Book Review

Effects of A-Bomb Radiation on the Human Body

N Engl J Med 1995; 333:1787-1788December 28, 1995

Article

Effects of A-Bomb Radiation on the Human Body
Edited by the Hiroshima International Council for Medical Care of the Radiation-Exposed, with Itsuzo Shigematsu, Chikako Ito, nanao Kamada, Mitoshi Akiyama, and Hideo Sasaki. 419 pp. Langhorne, Pa., Harwood Academic, 1995. $50. ISBN: 3-7186-5418-0

Ten years after the Nobel peace prize was awarded to physicians for efforts to prevent nuclear war, and 50 years after the atomic bombs were dropped on Hiroshima and Nagasaki, the Nobel Committee has again honored activists working against the bomb by naming physicist Joseph Rotblat and the Pugwash Conferences as recipients of the peace prize for 1995, emphasizing the continuing risks posed by nuclear arms. Yet the risks associated with atomic weapons have changed. From the charged political atmosphere of the Reagan–Gorbachev years, the world has entered a less dangerous but oddly unsettled time, characterized by the smaller scale but greater passion of its conflicts.

Gone from medical literature about nuclear war, then, are its speculative tone and political prescriptions. Effects of A-Bomb Radiation on the Human Body is a textbook derived from the experiences and research of physicians caring for those affected by the atomic bombs in Hiroshima and Nagasaki. Its tone is dispassionate and objective, and its focus is strictly on a disease model of effects from the bombings, rather than on a sociopolitical–medical model.

Of persons within 5 km of the hypocenter in Hiroshima, about 47 percent were dead within four months after the bombing; 89 percent of these fatalities occurred within the first two weeks. Most of the victims (60 percent) died of burns, and another 20 percent died of acute blast-related trauma. Twenty percent of early deaths are attributable to radiation effects.

Taken as a whole, these early bomb effects, which affected nearly half the people exposed to the atomic bomb, receive attention in only a small proportion of this textbook; nearly the entire book is devoted to the “late” effects of the atomic attacks. Since the nature of illnesses occurring in late survivors of the bombings is not fundamentally different from those occurring in the general population, statistical tools are often required to demonstrate that an effect is due to atomic-bomb illness. This textbook devotes much attention to the issues involved in teasing out the bomb's effects from those of background diseases.

In only rare instances do atomic-bomb effects have unique manifestations in people; an example might be atomic-bomb cataracts, in that the location of lenticular opacity at the posterior pole is highly suggestive (though again not pathognomonic) of atomic-bomb disease. Instead, the general tool for identifying atomic-bomb effects is relative risk according to estimated radiation dose. by this measure, malignant diseases of the bone marrow, thyroid, stomach, lung, breast, and urinary tract have all been found to occur more often in survivors of exposure to atomic-bomb radiation than in non-exposed controls. For additional sites, such as the uterus, lymph nodes, ovary, and gallbladder, a trend favors an increased relative risk.

The dose-related late occurrence of hyperparathyroidism in survivors of exposure to atomic-bomb radiation is associated with approximately the same distribution of histologic findings as naturally occurring hyperparathyroidism, with no proved increase in carcinoma or adenoma.

In addition to estimated dose of radiation, other factors influencing the effects of atomic-bomb radiation on the human body are age and sex. Women have had somewhat more overall neoplastic disease as a result of the bombings than men. Those who were children at the time of the bombings were found to be at increased relative risk for leukemia; in older survivors, leukemia was less likely to develop and had a longer latency period than in the young. Those who were exposed in utero were born with dose-related mental retardation and microcephaly. Chromosomal aberrations and somatic-cell mutations have been documented in those who were exposed to radiation in the bombings, although health effects from these disorders have been more difficult to demonstrate. Demonstrable heritable effects have not developed in children born to the radiation-exposed generation, although the study of ensuing generations continues.

Thus, it might be argued that the atomic bombings left a disproportionate legacy of late effects in the affected women and children as opposed to the combatants; this book does not make this case and in fact casts no direct judgment whatsoever on the current revisionist controversies about the appropriateness of the United States' “first use” of nuclear weapons in World War II.

This entire book is cool and objective to a fault. A page devoted to quoting Robert Jay Lifton on the psychological effects of the bombing stands out like a blossom in the desert, with its evocative prose a stark contrast to the gritty treatise in which it is planted. Likewise there is a sense that only the most conservative interpretation of the data is represented. Extrapolation to the potential effects of more modern (and many times larger) weapons is left to other writers. This book is explicitly about radiation effects and is committed to enlarging the understanding of those involved in caring for people exposed to radiation.

Nuclear war in the 1980s carried the risk of generalized holocaust, with potential global results different in kind from those of isolated atomic bombings. Perhaps this risk has receded with the dissolution of the Soviet Union; if so, the need for vigilance about the risks of atomic weapons has only become more important and harder to maintain. The world confronts the issues of aging nuclear arsenals as well as the multinational proliferation of warheads and the means and will to deliver them. Ironically, some of these issues were easier to deal with when the two superpowers were locked in struggle.

These large questions demand large answers. There must have been a strong temptation for authors of this textbook to draw lessons for the future and provide great prescriptions for humanity, if only in a foreword or epilogue. In the end, however, the editors, all Japanese involved in the treatment of atomic-bomb survivors in Hiroshima, can only be praised for their exacting discipline in keeping to a strictly objective purpose. If large answers are built from many small answers, this book is a powerful if quiet contribution. It should be in every medical library.

John W. Fowler, Jr., M.D.
University of Tennessee, Memphis, TN 38103