-ii.t -day re~leareb 1i the~ .Le.*Ld of- combaLtk ))01430ns in1 jali.tal-ycbtilot- ztry ad text cology- it. t,.iwc'l It% two d(trecltorWim: townard 1.1 ning mnore

VefcUetve chfirinlett'l. collpoljx!.n withi -I oxi, ;Jlng groupr, of C(,(vbafl 1)(11onv.(nerve giiuce;, tear giacse, otc . )and owavrd the do" -..:Loyvacnt ot unow typcoi of

22)

* Q~oinbut poiaono (f'or extuviVo, p:ivokioeI'v*_in~eaL polzoon~3 otiaIl o~tvpol sona. oet). We wlitL cito V-pol sone whtluh boltoig Lo the j~rm~p ofr neirve

wint~le, 111imttsof o>-.t 0gA.1-13In comibib *poinoln. TPhat :1ithe "Convolt~ionnCI."liervi- gtewrua nowin, tubtui, wid uouwLui (or 0-putoia~n u u they uiu othurvwLie

Clld bacmiUt!O of' tholl, ph~.~~~ici rp goomt Vohl.u101A.,yannd.'tile- 1Lck' ol' odor anld color *-- Ifui' anv4ougcLI p~r:hnvi:Ly Xoir poiaining by ill--

tirely proventewi by Trjttiiit oil a gi~ Tnime In ti~yi. Rno~ornch wime tbxornorvilmot 'at findting 00 )0Qnds~ Ini thiln group of poinol ganer) whIch wou~l ei'Ceu.-

- i~~Lv04~ piui;Gtrato the~ orguimaii~ by a~m othor meoule evon Utough 'Lik gus~ mus~ikwi- on1. jhi;z I~d to tho (511ovo"ry of' thiu V-poivoliv, lihich, flJr~nt, Iurvuooiviorrnbly iuoro toxic -0. .n thuo (i-poi~iontn, anid vuoyid, bocao ofV thu vtolloloi-n Of thlýAr. Dklwll~l thay .u.o not voi'3t vol~atllG tuid ý:iey vuary gu:Aliyiclltrato 11hr.o'gh vlothinpg tund. ukiln 1-1 U10 .Corii Of 11ml11b ktio opl.oU. WeVill 1LCito 'tileuyhcoik3 poi nonn, vualicnu menunn ot tcuuporari~ ilca-pacittating lwunn boings, poisom, usod by acommnaidos, vto.., afs (mi oxtuipi of'-tile dveloplient of' ne typou 01 Cali~but. ))oi:3oI3 which at~ the rjvIe.11 111110ci' oated u4pportuti~tieo A'r a now itode of' ubiiulk~i. wmirFaveo T.11 c&I .itOeFi be ato:W O.V 1-iopit~ o' m2or itrecent "1Cocnd-lotxy" konk 01I.1tr w o tlhi'tthey ar on.e etnoitl.ai.y (chemloalc and thal; -thetI' 0ct'fot ,Li bLooJe onl 1th1 Cre-ntion of' a bl~ichemidoat levion In tehoreanoami. 'lt'io v"vioxi "Aroned~inj-ywdapon. (Alapabll, wI-tte pouphoirn), ~uv, mid woopoll. muod -te dloatroy Plntor to dofollatte :toru'ta (1104AII~Cid) Mild eCIMeAIiict iUie to alter wowtlir

onl tUi ovt-nni..m all:i the vay to ;( lohQ oti~tcmcg~. 1\11 thamc i-mapomI; havoI)'been 1111d :in the1 11101- recent 1iiii.I3Lte-ty co~',~~(Koren , Vietnam!~f, ther Arfib-t-raeii conilict). 1owever, mihc ti-Lic Chemcint weapon in~ onjy that weapocnwlj.cll prtodile~e, &:IVeot1 Imid C'ex1:tl3ive:1j toxilc eff'ects on -the :t.1-ving orgmuil ill,

Ali: combmLt pOImiso: .intvo twvo eaheigo Ii C lYuthUIJ, jinixmidd.i to) do toy: man -pow0er) and( TonlIetlux),i which Il.'o flood -to teoiporml:i)yN :11)Ietqacitstav 1111111m bo-inC,- (.chci3.. 1.62 ierach, -90. rhi.s :lvinioll rA1l3Y re:leCt. 'thle proo-,unL-.txdy tarend in of~putl III( nhomca vroý(.kpQCul tC~i~n IId J.'I ot h po-lariztttI~on of combat poisions, Oil thc one hiand we scc the emergence ot ox-Lviuiiioiv toxic compoiuicb; writh a highly dead:Ly oifect (nlerve ,-k;ni.an OilUhu oi he wo :ýoc .Oipn(J With "i teinporuiý i oxic uCýCccl. Oil IIIlUpoWqc3 I;iaL(d0 not. hui-i the orguni-lam .-rvocNV:aiSb. AR .l'hi.;I d-viol 01, 00111t. P0ook3OhuemUf(A., of *ii'se , beC ýkvCQ)t:od .i'mn th1e lincd~ical "U110o~intiixc it; i.; di -

t'ieul tolrC(l:Ict. to Jrhzt.LI extclit alk~y pol.:3o10W vd..Lh:tne rl, be, ciPfoctiycto cm~u4iia otily revi.ro.1blo tmd Llteiuo.1i'ky paoo,;icAl.o. fMiicdwi;;iso cisi therefCore mnore Thmynortant froin the 3t,'UidpoDil of MilittiAry taC-

The idoa ot inorlyIdaactn1ig.'In enemy 311 war J. a no)t new.I t .I mcJ.kown thait 11an.%y chlxcain.eaJ ccallpoul.1da ,ý druty, anti, :-j oil (vin ~~tj.vxc]y cntfLvuiea~te dA :vinp ti. oil.; of' certitimi pI ynii Oogio~ Ca".. !ltinl;whichwou~ld tongporari.1.1,v parn :tye pc )op].ý for 11 ttJ.mei v~ith'Alt 3.~tmlng mpe1CllIniueit;

233

pLhmcu wich .11C1imR1CIAI afikiOat mouti M L (Wctoi'lu a~ind those poionc 11101 J c~t1Li-uE WI oj~~n :hi.y afc~t W:c mo'Ua p 1'ant~ltu or mv bCI £ittorgmiliea.'t~i.'int

ThG1VUM~i muil~ efuo-nw~lioii i~o;I.djj eomrý, '.t 0~~~~

f'or Jmiyn~ry ilc1Lu .to of human beinLgo are mioat 1requoxit-y ituwitioncidN In h~e ml,) . tn-an J.VYturatura , walX .31,; cils~d diw tytiouu O -tile 0111-1.0 Of tho

Af',diankp~Li~oi olf Wie coorclihinvtiofl of mfovcimci1ih, aurpriuoaliuang~e in blood pr~oam~i' (Onpaoi.13 lyOrthoetatitc hiyputansicn), varl'ovin d ia-Lur~biumciod of 'Lite gatroint-etinal apparatun (intana.1vm vomiting, diau'rhout.Ota.a), temi)morwy~ blArndoar, and dealnottone n i iIt-Laolve tlienving, i2-noc-zirnf

lcQ c.tqo~ o traj(tuiduldrublo ai'foctu~) ccui causo Uloae auuat-ic In-jurioni, orlv a fe oouivbuL jpoiuous~ hav beome uta vit 4dived lit tile Corii of7

(I~~obiunon, iS-poi memnc, and thell ~~cnme - h~l

vac.jY Lr~itatu, IA~bhi' '90) 11nd 1111vo-n tuld cause, Jtcliwte invo 1-c.aring Avocogi -mooý;n4- tud 11odclui U.JiIIg hiihoi conceoatruitiorio, the taxic of-fact of th1aupoottin agento 1miy even Rat sv'ral houvs aftor the end of'

wt 1J.1-L 011 iJcuii A t I~ o. k~nowil Olcl~u I'tiav 1.clXc 1Usc~t In Ial3Ay.l,11110111111 i uci ini v'LrimuJ wky,- in Lthe VAO't~nam v-~. ) MoyeLu\rc2. tle± CS- . N- aizd

Lhy ii uAd o p~ ~~jt ~u'' it vl monu ii L ci'.Cvc-tve poiw~onlit -ldAj. group Is~ cs3, bhcauj6i' U.1 ha., Lk vide ýtip lbetw'10r the Ia1-capa.Uk~l33g d~a uad Ula ei.Lelatad Lotha.L Ind",. Effoctivo hvwwcimct.n-.1Jt ~ bin~ip .1i achix-ved qj LhA contamidli'.LoIL or thcŽ !0'r wit tzvo

__ ~ ~ AZ iici3.ad3n1rn).,nncnntratioln of 3.0.0 nij/1i0I k/rn 3 ;the .2-ha.I~ndcx. 1.0 . thc- voIlm 1,1vikiuhil, bt.dLwce the concentration oil C.", j it

75,000 1u(,/,no 1/rnO. ill crlthev xfoi'd1,i CS0 coliic:.; c10o3c 1W (le Lypu ort tthc "1 io' teeosrt.owhcwuLdau clh:1ibtenhOOC ndum]

oughtb not -to cwdz3c the death k.) tIlen V11,IIý oC1l UiOý po~ jio;in.

We, aili0uI.( a-JI3o :i1.iicXte Ill th.111.': gLroklp 1,O poi ý'o~no U10 pi'v!-ou:;i.)F known

"g U""! jot o14 wlhichi calln aL-io Lc:prriv.I~pI1tl.~pcople wLIcI IZ3Cd:ItnolŽ33]et-1la3 Coll col Owa n 01

he )th.el' lOfL po'j m ~3In~ vwi:ch t3f(~r yiincapacI.nix pconj.o .iJ-ciudc', tilcm']c ellonde031 1rd L~e1W whi'611 caU:3Q 1i3 humn.3nx clnad ;uja0f11 01,11,13. lucit(LI. kLiiVLt.o.L i5 v, Cý conrtt wi.Ll Lill-h pJ't'\'io'i g7roup, o.ýpc-CRO.J.3.y 11110 (8-1.i ls0I'. tho lit) -jit~i1.) 1 cAC eCT. ofLw:cIc10:(1i,(:. pO1 ;0Il:..laInt'%; e"Voli u fIto v(t'Oflbe; wi. II.AA tIlcul . *WcIiV '3nr' nti~.~J e

&'kIhh 1i u3950, tu!'d the inlbl c wa:; t'trs' o'iŽ 0) ;~ ." t 'hwhe

A'

the Ur.ited States declared the so-ca:Lled policy of 'V*ar without death."M.ere are uinofficial data (Neilands, 1973) to the effect that these poi-sons were used in Vietnam. One sbach poison has been standardized as achemnical weapon in the United States Anued Forces under the code name BZ-poisons (Hersch, 1970). The BZ-poisons cause disturbances of higher )er-.vous activity and of the vegetative nervous system; these disturbances aremanifested by psychomotor excitation, dysphoria, hallucinations, and dis-orientation in that the victims cmrletely lose contact with the externalworld. It is well. known that along with the BZ-poisons there are also manyother compounds o:ý drugs -that can cause similar distuvbances of mental and - -i

vegetatie ftuictions, whether it is a question of taking the so-called"true" hallucigenic substances (LSD, amphetanmine derivatives) or, on theother hand, of accidental or suicidal poisoning with toxLc (loses of manydrugs (scc)olamine, atropine, phencyclidine, etc.). These psychomimeticcompounds are used in experimental psychiatry to evoke variouts types of""model psychoses" and axe of iaiportance as potential combat poisons.

In short, according "to the infonnation from the literature, thepresent-day arsenals of chemical weaponG consist of the following: Ox-tremely toxic nerve gases (G-poisons: sarin, tabun and soman and V-poi-sons) and poisons for temporary incapacitation of human beings: CS-, CN-,SDM-, and then nitrogen mustard and BZ-poisons.

The bibliography can be obtained from the author.

Suabix'tted 15 February :i.9'T4

25

[pp 345-347] UDC 615.Oi.099:623.459.446 (CS, CR)

PHARMACOLOGICAL AND TOXICOLOGICAL PROPERTIESOF PiESENT-DAY COMBAT POISONS WHICH CAUSE MAlAISE (CS, CR)

Medical Lieutenant Colonel NedeljkoRosic, doctor, Medical Lieutenant

Colonel Radivoje KIusic, docent and 'Idoctor, Medical Lieutenant Colonel

Bogdan Boskovic, docent and doctor,Medical Lieutenant Colonel Vladimir

Vojvodic, professor and doctor,Sector for Pharmacology and

Toxicology of the Institute forTechnical and Medical Protection,

Belgrade, and the Clinic forInternal Diseases of the Military

Medical Academy

The group of agents that cause malaise which have been standardizedand which are in the arsenals o' chemical weapons is made up of the follow-ing: orthoehlorbenzylidene-malononitrile (CS), chloroacetophenone (CN) andadamsite (DM) 1"8]. According to the most recent information, the recentlysynthesized poisons with the code name CR [3], which still has not beenstandardized as a chemical weapon, should also be put in this group. In-any case, agents that cause malaise belong to the group of poisons fortemporary incapacitation which have an irritating effect on the skin andmucosa most probably through stimulation of sensitive nerve endings. Thisirr .Ltative effect causes a nimzber of painful and unconfortable feelingssuch as intensive tearing-, blepharospamu, severe cough and sneezing. ByIand large these combat poisons have a short-lived effect, their toxic ef-fect occurs almost instantaneousby, and it lasts only so long as it is incontact with the organism. Agents that cause malaise were used on a largescale in the Vietnam war [6, 10, 13]. By way of illustration we can say

that in 1967 alone 580 tons of these poisons were used, and by 1969 theproduction of about 2,900 tons of agents that cause malaise was planned.TAside from their use in war, the poisons in this group are used to quellmass disorders, demonstrationc and strikes, which account for their beingcalled "polic- poisons." I

,6

V4

In this article we will present the principal phanmacological andtoxicological properties of only +',,i most recent poisons, i.e., of CS andCR, since ciloroacetophenone (0N) A:,-,d adamsite (DM) were used in WorldWar I and there is quite a bit of information about them [2]. Moreover,CS and CR poisons differ considerably from CN and DM poisons in that withrespect to their toxicological properties and tactical use they coir closeto the type of the- "ideal" poisons for temporary incapacitation. We-arethinking here primarily of those poisons which have a large gap between the 4dosage which effectively disables and the lethal dosage, i.e., they have abroad "safety" zone. According to the figures we give in Table 1, it isobvious that the CS poison is the most suitable, since the gap between thedose which is the threshold of irritation and the lethal index is great(0. 1:775,00 m000 in/m3).

Table 1. Toxicological Properties of Di:. -omforting Agents

y'eof PoisonION DM CS

Threshold of irritationK(mg/rn 3 ) 0.3.0.1 0.1 0.05-0.1

Maximum tolerance (mAg/m 3) 5-15 2-5 1-5r, Disabling dose (ag/min m3) 80 20 10

Leth_. index (mg/nin/m..0) 8,500-25ý,000 15,000-30,ooo o,ooo-0(.5,ooo.

L, Note: The figures were taken from a 1969 publication of the United Na-

Like CS, CR causes blepharospasms after local application of just afew drops of a 0.0001-percent solution, while the mean lethal doses formarmmals are between 0.6 and 7.0 g/kg of body weight. Consequently, evenin this case we are dealing with a strong irritant with relatively low "ox-

Thbe Toxicology and Pharmacology of CS Poisons

CS was synthesized by Corson and Stoughton back " 1928 [4], and theabbreviation CS comes fram the initials of the last names of the discov-erers. The English classified it as a combat poison only in 1950 [16],while the Americans used it for the purposes of war on a Vietnam battle-field in 1964.

Tile chemical formila of this poison is as follows:

\ CN

27

Orthochlorbenzylidene-malononitrile is a white crystalline substancewhich melts at 950 C and boils between 3100 and 3150 C. It is practicallyinsoluble in water and dissolves well in various oganic solvents such asacetone, dioxane, methylene chloride, ethyl acetate and benzol. It is lesssoluble in alcohol. In water it rapidly hydrolyzes and decomposes.

-General Toxic Effect of CS on E-,erimental Animals

The results of experiments concerning the acute toxicity on rabbitsshowed that intravenous or subcutaneous administration of doses between6.0 and 2.0 mg/kg of CS brought about the death of the animals in 10 min-utes [15]. The lethal doses for mice and rats are much higher and amountto between 200.0 and 800.0 mg/kg of body weight. As for the toxicity ofCS when administered orally, the present data indicate that the lethaldoses for rodents are between 200.0 and 300.0 mg/kg [7].

Vi The systemic signs of poisoning with CS poison are manifested by un-rest, rapid breathing, taehyeardia and convulsions. PathomorphologicalJstudies of the dead animals showed very slight changes in the form of con-

FV gestion of lung tissue, while no sort of pathological changes were found inother parenchymatous organs.

We should stress that the intensity of the general toxic mJ!ifesta-tions and also the magnitude of the lethal dose of CS in experimental ai-mals depend equally on the memner of administration and on the type of sol-vent used.

Effect of CS on the Eye

Local application of CS dissolved in methylene chloride (0.05 ml ofa 10-percent solution or 0.1 ml of a 50-percent of CS) very rapidly causessevere blepharospasms and unrest in animals. Moreover, intensive hyperemiaof all parts of the conjunctiva is noted, along with seromucous tearing - Itypical of the rabbits. The hyperemia was later accompanied by edema ofthe conjunctiva. At times one can also note a strong swelling of the nic-tating membrane accompanied by ptosir of the lower eyelid.

The blepharospaom and tearing completely disappear 20 to 60 minutesafter local application of CS in the eye of a rabbit, while the hyperemiaof the conjunctiva last considerably longer. Yhis lyperemia may be con-licated by suppurative inflamnatory changes which persist even more than I8 hours after drops containing CS are put in the eyes.

Effect of CS When Inhaled

Inhalatory application of CS in th.e form of an aerosol also causesintensive tearing and salivation just a few seconds after exposure (inha-lation). However, along with these signs, immediately after inhaling theCS aerosol. the anials become restless and hyperactive, and between 5 and

28

10 minutes later signs of impeded respiration and occasional apnea appear;

these disappear only about 20 minutes after the animal has been removedfrom the contaminated area.

Pathological anatomic findings in these cases of poisoning show W- 4peremia and edema of lung tissue and then necroses and hemorrhages in thegastrointestinal and respiratory tracts.

Effect of CS on the Skin t i5

CS has an irritative effect on the skin of experimental animals,causes erythema necrotic ulcerations, edema and depilation at the placeof application 17). It is interesting to mention that decontamination withater and soap does not prevent the development of these changes. Completerecovery of the injured parts of the skin occurs only 5 weeks after con-

tamination. In this connection we should emphasize the fact that the sol-vents also have an irritative effect on the skin in their own right.

Aside from the fact that in large concentrations CS has a directlytoxic effect on the skin, it has been demonstrated that this substance alsopossesses a sensitizing effect 117]. The skin is sernitized following re-peated applications (intradermal or on the skin it,.elf) or suberythemal Idoses of CS poison and is manifested by erythema, edema and necrosis of theskin at the place of application.

Phamacolcical and Biochemical Effect of CS

Judging by the chemical structure of CS poison, one can easily con-elude that this substance, since it is a very active alkylating agent, re-acts very quickly and easily in the organism with SH groups and inhibitsthe activity of those enzymes in the blood which depend on these biologi-

a" cally active chemical groups. The results of experimental research has in-deed shown that CS acts in a very manifold way, disrupting the activity ofvarious biochemical systems in the organism. For example, it has been es-tablished that CS causes disruptions of saturation of the blood with oxy-gen, inhibits the activity of pyruvic decarboxylase, and so on [5]. It isalso thought that CS and its derivatives affect the activity of biologicalsystems in the organimn of experimental animals such as bradykinin, hista-mine, etc. CS diminishes the activity of nonspecific esterases in the se-baceous glowds of the skin of mice, which in turn pointed to a possiblecarcinogenic effect of CS 11]. CS did not display embryolethal and terato-genic effects in the several species of maimnals studied [19].

This composite effect of CS poison in the organism indicates an un-known mechanism of pharmacodynamic effect and deserves particular atten-tion in fiuxther research.

29

29

Ai

Metabolism o,ý CS Poison in the mranism of RKPerimentaJ. Ani mal s

The results of experimental research have shomw that particles ofiCS aerosol can be resorbed frcm the pulmonary alveoli into the bloodstreamdepending on the concentration of aerosol in the air [i1]. This can alsoexplain certain systemic toxic effects of CS poison. It is interesting tomention, however, that CS is not detected in the blood following peroralapplication, and it appears that considerable quantities of this poisonhave to be administered for it to be reorbed from the digestive tract

The CS resorbed from the elveoli into the bloodstream disappearsfrom the blood very quickly. This has been proven on the basis of theshort half-life in the blood, which for human blood is 5 seconds and fordog and cat blood is 7 seconds [11).

As for the metabolism of CS poison in the organim, little is knownso far about its biological transfomation and secretion. It is known withcertainty that CS reduces to both orthochlorbenzyl-malononitrile and ortho-chlorbenzaldehyde [1.2]. The further fate of these metabo.lites is unknown.The results of research have shown that this reduction takes place in theblood with the help of enzyme of erythrocyte cytoplasm in which NADPHservos as a specific coenzyme.

"-oxicoloa or CR Poison

CR poison differs chemically from orthocblorbenzylidene-malononitrile,as can be seen from the formula below:

0

\ \, / /

The first data on the irritative effect of this derivative of oxaze-pine were published back in 1962 [9]. By contrast with CS, which rapidlyhydrolyzes in x.n aqueous medium, CR poison, though insoluble in water, re-tains its irritative properties even in an aqueous medium. This propertyof CR poison is important from the standpoint of military toxicology, sincethis makes it possible to use CR even when atmospheric conditions are unfa-vorable (humidity, rain, etc.).

CR causes severe irritdtion of the eyes and then painful irritationof the skin and mucosa of the mouth Ead nose in very snmll concentrations(a few drops of a 0.001-percent solution). It is distinguished by instan-taneous effect, intense biepharospasm, pain and tearing, which last about20 minutes.

30

The mechanism of the toxic effect is unknown.

-i1n Which Discogmforti. . Agents Are Used in Warfare

Like most incapacitating agents, CS and CR and other agents thatcause malaise are most frequently used in the form of aerosol contamina-tion produced by various means, all the way frcm the hand grenade to espe-cially designed frayers. The particles of the aerosol can be produced inseveral ways (thermal evaporation by pyrotechnic means, etc.).

CS is used in variouo preparations (CS-0 , CS-2) which are in fact amixture of CS with various additives either to improve its penetrative powerinto lung and other itssue (CS-I) or to increase the stability of particleson contaminated terrain (CS-2). 7

A special method of using CS poison which was practiced in Vietnamris to throw the poison into closed areas (bunekers, tunnels, and so on) withvarious pumps and sprayers. Used in this way CS poison ean cause the deathof a large nimber of the -3 stims because of asphyxiation and pulmonaryedema (141.

Bibliograpkr

"I. Barry, D. H., NATUIRE, No 24o, 1972, pp 960-562.

2. Bilic, B., "Combat Poisons and Military Medical Chemical Protection,"VOTNOSANI¶L'. PF]IXTL., Belgrade, 1956.

3. ... , BR. MED. J., No 5, 1973.

14. Corson, B. B., mid Stoughton, R. W., J. AMER. CHEM. SOC., No 50, 1928,pp 2835-2837.

5. Cucinell, A. S., et al., FED. PROC., No 30, 1971, p 86.

6. Franke, S., "Lehrbuch der Militaer Clhemie," Band 2, Deutscher Mili-taerverlag, Berlin (DDR), 1969.

7. Gaskins, J. R., et al., ARCH. EVIRON. HEALTH, No 24, 1972,, pp 449-

8. Ilersch, S., "chemical and Biological Warfare," Russiian translation,Moscow, 1970, p 39.

9. Higginbottom, R., and Suschitzky, H., J. CHIM. SOC., No 2367, 1962.

10. Kahn, F. M., "Chemical and B)iological Warfare," London Conference onCBW, Ed. S. Rose, London, 1968, p 87.

31

ii. I~dbc~tei', L., TOXICAL. APPL. PIMMCOL., No 25, 1973, Pp 101-iiO.

12. Leadbeater, L., Sainsbury, G. T., and Utley, D., TOXICOT,. APPL,PHAIMMCOL., No 25, 1973, pp 111-116.

13. Neilands, J. B., NATURWISSENSEFAFTEN, No 60, 1973, PP 177-183.

14. Neilands, J. B., et al., "Harvest of Death-Chemical Warfare in Viet-nam, and Cenbodia," New York, Free Press, 1972.

15. Punte, L. C., et al., TOXICOL. APPL. PHARMACOL., No )4, 1962, pp 656-66P.

16. Robinson,, J. P. P., "Chemical and Biological Warfare," London Confer-ence on CBW, Ed. S. Rose, London, 1968, p 19.

17. Rothberg, S., MILITARY MEDICINE, No 135, 1970, PP 552-556.

18. UN publication: Report of the Secretary General, UN Publications,Sa•le No B69. £If. 24, A (7575), Rev. 1, New York, 1969.

19. Upshall, D. G., TOXICOL. APPL. PMARMACOL., No 24, 1973, pp 45-59.

S3ubmitted 14 JAne 3.974

232

JA!I

I •

[pp 348-349] UDC 616.031.l-099:355.415. 6 "423.159.3 16 (, CR) 01)

CLINICAL ASPECTS AND CARP OF PATIENTS OF ACUTE POISONINGWITH PRESENT-DAY POISONS THAT CAUSE MALAISE (CS, CR) -

Medical Lieutenant Colonel Radivoj eKu•sic, docent and doctor, Medical

Lieutenant Colonel NedelJko Rosic, 4doctor, Medical Lieutenant Colonel A

Bogdan Boskovic, docent and doctor,Medical Lieutenant Colonel Vladimir

Vojvodic, professor and doctor,Clinic for Internal Diseases of theMilitary Medical Academy and 0ector•

for Pharmacology and Toxicology ofthe Institute for Technical and

Medical Protection, Belj-ade

Present-day combat poisons that causue malaise, like CS and CR, whosechemical, pharmacological and toxicological properties were presented inthe previous article, are among the nonlethnl ecombat potsons along with thepoisons of this group that are already well known: chl.oroacetophenone (ON)and adameite (DM). Acting as irritants, the poisons of this group tempo-rarily render people incapable of carrying out coabat actions or exhaustthem by forcing them to use protective equipment. Extensive use of CS poi-son in South Vietnam and Ireland [1, 2, 3, 4, 5] clearly confinned thesuitability of its uSe and its effectiveness for temporary inea pacitation,which also pointed up the possibility of the future use of the poisons inthis group.

Regardless of differences in their chemical structure and specificpreparation (CS 1, CS 2) the poisons of this group act as alkylating agentsox. the orgamism, causing through a manifold mechanism (by means of enzymeand biological systems) biochemical lesion [6, 7] which shows up clinicallyin t.he form of the same or similar manifestations. Knowledge about inju-ries to human beings with CS and CR poisons, which ia not so abundant asthe knowledge gained in experiments on animals, comes 1'rtce wartime use ofthese poisons in Sauth Vie'Vnam, their use In quelling demonstrations, from

33

"-*• .. • - I .... x-n . ...... ." . ...... -. . . . . .. . .. . .

accidental poisoning of workers in industrial production and from experi-mento on volunteers 12, 0, 9].

The poisons CS and CR are odorlean and tasteless crystalline sub-stances which can be used in the form of a solution and aerosol, but themowt frequent use iS in the form of an aerosol created by ex losivei, byspecial devices on aircraft, by sprayers (M-106, "Mighty Mite"), etc. [2].Poisoning can occur through inhalation, through the skin wnd cona, by in-gestion of contaminated water and food, and thrmgh a wound. In all these "cases we distinguish the local and general. (resorptivr) effect of the poi- Ason,

The clinical manifestations of injuries caused by CS and OR poisons Adepend on the form and dose of the poison and on the maimer and place of* their entry into the organism, but in all cases the irritative character :Aof these injuries is dominant.

Clinical Agpects of Poisoning

Depending on the eoncentvation of the poison in the air and theleng-th of exposure., i.e. , on tile dose of the poison received, we distlil- •guish light and severe degrees of poisoning in the clinical aspects of poi-

*oning of human beings with poisons of the CS and CR type. A light degreeof poisoning is caused by concentrations of 1-5 mg/m3/ndn of the poison!,o, 10., l and severe pisonl1r,, results from con-entrations tlat are Severs.i-times higher. Cases of death, which con occur when the poison is used ina closed space (tunnels, shelters), have been described at concentrationsof 4I0,OW0-70,000 mg/mO/min 1[2, 3i]. 11%ee doses indicate the large gap be-tween tile incapacitating dose and the lethal dose. S

The appearance and strength of the signs of poisoning are also af'-fected by great Individual dilferences in sensitivity toward these chemi•tcalsubstances as well as by atmospheric conditions (hutd dity, air temperature,wind, etc.) [4].

Poisoning with CS and CR poisons is manifested by instantaneous ap-peaurance of the following syriptonw.

a) Ey•e: tearing, pain in the form of infloiwmation, conjwietlval IIIJection, photophobla and blepharospasm. Redness and swelling appear on the

eyelids. Regenstorff 1,12] noted a transient reduction of the sharpness ofvision. It has also been found that trioetyl phosphate, which is the sol-vent for CS in containers, has an extremely irritative effect, causing con-junctivitis without demaging the cornea .131.

All of these signs disappeared more or less in 5 to 30 minu.tes fol-lowing termination of the poison's. effect, except for edema of the eyelidand a certain fatigue in the eyes, which lasts for 2A hours. A traxsientelevation of intraocular pressure has also been noted in a case of injurywith CR poinon [14].

34

In •eovre lviaonuilr till the adgns of eye. injurjer, are more inten.seand pernist for 5-7 dr'y' L311.

It is thought that the human eye ia Ymre oonnitive to aerosols thanto solventa, probably becaurie of the phylical lpropertleet of the agenhts.

b) The resiratory tract: sneezing, sevwr cough, abundant scoro-tions frm the nose, salivation and retrostertrn ). pain aeeompam.ed by afeelinig of oonstriotion in the chest.

All theoe signa are from direct -irritation of nerve end(ngo in therespiratory tract, wlvdch te)Qrerily incaIxtacitate people, and disappear,0-30 ndnutes after they leave the contminated atmnosphere or put on a pro-tective mask.

In severe cases of poisonjig those signs are joined by tdypnea, din-ruption of the respjiratory rit1m% and cyanosis. In exceptionally severecases which ended In death thevo was p lmonai-y edema and asphlkyxi.ation OnCeeatse has been deseri-bed of a 4-month-old baby wvi.eh was aouidantaJl ox-posedI to the effect of CS and in whom recurriig pneu•onia developed [16).

- c) The effect on the skin reaulti frAu parile'!cz of" the ,, l Fii, vty--trg on open paix't of the skin and i.s manifesotod by s:i.e:ni or n;kin irri.tta-tion: acute pain, burniiing od erythemia at the place of contact with thepoison. Vesnicules atlso appear in the severe case:.;, and in a tropical c.1.1-mate the orythm•a and vesieuL.es lead to bu;.lloo changes [4). rhe effect ofthe poison is intensifed if' the skin is %et [17]. p n o

In light cases the ql"uiges in the skin dimappear in a few hours, Wid

manioestLations of allergic contact denuatitis and eczema ha.ve been noted inworkers employed in the production of CS [11].

Punit et al. [8] and Woigand [4•] have noted that rinsing injurod.parts of the skin with water can intensily the pain at the place of con-tamination and can ca-use recurrence of the signs of skin irritatitlon1

d) ,Plic reoorpt:ioe effe,.t of Ioisons3 of the- CS and CR type are maini-fested by headache, taclwvcardia, nausea, vomiting, sndil diarrhea, and thenby hemorrhaging fromu the nose and a transicnt elevation of arterial bloodpressure, which changes along viith -the sy•iptoe1w of poisoning. ¶•le fearwhich is, aroused in the victims accent-uates the other syiptoms of polson-img, and it appears that it is a consequence of the stress caused by theIXsoning itself (91. The concmaitant leukocytos~i.s is explained in the

35

TVa 10 i MOOL A nt cc -lictionn reltxted to :tvli i fli w C" (k)II~n C11po.-OIUlIi4 (kre nkjj~krt.I~t Infections 0of thle eya tand voopi atWiy traoct. AItupovitioii tovard llpiiorgi~o veotiono is pwoniblo ini cormoction With ro-peated expxosuro to tJhoae -geito..

RKPCpO~ro to CC(J Uld"OR poitsons of' Porsono whio surfor rý,o bronchIaLL&antbimi or chronh. 'broncliitini tend to woroexk their prji cipa.l din-eaveliicoxe of~ Vietimu- of' C3 gand A& oio,

Firgat Aid to V'ictimw co ias"tg or f -A~ protective mn.inhala. 7ti~on of. wht.1moke miuxtu~re (tuidur tho nai-) and vithdawuwal iromf the' Contlufi-ncatod area (cont-tuidinted Zone), IEn miost catics other thorupoUlic mesurosare not neoeLsrnL1'y.Uj Irodiately upo~n wiftlrawal from the contmanated 1atref thle eyoul,Mouth and throitt are (1Coooitin)dAw0.tedu with a :L~-2- cnit iolution of :;odhu

r ~ bicarbonafte, and tho contwninated partai of' t-lie oldn (w r~ined W'ith the.smun colution o.r mi &lvohiol-water aoj~ution of' sodilum utdfto L110. Cohing in decontmiijnated by nimpy jhaking, it out. CblLurnavLcd 3.iine in not 1

reomiended, Aince Ant irritativc efact in intown .CteIn it l a nXture wi-thPEC0) (181. 1W1l3in& the (oyoL with WutC1! iv o3,o not recioulmeŽnced bjocau-no uvf tlin

UIItt3jr!Iw e frut'.o We izaWo describod 1.3.91.

In novie cas1en th~erfq'.r I., vsyptinatdie both A., ptirt ot.' general. uidiC;aad(batta:Llon ijiedical AtvLtioii and j'utginentai, wecti ca:l mtati on) and a-

part of' s3poolQ.I?.zd incdien:I. EAi (di~vIli~ol)Al IlekicUal StatLon): "Locai. 11110-thetics, cuntibiotic;s wnd corU-leolda r4i espeeial~ly wheia there are inju-rios to the1w jicoaa cund Akin. Aniti.10. ttuid.iieo are 0lso rc-ipt(lemded i11 1',and Jones tuid Isi'(Ae. IiJ.9j Cite good oxo~~eblronallto ofl oodilul tilosiul-fnAtc (1-0 mil of' a 30-POTrcent oolution, N .v. ), basing th~i oil the atiowiptionof the cynnido offtect. of 0S. Card:lotonlon, diureti~cs and oxygen axre givenaccording to i Indiclti.OflS, IA'Lllous chanige.- on itc *Imn Wim.Id be optened -ulIdtreated liko burns.

1. Kahn, F'. M. , '(le-ndeck). and Dl:o3.opelml WarfaOzre," Conferenw.,c on g:t

3.Karmkc~ehiy, N. I'., "Tox;icoj.ogy of Toxic Agent~s wid rlot~ection Agai nstWealolw01'MRS. NlodijthJRWTSS SCW\TISN, , Taolkent, .19'73. pp 232-P3.14

I..We~gmiwL, D)., MILI'I'ARY M.Ei)ICINE., No 3.34i, 1960. pp 4-3-1-101.

LI; (0n. 1kUrve.-L. of Dcah-Chem:Lc.a1. Wa1'~rfar in Vit

6. Chiclioi3t, A. S. od; al.. 1,11)i. P11OC., No 30, pp71 8P.6-01,

7. Jon110, GJ. It. N.. NATURE. VoI 235, Nio 5336) 1972, pp 257-261,

Mit, h.L.6t a.l.w ARCI. 1NVTION, IIMLTH, No .~1963, pp r('18,

9. IJoa-ick, V. W.,p Itotlwid , P. , and Krnip, K. 11. 13111T. J. INDU:3PR. ME-D. ,No 2%4 307, ,M-oO3o6.

1.0. Alokstnutdrov, V.* N * tr .ixihhy Voe~huhuat-va (I.xi ~b lolls),Minijiiry oi? De.Conts USSR., Moliot~ww 3.969, lpp .310

.11. UN Tt\)b~litcio~i: Report of thw Beecrtary Goiiori1, UN ib~licatlons,Siale No R~ 69. 1. 24; A (7575), R1oy, L, Noir Yorký 1969.

3.2. Rogeiuor.Cr Rl*I. 11 M(Jb3WAR'Y Nru\(-.CTN, No 1311 Y,) 396,lip P39-221..

13-3- g~iinv R. 11.) 11"d Mernon, M. M.0 MYXHLPARY MIKiC1N1. No 1.36, 1971,I ~I pp 2152.153-ih4 . .. P *11 - , No 5875, -19"13, v 5.

1YQ].tldihwtlie, B., IAulk Owfultoul 1). W.) AUTA . Pl~ift~.MAO. TO)OCOi.. (ýIjzI)No 32P 1-973, pp 266-277.

16 . l'ark, s., antfl uI minfona, S. v. , &1. . xs.i to. C0O, N~O i?3 :1(1p2,

1.llolhind , P. an'd h1iQ, ii. (t. , wi3v3:T .o.'. m-i. , No 86, p9:~ p TI5o-T-.?4,

18. F1ejtv.111Q, J. F .) et al.) * "Toxlco1o&)a,u CtUY.1iqw.- (J:. uim~~~u

19. Jrones, C.. R. N. , and M~~a~j,~. S. , NA'AuuRE, No 29-8 * :tsyO, pp :13:1.5-

13-1-7.

SubO.t~tld8 3111,v .1971