ATOM RADIATION INJURIES · confined to the bile duct a local resection is advised. If it appears to...

286 POSTGRADUATE MEDICAL JOURNAL J/lne I951

spect the ampulla when a local diatlieriiiy CxcisioIiof the polyp could have been carried out as advisedly Cattell (Cattell and Pyrtek, I950).

CommentaryI feel that the brief reports of these eight cases

offer their own lessons, but would like to sum-marize shortly my own opinions.

In a case of obstructive jaundice in which thereis some doubt as to the cause at laparotomy:

i. When the gall bladder is collapsed a carefuldissection in the porta hepatis may reveal a growth.UTsually little can be done but f would suggest thatby opening the duct below and dilating the malig-nant stricture, palliation may be achieved withtemporary clearance of the jaundice.

2. When the gall bladder is distended theduodenum and head of pancreas should be freelymobilized and the bile duct brought under directvision. If there is a growth and it is absolutelyconfined to the bile duct a local resection isadvised. If it appears to have spread outside theconfines of the duct and involved the pancreatichead, a pancreatico-duodenectomy should beperformed.

3. Where a lesion of the ampulla is suspectedand there is the slightest doubt as to its nature,a transduodenal inspection should be made aftermobilizing the duodenum. If doubt still exists,and facilities for frozen sections are available, adiathermy excision should be performed and the

treatiueoit -,ill bc depend(lent on the patlhologicalrepor..

Having performed a resection of one sort oranother, the bile duct should be anastomosed tothe jejunum, and this is much easier to performover a soft rubber tube. The portion of jejunumshould always be defunctioned (Figs. 5 and 6) toobviate the danger of ascending cholangitis. Ihave found that ligation of the proximal end of theduct and usage of the gall bladder to re-establishbiliary continuity is unsatisfactory, the dangerbeing that the bile duct will slough and thepatient succumb to a biliary peritonitis.The decision to perform a one- or two-stage

operation depends upon the age and general con-dition of the patient. A one-stage operation ispreferable but when the liver function is demon-strably poor a two-stage procedure is necessary.We have found that the most useful liver functiontests are serum protein, thymol turbidity andalkaline phosphatase estimations.

fn conclusion I would like to say that althoughthese are relatively rare tumours they are ascommon as carcinoma of the gall bladder and ascarcinoma of the pancreas (Willis, 1948). Theiridentification may often mean the saving of lifeby a relatively simple surgical procedure.

I am grateful to Mr. Norman C. Tanner forgiving me access to his notes, and to Mrs. Maceand Miss Mason of the photographic departmentof St. James's Hospital.

BIBLIOGRAPHYBRUNSCHWIG, A. ( 948), 7.A.M.A., 136, 28.CATTELL, R. B., and PYRTEK, L. J. (1950), S,,r. Gin. &

Obst., 90, 2 I.CHRISTOPHER, F. (1933), Siurg. Gvni. Le Obst., 56, 202.I)IC K, J. C. (io.19), Brit..7. ,'Sllkg., 26, 757.

GORDON-TAYLOR, G. (1942), Brit. Med..7., ii, ii9.ROLLESTON, and McNEE (1929), 'Diseases of Liver, Gall

Bladder and B3ile Ducts,' MacMillan, London.WVILLIS, R. A. (1948), 'Pathology of Tumours,' Btitterworth,

I ondon.

ATOM BOMBS AND RADIATION INJURIES *

By SURGEON COMMANDER G. D. WEDD, R.N., SURGEON COMMANDER D. A. HOVENDEN, R.N., andINSTRUCTOR LIEUTENANT A. J. ALABASTER, R.N.

J?oyal Naziy Medical School, Al? erstoke

The story of Hiroshima and Nagasaki is nowancient history. It is well known that the twoatomic bombs killed about ioo,ooo people and in-jured as many more, besides producing untoldmaterial damage. Of those who were killed about

* Part of this article has been taken from ' SomeMedical Aspects of Atomic Warfare,' G. D. Wedd,Public Healthi, June 1950.

8o per cent. died from burning or from mechanicalinjuries due to blast damage, which are the normalaccompaniments of any explosion. There re-mained a smaller number, variously estimated atfrom IO to 20 per cent., who were uninjured ortrivially injured at the time, but who died days orweeks later from the effects of radioactivity.

Radioactivity then is a relatively minor cause of

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casualties following atomic bombing, and if agreat deal of attention is devoted to it in thefollowing pages it is because it is something new ina weapon of war and its effects are not generallyknown.

Nuclear ConsiderationsBefore we can understand the medical effects

of atomic warfare it is necessary to know a littleabout the physics of the atomic bomb and thenature of the radiations it emits.

IsotopesAtoms are miniature planetary systems with

tiny particles describing orbits about (relatively)heavy nuclei. These particles are negativelycharged and are called electrons. Nuclei are madeof protons and neutrons, the former are positivelycharged the latter uncharged. Each has a mass ofabout one mass unit, or i,840 times the mass of anelectron.The number of protons in the nucleus is fixed

for a given element. Thus chlorine always has 17protons in its nucleus. The number of neutrons,however, is not fixed, but can vary between certainlimits. For example chlorine can have either i8or 20 neutrons in its nucleus. Hence chlorineatoms are not all of the same mass, some weigh35 units (I7 + i8), others weigh 37 units (I" + 20),and we distinguish between them by writing Cl35and C137 respectively. Atoms of the game elementwith different masses, due to the different numbersof neutrons in their nuclei, are called isotopes.Isotopes have the same chemical properties sincethey are forms of the same element, but theirphysical properties differ somewhat. In particularthey behave differently in nuclear reactions.

RadioactivityAll the heaviest atoms, and a few of the lighter

ones, are radioactive. That is to say that they arecontinually breaking down (' decaying') becausethe arrangement of protons and neutrons in theirnuclei is not quite stable.

If the neutron:proton ratio is too small, twoneutrons and two protons are emitted together inthe form of a particle called an ' alpha particle.'This, in fact, is a fast-moving helium nucleus witha mass of four units and a double positive charge.An example is the decay of radium into radon:Ra226 -* Rn222 + oc (He4). Alpha particles have arange of a few inches in air and a few thousandthsof an inch in body tissue.

If the neutron :proton ratio is too large, aneutron changes into a proton with the emission ofan electron called a beta particle. For example,actinium changes into thorium: Ac227 - Th227

+ f. Beta particles have a range of a few yardsin air and a few tenths of an inch in body tissue.

Sometimes a nucleus emits excess energy in theform of electromagnetic radiation called gammarays, which are identical with hard X-rays. Thesetravel with the speed of light and have such a longrange that they killed a number of people a mileaway from the explosions in Japan.Ionization

All these radiations from radioactive substanceshave the power of removing electrons from anyatom which they encounter. The atom thus be-comes positively charged and is called a positiveion. (An atom which had gained an electronwould be called a negative ion.) It is because ofthe ionization produced in living tissue thatradiations are harmful; it is also because of theirionizing power that they can be detected andmeasured.

Nuclear ReactionsIn i919 Rutherford succeeded in changing a few

atoms of nitrogen into oxygen by bombardingnitrogen nuclei with alpha particles. N14 + He4 -*0"7 + H', a proton (hydrogen nucleus) beingemitted. During the next 20 years a large numberof reactions of this type were achieved. In par-ticular it was found that neutrons were veryeffective in causing nuclear changes.Energy, ExchangesWhen a nuclear reaction occurs the total mass

of the products is often less than that of the re-actants. Einstein showed that this apparent lossof mass appears as energy, according to the re-lation E = mc2.

If E = energy in ergs, m - mass in grams, thenc2 is the square of the velocity of light in cm. persec., i.e. numerically c2 - 90oooooo000OOOo,000,000 = 9 X 020.

FissionIn 1939 it was found that when a rare isotope of

uranium, U236, is bombarded with neutrons, thenucleus absorbs one of them and becomes so un-stable that it breaks up into two fragments. A gooddeal of energy is released in the process and, also,two or three neutrons are released at the same time.If these released neutrons fall on other U235nuclei, further fission will occur and we shall havea ' chain reaction.'There are, however, two difficulties which must

be overcome before the chain reaction will proceed.First, any impurities in the lump of uranium maycapture some of the neutrons, in which case fissionwill not occur. Second, any neutrons whichescape through the surface of the uranium will be

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lost and again will not cause fission. The firstdifficulty we overcome by making our material aspure as possible, but this is not at all easy. U235occurs to about 0.7 per cent. in natural uranium,which is nearly all U238, and we cannot usechemical methods to separate them since they areisotopes of the same element. Physical methods,such as the difference in diffusion rates of theirgaseous compounds, are very tedious and in-efficient, involving thousands of repetitive pro-cesses. Escape of neutrons depends on surfacearea, whereas capture depends on volume. If weincrease the size of our lump we increase volumerelative to area, and thus by having a lump ofmaterial greater than a certain ' critical size' wecan reduce escape to an acceptable level.

The BombIf we have a lump of U235 which is less than the

critical size it is quite safe. But if we have a lumpgreater than the critical size it will explode, sincethere are always a few neutrons present fromspontaneous fission. The bomb may, in fact,consist of two lumps of U235, each just less thanthe critical size, which are brought suddenly to-gether when the bomb is detonated.

Since it is very difficult to prepare pure U235 anartificial element, plutonium, is used instead. Acontrolled chain reaction is used in an ' atomicpile ' to provide a steady neutron bombardment ofU238; plutonium is the result of this reaction.:

F,'ission ProductsWhen fission takes place the nuclei do not always

split in 'the same way, so that the fragments(' fission products') are of different sizes. Thesefission products are unstable, since they containtoo many neutrons, and decay rates varyenormously among them, but it is found that thedecay curve of a typical mixture of fission productsfrom an atomic bomb falls very rapidly at first andvery slowly later on. Roughly speaking the activityat a given time after the explosion varies inverselywith time. For example the activity one hour afterthe explosion will be roughly one-sixtieth of thatafter one minute.

Induced RadioactivityWhen an atomic bomb explodes, neutrons are

emitted and these neutrons may react with variouselements changing them into radioactive isotopes.An example of this occurs with sodium. Na23 +n -> Na24 -* Mg24 -* 3, y. This effect, however,is not of major importance.

Effects of the bombThe fission of a few kilograms of uranium235 or

plutonium releases energy equivalent to the ex-

plosion of about 20,000 tons of T.N.T. (Fig. I).This energy is released in the form of:i. An immediate heat flash sufficient to ignite

dry material up to about 2 miles and to causeburns on exposed parts of the human body up to2 miles on a cloudless day. However, this heatflash has a duration of not more than a few seconds,so that effective shielding is provided by quite thinmaterial provided that it is light in colour andreflects most of the heat. It was found in practicethat at ranges where survival was possible severeburns did not occur on clothed areas when theclothing was light in colour.

2. A blast wave which destroyed all buildings,except those strongly constructed of reinforcedconcrete, up to a mile and cracked ordinary brickbuildings up to ij miles.

3. A ' flash' of gamma rays which killed abouthalf the people exposed at X mile and a few at imile.

After the air burst there was no significantresidual radioactivity in the neighbourhood, be-residual radioactivity in the neighbourhood be-cause all the radioactive substances were carriedhigh up in the air from where they were eventuallydispersed so diluted as to be harmless. That wouldnot be the case after a ground burst or an under-water burst, either of which would result in heavycontamination of the site.

Radioactive ContaminationRadioactive contamination of ground following

an atomic bomb or the spraying of fission productsis always a possibility for which we must be pre-pared. Anyone who enters such a contaminatedarea exposes himself to two additional dangerswhich need not be considered when dealing withgamma rays from an atomic bomb.

i. He is now exposed to bombardment by betaparticles which must be added to the effect of thegamma rays.

2. There is the much greater danger of radio-active substances being absorbed into the bodyeither by inhalation or swallowing, and this in-cludes the unexploded part of the bomb whichemits alpha particles. Many of these alpha andbeta emitters are heavy materials which areeventually deposited in the skeleton from whichthey are excreted extremely slowly, and there isnot much that can be done about it. The ill effectsof such absorption may not be noticed for someyears but, given time, a fantastically small amountof some radioactive substances may be fatal. Itis probable that the lethal dose of plutonium is notmore than about IO [L gm., and some of its fissionproducts are nearly as dangerous.

Both these dangers can be largely avoided withcare. Suitable protective clothing must be worn

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juine 1951 WEDD, HOVENDEN and ALABASTER: Atom Bombs and Radiation Injuries

BLAST

CASUALTIES

FIG. I.-Effects of an atomic explosion.

to prevent radioactive substances from coming incontact with the body and from being inhaled orswallowed. Before any work is permitted the areamust be surveyed by a specially-equipped monitor-ing party who will record the level of activity andsay what length of exposure is acceptable.

Effects of Radiation on LiVing OrganismThe exact means by which penetrating radiation

damages the body is not fully understood, but itwill be sufficient for our purpose if we say that itis through the formation of ions in the tissue.One of the most characteristic properties of thisradiation, whether it consists of alpha or beta par-ticles, neutrons, X or gamma rays, is that ofstripping one or more electrons from an atom inwhose neighbourhood it passes and so producingions. If it were not so their presence could not bedetected.

Since the ionization of an atom leads to the de-composition of a molecule of which it forms a part,we can understand how a gamma ray passingthrough the body leaves a trail of destructionbehind it. The effect is insidious and any changeproduced may not be noticed for some time.

Firstly, the decomposition of protein moleculesin the tissues deprives us of their services and givesrise to a number of breakdown products, some ofwhich are toxic. Thus we can explain the in-activation of enzymes, which has been obserxedexperimentally, and the shock-like symptoms andvomiting which have occurred within an hour or soof heavy irradiation both in human casualties andin experimental animals.

Secondly, there is good experimental evidencethat an ionizing particle or ray passing through thesubstance of a chromosome can break it at thepoint of passage. Such broken chromosomes tend

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to heal in a short time, but if there are many brokenends in the same place the wrong parts may joinup. Naturally, the heavier the irradiation the morebroken ends there will be. If a chromosome isbroken it appears that the two ends can functionquite well unless the cell starts to divide. Whendivision occurs the fragments fail to reach theirappointed places. There is a serious'disturbancein-the chromatin complement of the daughter cellswhich are usually inviable.From these considerations certain important

consequences emerge.I. Tissues composed of cells which are actively

dividing, such as blood-,forming organs, gonadsand mucous membrane, are much more radio-sensitive than those whose cells have ceased todivide, such as nerve and muscle.

2. There is usually a ' latent' period of somedays between the irradiation and the signs of moreserious damage. This latent period represents thetime taken for the bulk of the damaged cells todivide.

3. A single large dose of radiation is much moredangerous than the same amount spread over alonger time or taken in divided doses. In point offact an X-ray worker may, during his life, receivewithout any ill effects at least twice the amount ofradiation needed to kill him if he received it in asingle dose.

Radiation CasualtiesAtom bombs will be used for their explosive

effect but, incidentally, produce a burst of ionizingradiation. Accordingly, among the ordinary airraid injuries from collapsing buildings and burnsfrom heat flash and secondary fires, a new type ofcasualty will be seen as radiation illness. This isnot fully developed until two to four weeks haveelapsed, when it is seen as a combination ofagranulocytosis, from bone marrow damage, anda haemorrhagic state.

It seems most probable that these bombs willbe exploded at a height between 500 and 2,000 ft.over a town, in which case serious structuraldamage to buildings will be confined to an areawithin 2 miles of the ground centre, though minordamage, such as broken windows, may occur outto at least 4 miles. The intensity of gamma radia-tion at i mile will have fallen off nearly to a sub-damage level, with the LD5o at about 3 mile.From ground centre to 3 mile it is to be expectedthat anyone surviving the explosion in the openwill be very lucky, so that in proportion to thesurgical injuries radiation casualties will be veryfew. However, at Hiroshima people did survivein a tram at iooo yards (Cogan, 1949) and in aferro-concrete building at 250 yards (H.M.S.O.,1946), and some died later from the pure radia-

tion syndrome; If, therefore, there is warning andpeople are in shelters there may be severalthousand primary survivors exposed to pure radia-tion injury.

For the radiation syndrome to develop there aretwo basic factors necessary:

i. That the victim should be exposed to thesource so that the whole body is irradiated at once.

2. That' the source should deliver severalhundred roentgens in less than two hours, of raysof such energy that ionization is evenly distributedthroughout the tissues.These factors are not met with except during

atomic explosions and in the event of careless ex-posure in the neighbourhood of high energy X-raymachines, so acute radiation sickness was not seenon a large scale in man before the Japanesebombing.The duration of the burst of ' immediate radia-

tion' is about io secs., during which time theintensity drops so that about half the dose isdelivered in the first second and the remainder inthe other nine. It looks as if one should be able toescape part of the gamma ray flash by takingrefuge behind a wall or other heavy obstructionimmediately the burst is seen. The same appliesin a lesser degree to the thermal radiation.The results of whole body exposure to radiation,

which is not heavy enough to cause death within afew days, are seen in the form of damage to thosetissues whose cells are most sensitive:

i. Blood-forming organs-lymph nodes andbone marrow.

2. Gastrointestinal mucosa.To these must be added:3. The gonads, though damage in this case is

scarcely likely to endanger life.

The Blood-Forming OrgansThe circulating cells,' with the exception of the

the lymphocyte, are relatively resistant and, themain damage falls on the immature cells. As aresult the numbers of circulating cells fall, but notat once; the time taken is related to the normallifetime of the cell. The early behaviour of theJapanese patients is not known with any accuracysince serious investigations were not undertakenuntil about the sixth week. However, such resultsas were obtained, combined with numerous animalexperiments, suggest that the lymphocytes begin todecrease at once, reaching a minimum about thefifth day. The granulocytes may show an in-definite rise in the first three days and then beginto fall, reaching a minimum early in the secondweek. The extent of the fall is related to the. doseof radiation, but there appears to be no limit to itsince total white counts below ioo have been seenin Japan (Le Roy, 1950). However, recovery was

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rare after lymphocyte counts below 200 or totalwhite counts below 8oo Cu. mm.

If there is to be recovery it usually starts duringthe second month, and animal experiments haveshown that those animals which die in the first28 days from the direct effects of acute irradiationseldom show any tendency to recovery of whitecells.

Platelets may begin to fall in the second weekand counts below 25,000 were seen in some cases,but their behaviour has not been studied to thesame extent as that of the other cells.Red cells, which are relatively insensitive to

radiation and normally live at least ioo days, areslow to fall. A marked decrease does not occuruntil about the fourth week, in the absence ofhaemorrhage, but may continue for a month ormore if the patient survives. Recovery from the

LYMPHOCYTESIN

PER CENT0F MEAN

resulting anaemia is always slow and is not likelyto be complete for many months.The direct consequence of the loss of leucocytes

is infection, which is inevitable after severe radia-tion injury. A further effect on the circulatorysystem is the bleeding from the second to thefifth week, varying from petechiae to massivehaemorrhage into the body cavities and fromvarious orifices. A number of factors appear to beinvolved, including damage to the endotheliumof the smaller blood vessels and an almost in-definite increase in the clotting time, due to loss ofplatelets and, perhaps, the liberation of a heparin-like toxin from damaged tissue.

The Gastrointestinal SystemAfter severe irradiation, loss of appetite, nausea

and vomiting are often seen on the first day,usually followed by early recovery. These changesare too early for the full effect of damage to cellsto be felt and are probably due to some chemicalmechanism. Towards the end of the first week, orlater, the symptoms recur, often accompanied bydiarrhoea, at first watery and later bloody. Thesesymptoms are an indication of changes takingplace throughout the alimentary canal, but moremarked in the intestine than in the stomach.The early changes include hyperaemia andoedema, which may be so severe that large sectionsof the intestine look as if they had been dipped inboiling water. Later ulcers appear which bleedreadily, and permit the infection of the body withintestinal organisms.About the same time as the bloody diarrhoea,

sore throat and ulceration of the mouth ap-peared such as occur in agranulocytic angina.

or

. 1-J000 or

1 -- 2-WEEKS

3

FIG. 2.-Estimated rates of fall of lymphocytes and granulocytes at different doses of ionizing radiation.

4--m4ftft4R-- a -1

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292POSTGRADUATE MEDICAL JOURNAL

The GonadsThe question of the possibility of permanent

sterility as a result of a single irradiation has re-ceived far more attention than its importanceseems to warrant. The fact is that both testis andovary are highly sensitive to radiation, and tem-porary sterility was a common finding in Japanin both men and women, though all who survivedrecovered within a year or so, so far as is known.The power of recovery of the testis is such that thesingle dose of radiation needed to produce per-manent sterility is far greater than the lethal dose.The ovary is less sensitive than the testis in thefirst place, but it also has less power of recovery.The sterilizing single dose is probably about thesame as the lethal, and permanent sterility in awoman who survives is possible but not verylikely. The possibility of genetic changes will bementioned later.

Treatment of Radiation CasualtiesNo first aid treatment is indicated for radiation

casualties, apart from the other injuries they mayhave received. In order that they may receiveadequate treatment they must be admitted tohospital, which will be made easier by the longlatent period before the appearance of the symp-toms.

In the event of an atomic attack it is likely thatthe casualties will number many thousands. Thismeans that if an attempt is made to treat them allthey will be treated inadequately, and many liveswill be lost which might be saved by a selection ofcases. There will always be a certain number forwhom nothing can be done. These should receiveno treatment beyond what is necessary for the re-lief of their symptoms. Likewise, many will betrivially injured and will recover without treat-ment. The main effort must be directed to thoseborder-line cases who may recover with energetictreatment but not otherwise.As prognostic indications the following may be

helpful:i. If the total dose of radiation received was

less than 300 roentgens recovery is probable, if itwas more than 6oo r. the chances are very poor.It is quite likely that the dose received may beestimated approximately either from the patient'sknown distance from the bomb or from instru-ments. Unfortunately both these methods aresubject to certain fallacies. If distance is used theestimation is based on the assumption that thepatient was evenly irradiated in the open, whereas,in fact, part or all of his body may have been inthe shelter of some solid structure. If he wasindoors at the time it would be necessary to makeallowances for such things as structure of walls andceilings, position of windows and scatter from the

walls of the room. Instruments carried on theperson should give a closer estimate, but only ifit were certain that the instrument was exposed tothe same extent as the rest of the body, which isunlikely to be the case. A great deal would de-pend on which way the patient happened to befacing at the time, whether the instrument wastowards the burst or away from it. Further, theinstrument might have been fully exposed whilepart of the body was protected. Installed instru-ments in buildings suffer from the disadvantagethat there is no reason to suppose that radiationwould be even approximately evenly distributedthroughout a room, let alone the building as awhole. It is certain that one should hesitate tomake up one's mind about the fate of a patientfrom the dose of radiation supposed to have beenreceived.

2. Fever in the first week after irradiation with astep-like rise of temperature, in the absence of anyother cause, means a grave prognosis.

3. A fall in the lymphocyte count below 200 percmm. on the first day means there is almost nohope of recovery, whereas a count above i,oooafter three days probably means that the damageis trivial.

4. A total white count below 8oo per cmm. afterten days means the patient will probably die, butif it is over i,500 per cmm. he has a good chanceof recovery.

5. If the white count is found to be rising at anytime after the third day the chance of recovery isgood.

6. Nausea and vomiting on the first day is asign of serious, but not necessarily fatal, damage.If the vomiting recurs within the first five daysaccompanied by bloody diarrhoea the prognosis isvery bad.

7. If there is no epilation by the end of the thirdweek the patient will probably recover.

General TreatmentI. Complete physical and mental rest. This is

necessary in view of Cronkite's (I949) finding thatanything tending to raise the metabolic rate ofmice diminished their chances of recovery fromradiation injury. Sedatives and morphine may benecessary.

2. Prevention of chilling for the same reason.3. Diet should be semi-solid and non-residue

on account of the damage to mucops membranesand difficulty in swallowing. Protein should besufficient to meet basal requirements, but excessshould be avoided in the early stages owing to itsspecific dynamic action. Later, as recovery begins,the diet should be high in calories and protein.Liver extract should be useful at this stage.

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4. Nursing care to avoid bed sores and otherinjuries which might act as portals of entry forbacteria.

5. Asepsis when using hypodermic or intra-venous needles. Injections should be given as in-frequently as possible in order to avoid infectionand bleeding.

Specific Treatmenti. Penicillin will be needed to guard against

infections. Probably the best way will be to usean oily preparation which retains its activity fortwo or three days and give an injection of 0.25 toi mega unit every other day. Streptomycin or,

GRANULOCYTESIN

PER CENTOF MEAN

I

A

IIIII

some other antibiotic may be needed in some casesto treat penicillin-resistant organisms, but strepto-mycin should not be used indiscriminately. Of thenewer antibiotics aureomycin has given promisingresults in experimental animals and looks like beingavailable in large quantities shortly.

2. Blood or substitutes. During the anaemicstage whole blood will be needed in amounts ofabout one to two pints per week according to theextent of the haemorrhage. At the same timedried plasma should be given, as necessary, tocorrect the low blood protein. Weekly or morefrequent estimations should be done on thehaemoglobin and plasma protein levels as a checkon the treatment. If blood and plasma are notavailable in sufficient quantities the best substituteis probably dextran, a polysaccharide which canbe prepared in large quantities, keeps indefinitelyand is said to be non-toxic provided the optimummolecular size is selected.

3. Toluidin blue, protamine and rutin have allbeen used to diminish the bleeding tendency.Toluidin blue and protamine act by combiningwith heparin, and have been found to decrease theclotting time in animals. Unfortunately they wereof no value in saving the lives of the animals inquestion. Rutin has the effect of diminishingcapillary permeability. Good effects have been re-ported from its use in some animals, but only ifthe administration had started before the radia-tion. In other experiments it has been of no valuewhatever.

* -I 'wasLp

mmt m I0

1 2WEEKS

3.m m- o 1

4

F IG. 3.-Estimated rates of fall of lymphocytes and granulocytes at different doses of ionizing radiation.

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4. Certain vitamin preparations, particularlypyridoxin and folic acid, are useful for relieving thesymptoms after 'radiotherapy. It appears fromanimal experiments that they are only likely toassist in saving life if the administration beginsbefore the radiation.

5. Suprarenal cortical extract is also favourablyreported as relieving the symptoms after radio-therapy in a high proportion of cases.

6. Pentose nucleotide has. been shown to beeffective where active bone marrow is present, andin those cases where recovery is seen to havestarted it may hasten the process.Although the above drugs have not helped to

save the lives of animals after a lethal dose ofradiation it is still possible that any or all of themmay shorten the course of the illness in less severecases, and they should be tried if they are not likelyto do harm for other reasons.Forms of treatment which might be expected to

be useful on general principles but which havebeen disappointing in practice include vitamin K,bone marrow transfusion and leucocyte concen-trates. Sulphonamides, when given internally,have done nothing but harm, but there may be aplace for them in preventing infection of externalwounds.

Long-Term EffectsIf a patient makes an apparently complete re-

covery from a heavy dose of radiation it must notbe assumed that he is necessarily safe. Newgrowths in various parts of the body are to beexpected after a long interval in a proportion ofcases though, up to the present, there is no newsof such complications from Japan. What has beenfound in' Japan in the last two years is a smallnumber of cataracts occurring mostly in thosewho were just over i,ooo yds. from the groundcentre, and attributed to the effects of neutronbombardment.

Chronic Sub-Lethal RadiationApart from the immediate acute irradiation from

the high air burst, we may have to cope with themore chronic effects on people working in areaswhich have been contaminated by an under-water explosion or by the dropping of fissionproducts from some such vehicle as a rocket. Ifsuch an area were heavily contaminated it wouldhave to be abandoned, but if the contaminationwere light and the work important the risk mightbe accepted. Alternatively, it might not be knownthat there was any contamination until somedamage had been done.

It is generally accepted that a daily whole bodyexposure to about o.i roentgen will do no harm inan indefinite time. At about two to three times

that dose rate a few specially susceptible peoplemight suffer from minor degrees of leucopeia,.At dose rates around 5 r. per day more severeleucopenia would be common and probably alsosome degree of anaemia. Leukaemia would be ex-pected to occur after a considerable interval in aproportion of such subjects.

Skin changes may be expected in the form ofatrophy or proliferation after repeated excessivedoses, but at what level it is not clear. That thelevel is probably high is suggested by Americanevidence. It was found as a result of a questionarythat a large proportion of radiologists of more thanfive years' standing were found to have changes intheir finger ridges, such as atrophy, proliferationand fissures. An attempt to produce similarchanges in monkeys was successful, but not untilabout iooo r. hadl been given in divided doses atabout 20 r. a sitinig.

In dogs deformed sperms and low sperm countshave been found as a result' of repeated irradiationat dose rates below i r. per day. However, com-plete recovery followed the stopping of the ex-posure. The power of recovery of the testes isvery great and sterilization is unlikely to followexposure at low dose rates. The ovary has muchless power of recovery and it is possible thatdamage might be done in time at rates not muchabove the maximum permissible dose rate. Infact it has been suggested that the maximum per-missible dose rate should be considerably lower forwomen.

If the daily rate is somewhere about 25 r. perday we step out of the chronic zone and all theeffects of acute irradiation may be expected tooccur after about 400 r. td 500 r. have beenreceived.

Genetic Effects,The genetic effects of radiation are expected to

take the form of an increase in the normal'numberof mutations.

Mutations due to some chemical change in agene or a system of genes occasionally occurspontaneously as when a black or a white rabbitarises from wild stock, or when a case of poly-dactyly or haemophilia suddenly appears in ahuman family. Few genetic experiments havebeen done with vertebrates, but a great deal ofwork has been done on invertebrates, particularlythe fruit fly, drosophila. In drosophila a numberof mutations are known to occur with considerableregularity, and it may be said that the chance ofa mutation occurring in any particular gene isbetween i in iooooo and i in i,ooo,ooo pergeneration. This chance can be increased bychanges of temperature, by certain chemicals and,above all, by irradiation. For those organisms

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June 195I WEDD, HOVENDEN and ALABASTER: Atom Bombs and Radiation Injuries

which have been extensively studied, the amountof radiation needed to double the number of muta-tions they produce is about 40 r. to So r. or theamount received by a human worker who keepsjust below the tolerance dose for two years.

Since nearly all mutations are subnormal insome respect the conclusions to be drawn fromthe foregoing might be truly alarming if it were notfor certain redeeming features.

Firstly, many mutations are lethal. This meansthat if a man receives from 40 r. to 50 r. he mayproduce an additional small fraction of i per cent.of infertile sperms. If the whole population re-ceive the same dose the general birth rate maydecrease by the same small fraction of i per cent.

Secondly, nearly all viable mutations areMendelian recessives. They will not be noticed inthe developing organism except in the extremelyunlikely case where both parents receive the same

altered gene.It has been estimated that at the present rate of

irradiation of the whole population there may be aserious increase of deleterious mutations in from20 to 40 generations.

SummarySome account is given of the casualties produced

by atom bombs., Of these a relatively smallnumber are due to ionizing radiation. The actionof ionizing radiation on living organisms isdescribed, with the clinical syndrome of radiationsickness. The organs most affected are thehaemopoietic system and the gastrointestinalmucosa, and the symptoms which arise are due todamage to those organs. An attempt has beenmade to estimate the prognosis of radiationcasualties and suggestions are given about theirtreatment.

SUMMARY OF CLINICAL SYMPTOMS OF RADIATION SICKNESSFrom ' Effects of Atomic Weapons'

Time after Lethal dose Median lethal dose Moderate doseexposure (6oo r.) (400 r.) (300-100 r.)

Nausea and vomiting after I-2 Nausea and vomiting after I-2hours hours

First week No definite symptoms

DiarrhoeaVomiting

- - - - - - Inflammation of mouth and No definite symptomsthroat

Second week Fever No definite symptomsRapid emaciationDeath(Mortality probably ioo per Beginning epilation

cent.)Loss of appetite and general

malaise E*Third week Fever Epilation

Severe inflammation of mouth Loss of appetite and generaland throat tmalaise

Sore throat

Fourth week Pallor PallorPetechiae, diarrhoea and nose Petechiae

bleeds Diarrhoea

Rapid emaciation Moderate emaciationDeath - (Recovery likely unless com-(Mortality probably 5o per plicated by poor previous

cent.) health or super-imposed in-juries or infections)

BIBLIOGRAPHYCOGAN, D. G., MARTIN, S. FORREST, and KIMURA, S.

(1949), 'Atomic Bomb Cataracts,' Science.H.M.S.O. (1946), 'The Effects of Atomic Bombs at Hiroshim; and

Nagasaki,' Reports of the British Mission to Japan.LE ROY, G. V. (I950), ' H-aematology of Atomic Bomb Casualties,'

U.S.A.E.C.

' The Effects of Atomic Weapons,' Los Alamos ScientificLaboratory. McGraw, Hill, I950,

CRONKITE, E. P., and CHAPMAN, W. H. (I949), 'A ClinicalAnalysis of the Syndrome of Acute Total Body Radiation Ill-ness, its Role in Atomic Warfare and its Influence on theFuture Practice of Military Medicine,' The Military Surgeon

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