A-BOMB CASUALTIES AND ARRANGEMENTS FOR THEIR CARE *

Transcription

1 A-BOMB CASUALTIES AND ARRANGEMENTS FOR THEIR CARE * By PATRICK CLARKSON, F.R.C.S. Casualty Surgeon, Guy's Hospital; Plastic Surgeon, Basingstoke Plastic Centre and Royal Northern Hospital I PROPOSE to limit myself to the discussion of four aspects of this difficult and complex problem. I. What happens when an A-bomb explodes? 2. The pattern of disaster. 3. Diffuse ionising radiation illness and its influence on burns and injuries. 4. Medical plans for A-bomb warfare, I. WHAT ttappens WHEN AN A-BOMB EXPLODES? The character that distinguishes an A-bomb from a T.N.T. explosion, more even than the greatly increased amount of energy released by it, is that the A-bomb effect is triple ; that is, ionising radiations, thermal radiations, and blast waves all arise from it. In the T.N.T. explosion the pressure wave predominates ; there is a relatively small thermal emission. Most of the enormous release of energy in an A-bomb takes place at the moment of the explosion, but some is delayed. The energy released at the moment of explosion covers the whole spectrum ; that is, there are ionising gamma radiations, ultra-violet, light, infra-red, and heat waves. The particle emissions are of alpha and beta particles, and neutrons. We may remind ourselves that ionisation is the " knocking off" from an atom of a negatively charged electron revolving in one of the outer orbits about the nucleus ; the atom is then positively charged and " ionised." It is the gamma rays, the alpha and beta particles, and the neutrons which cause ionising effects. Neutrons, like gamma rays, are highly penetrating ; many feet of concrete or wet earth are needed for protection. They have the power, too, of rendering atoms radioactive. These radioactive isotopes are a source of delayed emissions of ionising radiations. The alpha particle (a helium nucleus) and the beta particle (an electron) are of low penetrability--a few millimetres of tissue or a few sheets of paper for alpha particles ; and a few millimetres of aluminium or tissue or several feet of atmosphere for beta particles. Both particles are highly ionising, and are a dangerous source of local burns when in contact with the skin ; if taken internally they are deposited in internal organs and in the bone marrow, and again cause intense local ionising effects. The " delayed" effects of the A-bomb explosion include both thermal and ionising radiations. The delayed thermal effects are of short duration ; they arise from the heat of the " mushroom" and affect chiefly the area under it. The late ionising radiation effects are more prolonged. They arise from radioactive isotopes caused by the action of the neutrons on atoms in the atmosphere and * Abstract of paper read at a meeting of the British Association of Plastic Surgeons on 9th June 195o. 188

2 CARE OF A-BOMB CASUALTIES 18 9 underlying structures. The nuclei of these radioactive isotopes suffer from neutron excesses or proton deficits. Such nuclei are unstable, and their atoms undergo a number of " beta decays " before reaching stability. At each "beta decay '" beta particles and gamma radiations are emitted. During this period the radioactive isotopes can be a dangerous source of local skin burns, or, if taken internally, of ionising effects on the bone marrow and other tissues. 2. PATTERN OF DISASTER As an introduction to this section, the " pattern of disaster" of the Texas City Disaster, as described by Professor Truman Blocker, was studied in some detail as an example of full documentation and of experience in coping with such mass casualties. Three Main Types of A-bomb Explosion. I. Above ground. x. Ground level. 3. Under water. As far as we know, all A-bomb expiosions to date, except one of the two at Bikini, have been detonated above ground. The chief distinction between the above-ground and the other two types of explosion is that contamination by radioactive isotopes is less when the bomb is detonated high in the air. In under-water explosions, when a great column of water descends on ships and neighbouring lands, its sodium salts have been rendered radioactive. The half-life of radioactive sodium is fourteen hours. The water is therefore a danger as a source of secondary radiation for about three days. A further point about sea-level and under-water explosions is the effect of the gamma radiation on the personnel of ships. Some gamma radiations may be expected to be so " softened " by scattering in the plates of the hull or of bulwarks as to cause skin burns at dosages compatible with life. Ordinary gamma rays and hard X-rays burn the skin at I,OOO to 2,ooo r ; diffuse exposure of the body to this amount of radiation would certainly cause death from diffuse ionising radiation illness, independently of the burn. Three Main Effeets. I. Radiation effects--diffuse and local (in "fall out" area). 2. Thermal effects--direct and indirect. 3. Blast effects--direct and indirect. These three main effects occur in accordance with the zone affected. The zones described here are of radii I,OOO, 2#00, and 4,ooo yds. respectively from the hypocentre of a bomb exploded at 1,5oo ft. The figures are entirely approximate, and would obviously vary with a number of factors, including size of bomb, weather, and type of building predominant in the city. Nevertheless, the general concept of three main effects occurring in three main degrees in accordance with distance from the hypocentre is a useful one. I. Radiation Effects.--These are diffuse ionising radiation illness, caused by gamma radiations and neutrons at the time of explosion, and local radiation burns

3 I90 BRITISH JOURNAL OF PLASTIC SURGERY caused by radioactive isotopes in the " fall out " area after the explosion. These late local effects were notably rare in the Japanese explosions. A dosage of I,OOO to 1,5oo r can be expected over all Zone I ; 6oo to I,ooo r can be expected over all Zone 2; ioo to 6oo r over Zone 3 (Fig. I). All in Zone I, except those FIG. I Fig. I shows the ionising radiation effects to be expected from an aboveground A-bomb detonated at about 1,5oo ft. above the hypocentre X. Zone I extends for a radius of I,ooo yds. beyond this hypocentre ; it receives up to 1,5oo r of ionising radiations. Zone 2 extends for a range of I,OOO yds. beyond Zone I, and receives a dosage of 60o to I,OOO r. Zone 3 extends for a radius of 2,ooo yds. beyond Zone 2 ; in it the dosage of ionising radiations is of I5 o to 6o0 r. The " fall out " area, which is the area of scatter of radioactive fission products, is chiefly determined by the prevailing weather. sheltered at a great depth, would be expected to receive a fatal dose ; over 50 per cent. of those in the open in Zone 2 would ; radiation illness would probably cause death in Zone 3 to many of those casualties with thermal burns 8nd lacerations. 2. Thermal Effects.--These may be direct by rectilineal heat rays at the time of explosion, and indirect from secondary fires. The temperature in Zone I may be 2,ooo C. or more, and all except those protected at considerable depth would be fatally affected. In Zones 2 and 3 the temperature will fall rapidly. Nevertheless, fatal effects can occur in all zones. Thermal effects through secondary

4 CARE OF A-BOMB CASUALTIES 191 fires in Zone 3 are a source of casualty similar in type of burn to those seen in civilian life. Many of the direct burns in Zone 3 from the primary rectilineal rays are not much more than severe sunburn, but some are fatal. White clothing affords more protection to the underlying skin than darker shades. 3. Blast Effects.--These again are direct, due to the pressure wave, and indirect, due to flying masonry and glass. In Zone I the pressure wave travels at 8o0 miles per hour, and total destruction of all buildings, stone and brick and wood, is to be expected. In Zone 2 it is the brick and wooden buildings which are demolished, while in Zone 3 only wooden frame buildings are destroyed. The indirect blast effects due to flying glass and masonry are a potent source of.casualties in this zone. Numbers and Types of Casualty to be Expeeted.--At Hiroshima a 2o,ooo-ton H.E. equivalent bomb, and at Nagasaki a 4o,ooo-ton H.E. equivalent bomb, were used. Nevertheless, the total fatal casualties at Hiroshima were double those at Nagasaki, that is, 8o,ooo dead as compared with 4o,ooo. Both these bombs are now said to be out of date. These figures indicate the very great reduction in numbers of casualties which an adequate warning system can be expected to produce. Reasonable dispersal of populations, a reasonable warning system, and some provision of deep shelters may be expected to reduce the number of casualties to a much smaller and a much more manageable figure. Nevertheless, the total number of casualties to be expected from any A-bomb explosion on an industrial city remains enormous. In Zone I in most European cities there would be some 5,000 people at risk; they would perish from a multiplicity of causes, except the few protected at great depth. In Zone 3 the population would be about 2oo,ooo, the majority of whom would be exposed to varying degrees of ionising radiations, thermal, and blast effects. Seventy to 8o per cent. of these casualties would be expected to show initially only minor lacerations and minor burns, but many of these minor lacerations and burns would be complicated by diffuse ionising radiation effects which would have a major influence upon the course of burns, lacerations, and fractures, especially in predisposing to invasive and fatal infections. 3. ACUTE DIFFUSE IONISING RADIATION ILLNESS This important illness may be defined as the constitutional reaction of the body to ionising radiation. Some such response is present at very low dosages of X-rays--25 r or less. But the fully developed syndrome is seldom seen at less than 5o to Ioo r, and then only if given at one dose and over a wide area of the body with considerable exposure of hmmatopoietic tissues. As far as we know, a 1,ooo r diffuse exposure at one dose is fatal, and at 4oo to 6oo r, 5 per cent. may be expected to die of this illness. In most cases the syndrome shows a characteristic course. There are nausea and vomiting at the time of exposure if the dose is large, and then a latent period before the onset of further symptoms. When the dosage is high, I,ooo r or more, this latent period may be short--two to three days, and the case is then almost certainly fatal. In most of the Japanese patients the latent period was ten to twelve days, when hmmorrhagic symptoms occurred ; that is, bloody stools, bloody vomiting, epistaxis, bleeding gums, and generalised

5 192 BRITISH JOURNAL OF PLASTIC SURGERY purpura. About this time, early in the third week, bacterial invasion starts, particularly of the mouth and gums and any open wounds or burns ; it is rapidly progressive. Epilation also starts in the third week. Most deaths occur in the fifth to seventh week ; some occur much later. A lymphopamia is the earliest blood change and is detectable twenty-four hours after exposure. Leucopmnia is later--it starts towards the end of the first week, and is marked ; if the count falls below i,ooo the result is always fatal ; if it stands consistently above 2#o0, the casualty is likely to survive. Some promising lines in therapy are being developed; but these are still experimental. They include prophylaxis by preliminary bleeding, phenylhydrazine, preliminary X-ray, desoxycorticosterone. In practice, treatment is by repeated fresh blood transfusions and prolonged antibiotics, combined with careful nursing, oral hygiene, and a high protein, high vitamin diet. 4. MEDICAL PLANS FOR A-BOMB WARFARE Plans for the treatment of mass casualties, whether in set battles or in bombarded cities, present, in addition to the question of choice of treatment, four main problems :-- I. Problems of evacuation, and triage. 2. Problems of accommodation. 3. Problems of supply. 4. Problems of personnel. I. Problems of Evaeuation.--The great majority of surviving A-bomb casualties (? up to 2oo,ooo per bomb) will have minor injuries. Most of these cases will have to be treated locally, without evacuation, and by non-medical personnel without close medical supervision. The overwhelming numbers make sorting the main early problem. In this, sorting ionising chambers, personal and at fixed points, will help to separate those casualties who have had a fatal dose of radiation from those for whom scarce supplies of blood can be given with hope of effect. Note that air travel is apparently tolerated well by patients with ionising radiation illness. 2. Problems of Accommodation. "Viable nuclei" of mobile stations such as Colebrook's Mobile Air-conditioned Dressing Stations, and Burns Centres --based on teaching and large hospital units--should be started now. These mobile dressing stations sent into affected areas could be expected to have a most valuable effect on morale, as well: as providing a practicable answer to the problem of mass dressings when many hospital units are out of action. 3. Problems of Supply.--The need is for simplicity and standardisation of treatments, especially for minor lacerations and for burns. This implies standardisation of dressings, particularly standardisation of burns dressings, e.g., by issue of nylon envelopes in standard sizes, the mass manufacture of materials such as nylon and detergents, and the dispersal of these essential stores in "medical dumps " throughout the country.

6 CARE OF A-BOMB CASUALTIES I93 4. Problems of Personnel.--I am confining myself to the training problem which comprises :-- (a) Training (with registration) of more civilians in the full treatment of minor injuries. (As plastic surgeons we have a special responsibility in directing and encouraging further training, and can profitably work now through such existing organisations as the St John Ambulance Association.) (b) More intensive training of all medical personnel in the primary treatment of severe burns. (c) More intensive training of general surgical trainees in the later treatments of burns, especially in the grafting of severe deep burns, plus diffusion of a wider knowledge of plastic techniques to general surgeons as a whole. CONCLUSION With a problem of such gravity it is easy to be carried away by the obvious and overwhelming need of employing to the very best advantage the scant available medical resources--at whatever cost. I am thinking particularly of proposals for vast capital expenditure (as for the provision of deep shelters), and of.radical proposals for unifying the administration of doctors. But it is also extremely necessary that we should ask ourselves very carefully what effect the changes we may make will have on the other national interests involved in this matter. I think we should remember that it is not only in nuclear physics that considerable advancements have been made in the last decade. Advancements in genocide and in mass transfers of populations make it reasonable to ask what the fate of the survivors in these islands will be if any future war is lost. We may well wonder for what are these extra lives being saved if they are bought at a cost to our capacity to defend ourselves. It is clear that A-bomb casualties are likely to be pre-eminently a civilian problem, in that civilians will provide by far the greatest number of casualties. Nevertheless, the allocation of our limited resources has to be most carefully considered and cannot be made simply on the basis of what is medically desirable. All our national capital and all our energies would not purchase either complete security or perfect medical plans. It is, however, clear that there is a great amount of a direct nature which can be done in preparation for such disasters, and which does not involve great capital expenditure. There are a number of quite simple steps to be undertaken first which would be certain to have an effect in reducing casualties, and in ensuring both that those that do occur have the best possible treatment, and that civilian morale and confidence in the medical profession is maintained when and if this country comes under A-bomb bombardment.