Radiation Burns Due to Atomic Explosions

JOHN J. MORTON, M.D.

From the Department of Surgery, Division of Cancer Research,
University of Rochester Medical Center,
Rochester, New York

WHENEVER an atomic explosion occurs,

either in the field or in the laboratory,
burns of diverse types may result. In the
atomic bomb disasters at Hiroshima and
Nagasaki, injuries were due to a combination of intense mechanical energy (blast),
to instantaneous intense heat (flash), and
to ionizing radiation. People within the
2,000 meter zone were exposed to all three,
and in addition, also to trauma from flying
objects and to ordinary flame burns from
the fires which swept through the cities.
Most of the people on the periphery of this
zone and some few in the zone who were
adequately shielded, escaped the ionizing
radiation. In effect, therefore, in these cities
there were people who suffered burns, some
complicated by ionizing radiation and others
not so complicated. There were no radiation burns in the Hiroshima and Nagasaki
populations.
The acute flash burns have been well
documented by the Japanese physicians at
the time of the atomic explosions.", 19, 22
Studies of acute flash bums have been undertaken in laboratories by American workers, Pearse, Payne and Hogg.16 Field studies
with animals were also done in subsequent
atomic tests in the South Pacific, Pearse and

Kingsley."?

By the time the Atomic Bomb Casualty

Commission had been established, the acute
phase of the burns had passed. The burns
studied by the ABCC consisted of partially
healed or healed areas. Striking features
* Presented before the American Surgical Association, Chicago, Illinois, May 8-10, 1957.

314

were contractures as noted in any

series where skilled care cannot be

burn

given

for various reasons, and the keliodal appearance of the scars in large numbers of
the victims. Within the four to five years
following (Wells and Tsukifuji),23 the appearance of these scars was greatly improved. Much of this improvement was due
to the fact that foreign bodies such as
wood, pebbles or metal blown in at the
time of explosion, had been extruded or
removed by surgical methods. It was noted
that the burns complicated by ionizing
radiation in those who survived healed
more slowly, and were accompanied by infection more often than in those subjects
who suffered from burns alone. But healing
eventually occurred even in the radiated
group.
The atomic bombs were exploded in the
air above the cities of Hiroshima and Nagasaki. The ionizing radiations travelled a
considerable distance through a medium of
moist air before making contact with the
individuals who were exposed to their action. The radiation doses in the fully exposed Japanese were uniformly distributed
throughout their bodies. The radiation effects from such atomic bombs are delivered
in a very short period of time-98 per cent
of the gamma rays and neutrons by the end
of one minute, Dunham et al.5
In handling radioactive materials following one of the bomb tests at Eniwetok, four
men received severe radiation burns of the
hands with lesser amounts of total body
radiation. It was estimated that the total
body radiation did not exceed 15r of

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RADIATION BURNS DUE TO ATOMIC EXPLOSIONS

gamma rays in any of these individuals. But

the hands were subjected to from 3,000 to

16,000 roentgen equivalent physical (rep.)

dosages of radiation to the outer surface of
the skin. These beta rays are 99 per cent
absorbed in the outer 6 mm. of tissue and
the dosages below this depth were from
300 to 1,600 rep.
This type of radiation burn was essentially a localized beta burn quite severe for
a limited amount of tissue. The generalized
total body radiation was slight and as such
had little bearing on the progress of these
local injuries, Knowlton et al.9
Two nuclear accidents which occurred
at the Los Alamos Scientific laboratory exposed ten persons to bursts of penetrating
ionizing radiations. Two of these individuals died from the radiation effects. The
others received varying dosages of radiation so that differing types of reaction were
noted. One survivor showed the typical
acute radiation syndrome. Four others manifested hematologic damage, Hempelmann
et al.8

The radiations in these patients were

chiefly fast neutrons and hard gamma rays.
The neutrons were absorbed in the few
inches of tissue near the experimental reactors. In the fatally injured persons a very
heavy dose of radiation was received in
the hands and over the abdomen. This
was decidedly more than the general radiation received by the rest of the body. There
was no uniform general irradiation of the
bodies of those exposed in these accidents.
The radiations travelled only a short
distance through shielding materials. This
short distance increased the effective action
of these ionizing radiations.
These examples of radiation burns received in the field and in the laboratories
differed from the atomic bomb injuries produced in Hiroshima and Nagasaki. In the
latter, the radiation effects were total body
irradiation from a distant source. In the
former, there was severe local irradiation
damage with either negligible general ef-

315

fects, with moderate total body irradiation,

or with severe lethal total body irradiation.

The radiation source was close at hand and,

consequently, very damaging.

In the hydrogen bomb test at Bikini in
March 1954, another type of radiation burn
was encountered. This was due to the fallout of powdered coral dust which came
down through the explosion cloud bringing
radioactive fission products of the rare
earths with it. This dust was carried widely
by unexpected air currents. The fallout of
this radioactive dust exposed Americans,
Japanese and Marshallese to burns of the
uncovered surfaces of the body.
The writer was fortunate in being asked
to see the Japanese fishermen and after that
to survey the Americans and the Marshallese
at Kwajalein.
The Japanese were on a fishing vessel,
the Fukuryu Maru, at 1660 26' E., 110 52' N.
This was 70 miles E. of the Bikini Atoll
where the bomb test took place. The Japanese sailors saw the flash of the explosion.
Three hours later a fall of powdery material
like snow covered their fishing vessel. They
had some of their nets out at the time. They
remained in the area another five hours
until all their fishing equipment had been
retrieved. Then they headed for their home
port of Yaizu where they arrived two weeks
later.
After the Fukuryu Maru landed, the sailors were examined by Japanese physicians.
Two who appeared to be sicker than the
others were sent to Tokyo University Hospital for study. The remainder were hospitalized in Yaizu.
These sailors had washed off the dust
with a detergent as well as they could. But
for two weeks they had lived on a radioactive ship, breathing contaminated air and
eating some of the fish which were probably radioactive. Much white dust remained
in the cracks of the deck, on the pilot house,
in the life boats and in recesses about the
ship. Coils of rope, chains, all sorts of gear
usually found on such fishing craft trapped

Annals of
MORTON
316
dust which was radioactive. We collected and ulceration. Many had a very dark pigsome of this dust by use of a vacuum
mentation of the face, neck and backs of
cleaner on our second trip to Yaizu.
the hands. A few had scattered pigmentaWe saw two sailors in Tokyo University tion about the ears, eyelids, lower extremHospital 19 days after their exposure to the ities and abdomen. There was radioactivity
fallout. They had no complaints. Both sail- in the hair easily measured with a Geiger
ors had practically identical lesions. The
counter. The Japanese oil their hair and it
exposed areas of the face, neck and sldn was difficult to free it of the contaminating
of the distal forearms to the back of the dust. There was epilation in at least four
hands showed intense deep brownish pig- of these people, the hair coming away with
mentation and roughness with desquamathe slightest pull. These burns appeared to
tion in some places. Vesication was apparbe typical beta burns such as one sees after
ent on the hands. Eroded areas were presapplying a radium plaque.
ent on their left ears. There were several
We learned that about 50 per cent had
pigmented spots on the abdomen. The hair noted a burning, itching sensation on the
was dry and came out easily. Acute conneck, eyes, ears, nose, and occipital regions
junctivitis was present. The eroded surfaces
shortly after the fallout. The symptoms
on the ears gradually spread during the
noted were vomiting in one shortly after
next week, epilation continued and scabthe fallout; anorexia in two, on the third
bing appeared in areas of the scalp. The and fourth days later, with diarrhea two to
Japanese physicians reported that there three times in the same patients. Three
was a mild anemia and decrease of the
complained of general malaise, and three
platelets and of parenchymal cells in the complained of headache. Otherwise there
bone marrow.
was no evidence of a general intoxication.
We flew down to Yaizu to see the Jap- There was no fever, no purpura, no gastroanese fishermen and to inspect the Fukuryu
intestinal bleeding in any of the patients
Maru. It is not easy for Americans to ex- when we observed them.
amine patients on the floor. Our contact
The Japanese physicians told us that all
with the patients was very limited but we but two of the Yaizu patients had white
saw enough of the radiation burn effects to
blood counts ranging from 6,000 to 4,000
get an idea of their type and distribution.
cells. Two were in the normal range and
The distribution was on the uncovered two were below 4,000 cells.
areas of the body especially at creases
After all the patients were assembled in
where dust could settle: behind and inside Tokyo, several were reported to have white
the pinna; on the neck at the collar line; blood counts below 3,000 cells, and one had
under the eyes; in the conjunctivae (many less than 1,000 cells. Platelets were said to
had conjunctivitis); at the bend of the be low, and a relative lymphopenia was
wrists; on the backs of the hands, between present in all. There was some degree of
the fingers and under the finger nails; and anemia in several.
especially in the skin of the adductor area
The question which bothered the Japabetween the thumb and forefinger where nese physicians was how much internal
the net ropes were pulled. A few had radiation these patients had by inhalation,
burned areas around the nostrils, and one by ingestion through food, or by penetrahad bums at the belt line. Another had tion through the skin ulcerations. In order
burns on the torso where the shirt was to determine this, it was necessary to test
opened. The bums were superficial. They 24-hour samples of urine. We succeeded in
consisted of multiple patches of purple or getting a few samples of this kind and the
dark brown spots, some with vesication determinations were made in the New York
S
September 1957

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RADIATION BURNS DUE TO ATOMIC EXPLOSIONS

laboratories of the Atomic Energy Commission. These tests showed strontium 89, barium, and the rare earths, but not the
dreaded strontium 90. This element with its
long half life (25 years) and its deposition
in bone with low excretion leads to destruction of blood formation, to severe anemia,
to leukopenia, and probably, at long last, to
bone sarcoma.
Our studies of the Japanese were restricted and incomplete due to circumstances beyond our control. But on April
12, 1954, we were fortunate in being able
to observe the Americans and many of the
Marshallese on whom excellent studies had
been made by Cronkite and his associates.4
These victims of the fall-out differed
from the Japanese fishermen in that they
received treatment soon after their exposure. There were 267 individuals who were
exposed to estimated total gamma radiations in air from 14r to 175r. This gave a
series with differing gradations in response.
The 28 American service men were on
the atoll of Rongerik about 150 miles east
of Bikini. The fall-out of mist-like dust
came six and eight-tenths hours after the
explosion. It was estimated that they received 78 gamma radiation in air. These 23
white and five Negro Americans were
evacuated to Kwajalein by air or sea within
34 hours. They had realized the danger
from this dust, had remained inside aluminum buildings, had bathed and had put
on extra clothing. None of these patients
developed ulcerating lesions and they had
no gastro-intestinal symptoms. Itching and
burning of the skin was noted during the
first 24 hours by one or two individuals. No
erythema was apparent and the superficial
skin reactions appeared only in the third
week after exposure, a week later than in
the Marshallese on the Rongelap and the
Ailinginae atolls. Only 40 per cent of the
Americans developed very mild beta skin
lesions. The Negroes showed hyperpigmentation of the damaged skin, and this
was less marked, though present, in the

317

whites. There was no primary or secondary

erythema observed in any of the Americans.
The majority of the skin lesions consisted
in macules, papules or raised plaques with
dark brown or black pigmentation. There
was no vesicle formation and after drying
and desquamating, healing appeared to be
normal.
The Marshallese were on the atolls of
Rongelap, Ailinginae and Utirik at the time
of the bomb test. Ailinginae is only about
80 miles east of Bikini but it is a little south
and was on the edge of the fall-out. There
were 18 Marshallese there when the mistlike dust arrived six and eighth-tenths hours
after the explosion. It is estimated that they
received 69 gamma radiation in air.
The largest number, 157 Marshallese,
were on Utirik, which is approximately 310
miles east of Bikini. No fall-out was observed there though it occurred at 22 hours
after the explosion. It is estimated that they
received 14 gamma radiation in air. The
group of 64 Marshallese on Rongelap, 120
miles from the explosion, saw a heavy snowlike fall-out at four to six hours after the
explosion. This corresponded to the type of
fall-out on the Japanese fishing vessel. It is
estimated that these Marshallese received
about 175 gamma radiation in air. This corresponds with my estimate of less than 200
gamma for the Japanese-a guess on my
part from the time of development of symptoms after the explosion.
The Rongelap people were evacuated to
Kwajalein within 51 hours, the Ailinginae
within 58 hours, and the Utirik group from
55 to 78 hours.
Itching and burning of the skin occurred
in 28 per cent of the Rongelap group, in 20
per cent of the Ailinginae group, in 5 per
cent of the Americans and in none of the
Utirik people.
Neither the Americans nor the Marshallese on Utirik had gastro-intestinal symptoms. Only one of the Marshallese on Ailinginae was nauseated. But "two-thirds of the
Rongelap Marshallese were nauseated dur-

Annals of Sur
MORTON
318
Septembr 19S7
ing the first two days and one-tenth vomited
lowering of the total white blood count
and had diarrhea."
which persisted over the next five or six
The Rongelap people were the first to weeks. There was an early relative lymphodevelop skin lesions and epilation, 12 to 14 penia and a failure to return to normal for
days after the explosion. The Ailinginae months or even longer. The lymphocyte has
and Americans developed skin lesions one been shown to be a very sensitive cell to
week later than this. Skin reactions devel- radiation effects (Murphy, Morton) .12 13
oped in a large proportion of those exposed, Lymphocytes remained relatively constant
but ulcerations were much less frequent.
but neutrophils varied and fluctuated in
The skin lesions were spotty and oc- number during the whole period of study.
curred on exposed portions of the body.
The platelet counts appear to be reliable
Most of the lesions were superficial, pig- if done by the Brecher and Cronkite
mented macules, papules, or raised plaques, method.' 2 This is a delicate measure of
small at first but tending to coalesce. The the amount of radiation received. It is a
distribution was interesting in comparison sensitive indicator of damage to the hemato that in the Japanese. The most frequent
topoietic system. The maximum depression
locations were the scalp, neck, axillary re- of the platelets occurred during the fourth
gions, antecubital fossae, trunk, arms, legs
week after the bomb test (30 per cent of
and feet. Flexor surfaces were the sites control value). Purpura may be delayed
more frequently than extensor surfaces.
until this time of low platelet formation.
There were lesions in the anal region in Recovery started in the fifth to sixth week
several babies and in one woman. I saw one but a second lesser depression occurred
child with a burn which followed a drop of during the seventh and eighth week (70
perspiration which had trickled from his per cent of control value). Even at one
neck to the thoracic area of his back. Some year, the platelet counts had not reached
of the burns on the dorsum of the feet be- normal value.
came infected. When I examined some of
There is a definite relation between the
these patients, healing was occurring in the time elapsing between the exposure to raulcerated areas with new pink epithelium diation and the onset of symptoms. This
extending across the ulcers. Pigmentation was determined at the time of the atomic
was moving in from the periphery in some.
explosions at Hiroshima and Nagasaki. The
Others had patchy depigmented areas with most severe radiation resulted in death in
hyper-pigmentation at the periphery. Heal- 100 per cent, in from four to ten days.
ing was delayed but healing ultimately oc- Vomiting was noted on the day of bombing,
curred in all. Some showed mild atrophy of fever, diarrhea and leukopenia in two to
the skin over the deeper ulcerated healed seven days following. Purpura developed in
areas. The Marshallese and the Negroes
from four to seven days.
showed bluish-brown transverse pigmentaPeople with less severe exposure show
tion of the nails. This disappeared with nail symptoms somewhat later. If diarrhea, epilagrowth after six months. The whites did not tion, depressed white blood counts and
show this, and I did not see it in any of the anemia are noted during the first week after
Japanese.
exposure; and fever, purpura and epilation
Changes in the white blood picture during the second week, death will occur
showed in the first two days an initial rise within six weeks in 50 per cent. If depressed
in the total white blood count due to neuwhite blood counts and anemia are noted
trophil increase. This has been noted as the within the first two weeks; and mucous
characteristic first response as long ago as membrane ulceration, epilation, purpura,
Heinecke's studies.7 This was followed by a diarrhea, malaise and weight loss after two

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Number 3

RADIATION BURNS DUE TO ATOMIC EXPLOSIONS

319

TABLE I

0 sickness
50r .................
100 r .................
2% sickness
150 r .................
25% sickness
200 r ................. 50% sickness
300 r ................. 100% sickness
450 r ................. 100% sickness
650 r ................. 100% sickness

weeks, death may occur up to 90 days in a

small proportion.
There is a rule of thumb for estimation
of radiation hazards which is valuable in
the field when no precision instruments are
available. The "2-4-6" rule estimates that
50 per cent of the personnel will be sick
with no deaths if exposed to 200r; 100 per
cent of the personnel will be sick with 50
per cent of deaths if exposed to 400r; and
600r will cause all the personnel to be sick
and the mortality will be 100 per cent with
a few possible exceptions."
Tables have been constructed for acute
dosage of r units with probable effects on
personnel.' (Table I.)
In any atomic explosion there are two types
of radiation which must be kept in mind.
One is the penetrating radiation of gamma
rays and neutrons producing internal body
radiation of mild or severe grade depending on amount, distance, shielding and
other factors. The other is the local radiation of exposed surface areas from beta and
soft gamma rays modified according to the
factors enumerated.
The tissues most sensitive to radiation are
the hematopoetic system, the sex cells, and
the gastro-intestinal tract. It has long been
known that following x-ray treatment there
will be a lowering in the white blood cells,
lymphocytes especially. Continued exposure results in depression of the whole
blood forming apparatus. Unless there is
shielding of the gastro-intestinal tract and
the sex organs, damage will be done by
relatively small exposures to radiation.
In total body radiation of severe degree,

0 deaths
0 deaths
0 deaths
0 deaths
25% deaths
50% deaths
100% deaths

no sign sickness
n. and v. in 2% 1st
n. and v. in 25% 1st

day
day

n. and v. in 50% 1st day

n. and v. in all 1st day
n.
n.

and v. in all 1st day

and v. in all within 4 hrs.

cell injury and cell death are noted in the

irradiated superficial tissues; this is even
more apparent in the radiosensitive organs.
The depression of the blood cells removes
one of the principal lines of defense against
bacterial invasion. The damage to the gastro-intestinal epithelium opens an avenue
for this invasion. The failure of coagulation
of the blood enhances the spread of the
bacterial invaders.
The physician attending the victims of
such an explosion must remember that
there is a latent period when the patient
appears much better than he really is. The
radiation effects are insidious, coming on
only after a period.
The acute radiation syndrome is produced by penetrating radiations which
cause damage to radiosensitive tissues
throughout the body. It is a toxic response
with a delayed appearance as the effects
may not be manifest until the damaged
cells attempt to repair. This is a variable
factor depending on the rate of turnover
of the different types of tissue.
All types of radiation burns have a similarity in their evolution and progression.
The factors which have been long recognized in radiation therapy operate to the
same degree in these injuries. Such factors
depend on the radiation power, time, distance, medium, filters, and surface exposure.
There are phases in radiation burns which
characterize the acute radiation response.
Within the first 48 hours, if the exposure
has been severe, an erythema, edema, and
blanching may develop. This sometimes
gives symptoms of tingling, burning, itchi-

320

320

M
ORTON

ness and stiffness. During the next three to

five days no further developments may be
noted. But by the sixth to eighth day, a
secondary erythema with extravasation of
blood into the burned areas may take place.
During the next two weeks there will be an
increase in erythema, and vesicles may form
and coalesce.
At the end of two to three weeks the
process becomes quiescent, and if the blood
supply has not been damaged too much,
epithelium grows over the areas which have
desquamated. If the blood supply has been
seriously damaged healing does not occur.
A chronic ulceration results. Surgical intervention with excision of the ulcerated areas
and skin grafting may help in repairing
these areas. The healing without grafting
is prolonged and when it does occur the
epidermis is atrophic without hair or
sebaceous glands.
Beta burns from radioactive dust can be
prevented by taking cover, by early repeated bathing, and by change of clothing.
The hair should be shaved off if it retains
any of the material. If such early attention
is possible there is little danger of serious
injury from the dust.
The amount of gamma exposure constitutes the hazard in these explosions.
Treatment must be directed at prevention of infection in the burned areas. This
is not essentially different than that for any
burn. When the blood count gets dangerously low transfusion is indicated. The use
of antibiotics may be helpful in preventing
septicaemia after the resistance to infection
has been lowered. The Japanese asked for
aureomycin for some of their fishermen and
we supplied it. The Americans and Marshallese did not require any antibiotics.
Years later, secondary ulceration may
take place due to impaired sclerosed arterial
supply. The familiar secondary late effects
of radiation injury are well known-atrophy,
hyperkeratosis, teleangiectasis, and in some
cases malignant degeneration.
Late general effects of atomic radiation

Annals Surgery
MOTNSeptember
1957
of

have been studied in the Japanese survivors

of the Hiroshima and Nagasald explosions.
Neil and Schull 15 in an exceedingly thorough study of the genetic effects of these
bombings were unable to demonstrate "any
conspicuous genetic effects."
Microcephaly was noted in intra-uterine
exposed fetuses by Plummer."' A slight retardation in growth and development of
children born to exposed parents was demonstrated. It lasted for about four years and
then no differences could be shown as the
children caught up in growth and weight
with the control group.10 Slight hypoplasia
of the enamel in the teeth of the exposed
children was observed.2' There was a definite increase in leukemia coming five to
six years after exposure and after that subsiding to the normal ratio (Moloney )."
Evidence of increased lenticular defects
called "radiation cataracts" was noted.20
Perhaps there was a slight difference in
capillaries in the nail beds of exposed people, an old observation in x-ray treatments.
There has been no increase in cancer ratio
as yet. Complaints of weakness, dizziness,
chronic anemia are frequent but all are
difficult to evaluate. Many complaints are
probably due to organic disease and not
related to radiation. Others are psychosomatic in all probability.
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Cronlite: The Reproducibility and Constancy

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159: 430, 1955.
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