Thermal Effects of Incendiary Weapons on the Human Body

8/7/2019 Thermal Effects of Incendiary Weapons on the Human Body

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Chapter .3. Thermal. 'effects 'O f incendiaryweapons on the human. body

I. lntrod'uctio.I'l'A vital ceasideration i.nargiUments about miHtary necessity versus humani-tarian prioriries is the medical aspect of the use of incendia_ry'weapons . .Such q,uestiDns as the nature .o f the casualty ,eiIeds, the prDblems, ofmedical treatment, .he prospects for tlileurviving casuahies, and l.helikeli-hood and the time of death are all relevant to any asse sment of the8ft10UrUo .f suffering cau ed tnvictim of incendiary attack .. From the view-point . of th.eintemaeional laws of war, this amount ,o f _uffering has some-how to be weighed against the "military necessity" of the use of incendi, ary weapons, for it is presumaely only in this way that it may be deter-miaed whether allera part oethis suffering i ,"unnecessary" ..The traumatic effect , . o f mot weapon is topeneeate the sldn and!dam-age internal organs. Although the acsion .o f flame weapoa .is essentially to

damage only the skin, fire may cause death ina number of w.ays so thatthe exact cause may be difficullt to determine in a given case. In gcnera] ,death by firemay be due to' thefoUowingcau e: (a) hearseoke, causedby the transfer .o f heat to the body suffici.ent to increase the body tempera-ture above a critical level ( ap p rQ ) :: im a l~ e ly 4 lOC ) , ( b )p u lmDn a ry damagedue to inhalation of make aad toxic fumes. (c) carbon monoxj~t.epoisoning, (d) depriva.ti.on .o f 0. ygen, and (e) seventy of the bum woundin terms ofdep,th and the extent of the body sutface area affeceed,The likielibood of death from bum wounds i aI!soaffected by .uch fac-tors as the age, the general heahh and the nutritional. status o .f the victim.a n d . t h e p o te li l. ti al r is k ofin fection. . ._ ,Heaestroke may bean important cau e of immediate death from fire,

bU I it j . noE,a,ignmcant cause oflater death. The same applies to earbonmonoxide poisoning and thedeprivaticn of oxygen, since these reactionsare abo reversible (a:I[hough some 10llg~itennil\iury may result: see Chap-ter 4). Major factors related to the death rate from bums. after initialurvival, are the degree of pul1monary injury and the extent of the bodysurface area involved. The age of tile patient and his general health. andn.utritional status are additional factor which may wnfluence the progne-SI . One analy is of the complications causing Oil' contribuHng to deathdue to buras is shown in 'table 3. L. Where [oxic and respiratory complication ar e not present, the mortalityfrom bum in mdlvidualsof giv,en age and general health depends pri-1 2 2

I1 819

:Baeunall cnm pU catW n 'Septicaemia'Bronch.opneumonia,PyelonephriliMeninpji t i .sPe r i ton i lis: E n te r o. c ol i ll S0.3'5 gang!iem~Ex .l ra - re n a l a b sc e ss ,t :o U l b ac te ri la l c om p Uc aU o ru ,

Num,berojcaSi!$Tlllble 3.1. Complicat ions rrom bUI 'n1.ng wbl.ch eaused or eontributed 1.0deaib

Number ,a/coses

Non,bKte:r i l1 . o m p U ( . a . t i o n s ,E arl.y ho ck n nd /o rc ardia c fa ilu reEar lyl lyperkalaemla, ther hockSubtotid

Res p i r at oF l I c .omp :1 i. ca l ionsa r be n ' Il lO I 1 .o x id eInhal'ation of smokeGlouicbumsOb s tr u ct iv e t ra c he o b ro n c hi li sBlast injury to l un gCongestive ateleeta iNlmonary,oedemaI nh al ati on o f vomitubtotal

A.cute cardiac complic3.l ionT,oxic myocanlilisCardiac arrest

SubtotalR e n al f a il u reHypokalaem!EIPUtmana.! ' ) , ,emboli IIIHepatlc jaundice .Acu te d il a .t a ~i o n ofllH~ tomatoParaly tic ileu , . .Agranulocytosis lind thrombocytopemBHaemorrhage from acute du denal ulcerAnoxic eerebra l -of tening

Subtotal

1.342IIII22l S

4524

'*523IIII42 To ta l o o n b a c te r U II

eompUc.adOIt! ! ,T,omlall ase5

Source: S ev in ( 19 66 ).

m arily U pO D.the depth and extent of the bum. because of the physiologicalimportance of the skin as a.vi~,al ,.organof the bod. y . This is true whetherdeath results from iinadequat'ely treated shock in the early t.ages of burncare, ubsequem infections or other less frequent causes of dea1thsuch IIIbum-induoed gastric ulceration. Except for etectricld bums"ch~~cteriZl~dby the deep destruction of oru des and other l~Sue. but .~th t im 1 te d . ' .kindamage the causative a.gent is lea "important Inde1ier:nurungtheoudookfor a bum patient. .. . . . ." ..... . .For the e reasons. the m~jor thermal effects ofmcendlary weapons ~nthe human body to be described in this c.bap1ierrelate to bum of the S~1D,althougb reference is also made to the so-called "p~mona:ry burns" : whIchhave now been shown to be due more (,.0 theillhalauon of smoke, ~nd fU,~ethan to actual thermal bum of the lungs. The. ~oxic effects ofmcendlluy

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weapons are described in chapter 4 where further reference i made tolung irritant effects.It i somethnes useful to dist ingui h between pr.irna,ry bums, due to the

direct effect of an incendiary agent on the body I and econdary bum ,due to the ombu tion of clothe equipment. house, and oon.Primarybum ..caused by miliitaryincendiary agentsare :Iikelyto be e peciaUy severesince they are the r ul t of extensive technol gicaJ efforts to increa e boththe heat of combu tion and the burning time. Secondary burn resultingfrom incendiarie are in principle little different. from bum experiencedin civilian l ite, about which there is a voluminous medical literature. Enthi chapter, the general medical l iterature on bum j urveyed in ordert . convey orne indication of the complexity and severity cf the bumwound and the resulting demands n treatment. facilitie e Morepecificeffects of the use of incendiary weapon are al 0 described. The chapterconclude with a di cu in of orne additional factor which complicatemedical treatment-and therefore the prognc L for the patient-inwartime condition.

II. Pathological effects of bumsThe kin a a vital organThe ignificaace of the phy iological role of the kin i not. commonlyappreciated. The kin i not onlyan e ential part of the body, but it al 0ha can iderable p ychological significance to the individual. In both casethi is because the kin forms the ineerfaee between the individual andthe outside physical and social world.A living organi m may be de cribed as an 'open y tern" maintaining

it elf in a . dynamic equilibrium with it'. environment Th:i .e.quiUbrium..,known a homeo ta i ,Ii maintained by balancing man.y pre e. in-eluding the inge tion of food tuff and the excretion of waste productsthe inhalation of oxygen and theexhalarion of earbon dioxide, and theimbibing of water in order to com pen ate for the 10 f moi ture byevaporation or excretion.The skin playa. vital role in maintaining borneo ta i particularly in

controlling the temperature of the b dy and inlim:iting evaporati 0 fmoi ture from it. When fo d i metabolized in the body it pr du e heatenabling the body to maintain the normal temperature f about 37C.The kin . cts as an in ulating layer. actively controlling the 10 of heat[0 the urrounding air, and thereby diminishing the f od intake neededimply to provide the body' "central heating".

I H m('O$1(I.I";.I': he maintenance of 8 . LIe of equil ibr ium within the body with re 'peel10temperature. heart rate, blood pre ure, water content. blood ugar level, and 0 on.12 4

Preventing water from evaporating from the body i important for threemain rea ons, ir t, evaporation ha a cooling effect. Without control bytile kin the heat Io . due to evap ration placesexce ive demand onthe body capacity to generate heat by rnetaboli rn. Second, water je sential f r the tran port f ub ranees in the body. If water i lost byevaporation, the body fluid become more concentrated, and in an eff rtto res tore the balance, water pase out of the cell into the fluid ur-rounding them, and may be lo-t from the b dy by further evaporation.The cells can only tolerate a minor water 1.0 before they die. Third. theeffectof the 10 of water whether due to the 10 of circulating bloodfrom damaged blood ve el or by evaporation from open wound I i todecreae the flow of fluid through major organs uch as the brain, heartand kidneys, threatening thee major body systems with injury or death.Further. the skin i a major means of contact with the environment,

containi.ng nerve ending which provide the brain with a continual feed-back of in~ormation about pain., temperature, ~oucb and pressure throughproprioceptive en ors. If the skin i removed. the e en or are removedwith it depriving the brain of much of the information nece ary foradaptive behaviour.Although much f the kin i u ually clothed for ocial and practicalreason, it has great p ychologica1 importan for the individual incebeing the outside of the body. the. kin i mo t


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effective in mediating the pain sensatien have III thre hold of approxi~ma.lely 43~:C.In a. major series of experiment Moritz and hi colleagues {Henriques

& Mori lz .1947;. Moritz ,& Henrique 1947; Mori tz" 1947)-how.ed thatthelower temperature limit for a cutaneous bum due to hot water i .approxj-ma'ely44C.At 44"Cit !iook about three hOUfS to raise [he temperature of the un -dedyin8 skin at.the dermis-fat interface to 44"C. damaging the full thickne sorthe skin. Ala temperature of 55"C, it took only 0..4:minutes to createtheSame effect At lOO"Cit wok only some O.leconds to de troy the epider-mis, bur in that short time there was 110 significant temperature increase atthe dermis-fat interface, That is. thephy iologica:ichanges ln the kin dueto bums depended UPOO! both the tempemtuflea:nd the time of contact withthe buming agent; tbe hotter the agent, the ' horter the contact thue re,quiredto deslroy the tissue.It w ili ll b eo bv io us f ro m the de se rip tio n o f the func tion s of the _ kin th atthe severity of a cutaneous bum wound depends not only upon the depth

of the bum but al 0 upon tile extent of the body mrface are.a.af~fected, which determines the 1 .0 .o f fluid and heatand therefore the irn-pact on the majorphyiologicaJ. ystem of the body.The depth of burns (degree)Bums w hic h o nl!y il\iure the epidermis, such as mild unburn, are knownas first degree burns (see figure 1.1:). T he y :r es ulit in temporaryerythema( re ; dn e s ) , due to dil:alion of tll.e capillaries, and oedema ( wening).Theyusually heal within a few days after sloughing off the epidermis, and leaveno scar.Buras which extend in to the living lay,er ,o f the skin. the dermis. ar e

much more serious ..I t is common to distinguish between second degree.or_partial thicknes , bum, and 1 I / 1 ' r d degree, or full thickness. burns,Second degree bums denote those in which necrosi 2 extend into thedermis, but with the urvival D f a su :f f ic i :en t ounda t i. o n of such skin ap-pendagesas sweat glands and hairf ioUicies toensure that the skin regener-ales without having to heal from the edges of the, wounds. There is a widevar.iati:onlll.tbe severity of these bums. Some. such as severe sunburn withblistering., wt U heal within a week or two and leave no scars; others wil l healwithin a.month with reasonable care: and stilil.others will no~heal sponcane-ously unless specific treatment is ginn to prevent the destruction of surviv-i.ng ,epithelial" cell of the skin by secondary infection and to encouragethese cells to grow. Third degree or filii. thiekne .bums are those ilD whicha1Jtbe dermis is,destroyed.I Necrosis: ['he death o f one or more cell Of a. :ponioll of a tissue or organ.3 .E;pil ludirm!: A thin laye r of tlis ue without blood ve sel which coversaUi the freesurfaces of the bod.y, including eyes, glands, respiratory passages, and so on.1 : 2 6

Figur,e'3.1 Scbemat:ic outline of (;-Itoss-sedtonof tbe Idn sbowing d:egrees of bum"

'Fi~61:de:greebum

Second degree'bum

Third degr,e9burn . . . . i f i I i I I i . . _ - Su lbcu tl lneou 'f !!t tissue

fol lldle ,glandl capillariese n d I n g

irst degree, ofuperficia'i buras, invo'iveonly the epidermisand heal I~apidly. Seconddegree bum darnagetbe uppe r part of the ' de rmis but ilei , ef living dermattissue remainand proliferate to cover 'the area it! :aboUll4 days. Third degree, d'eep.er fIJU!hick:lles ,bumse tend through the d rmis and may extend to underlying [i ues, Some authors refer 10'bumw hic h exten d in to underlying tis ue a four th andfif ih degree bum . In general, UJirddegree burns greater {han 1-2 cml in area I"!!Q,uirekintran plantation in ordu to,heal.

In addition there may be destruction of the underlying fat. muscle. boneand other tissues. The terms fourth an d fifth, degree burns are some-times used to describe sucll inj,uri.es.,althollgn in general this nomenclatureis no longer favoured in the interna:tiona:llitera.tllJre, as speclfi.c deeper in -jlllri.esof'this sod ar e beUer recorded a uch.The depth of the bum is easily misjudged and depends upon the cause,the temperature, the length of e.xpo urevand tbethickness, .of the sk~n(the, soles of the feet, the paIDm- of the hands, a:nd the back being thickerthan elsewhere). Intense heat over 3.short period may produce a bumwhich looks very m uch dike one produced by less beat over a longerperiod, although the I laU .er may de troy more of the underlying dermalelements, Both first and _uperfJdaI second degree bums blanche on pres-Uire with an ins~nllrteJil tueh as a sterne m:i.croscope .l ide; the colour re-turns when t:he pressure is released. Third degree bums do not blancheorflush 0 1 1 1 pressure or release. The persistence ,of sensation, which iseasily tested with a.st,erite needle, is often helpful in differentiating .econdand thiird degree bum , although th.i test is no t completely reliable, De-structjon of the fuUskinthickness kiUthe nerve endings,result ing in lossoffeeling (Pbillip- & Con table, undated], Bvenexperts 1IDli)' have difficlLdty

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in estimating bum depth. and ubequent epsis" may invalidate initiallycorrect judgemen by converting a econd degree bum to a full thicknesi.nJury. Thi is pa:nicl!. li Iaily l ikely to happen ill1,malrteuri hed anaemic pa-tients. who al 0 commonty have no ace to adequate medical facilitie .Deep econd degree bum- often heal with evere earring.Deep bum, heal only after the dead tis ue i removed eil ther by un-

as it ed or na tural eparation, which usually inv lve bacterial infectien,or by repea ted dre ing (debridement) or surgical exci ion. The 'clean'bum: wound may then heal by epithelial ingrowth from the edge, if it iIe s than m-2cm z in area, by theeffecti.ve urgical closure of smallwounds, or by the application of kin graft from other parts of the b dy.The cropping of kin gr.aft leave painful donor ites, comparable to

econd degree bums, which u uaUy heal in about two week with no morethan minimal scarring. nder Ie tban optimal c ndition , however.ep i may intervene and the e donor ites, in turn, become area of fullthickaes or third degree skin 10 '. Thi may account for the reluctanceof surgeon to apply ki n gr (1 to bums which o therwi e appear to neces -itate them when patient are in poor condition an d medical facilities ar eminimal. At present, permanent skin graft can only be taken (mm therecipient him el f, identical twin excepted.

econd degree burn are characteri itically extremely painful until theyare esentially healed. Third degree burns, becau e of the de tructi:on of thenerve ending in (he dermi are characteristically not trikingly painful:during the fI T t few day after the injury. With progre ive healing andremoval of the in en itive overlayer of dead ti ue, the wound becomem re and more en iuve until covered with graft or by the: ingrowth ofepithelium. Daily changes of dre ing are e cruciat ingly painful . equiva-lent to tearing off the outer, insen Hive layer of the skin from the inner. en itive layer.Tbe extent of burnsThe second factor determining t:he everity of bum i the extent of theb dy surface area involved, which i igniflcant for everal rea on. Thegreater the area f kin de troyed, the greater the Jo of moi ture andheat by evaporation, whichare major factor in the pathophysiology of thebum. injury. Second, the greater the area involved, the greater the problemof coping with infection. Third, the greater the area of skin de troyed,the les kini available for grafting-a procedure which i_ all the morenece sary, As a re ult of the e and other fact there i .a direct relat ion-hip between the extent of a bum f a given depth and the chane f ur- Sepsis: The local ized or uperf ic ia l presence of var iou pu forming l ind other pathogenicorganisms Of their to ins wh ich kill the Ii ues, The presence f mi ro rgani ms or theirto in in Lhe ireulating b lood may give ri e [0 y temic discs e, a condition known IIsepticaemia.1 28

Figure 3.2 The rille of nin .. as a method ro r estimating the approximateextent. ofbums In an adult

9% 9%

ource: After Berko (1924).vival. A convenient mean of estimating the extent of body area burnedwas introduced by Barkow in 19'24 and i often presenteda . the "rule ofnine" (figure 3.2. The face, r an arm make up approximately 9 percent of the total body urface area whereas a. leg, the front (che tandabdomen together) or the back each make up about 18 per cent. a mul-tiple of 9. The prop rtion are only approximate and are omewhat differ-ent for a child. under five years of age (see table 3.2 . The palm of the handand finger make upab ut WpCI" cent of the bedy serfacearea, 0 tha t theextent of the burn may b measured approximately by the number of"hands" required to cover it.Tbe severi ty and mortal ity of burnsA a rough guide, third degree burns of Ie than 5 per cent of the bodysurface area may be regarded as, tight. wbHe those of more than. 1 .0 percent or first and second degree bums of more than 30 per cent, areregarded as severe. In addition. any t r u r o degree burns affecting the face,band ,5 feet andgenitelia we clas i fied as evere, a well as circumferentialIi Bum of tb.e h and account for . apprQximalely one-thi rd and bum of the face for approx-imately one-quarter of all burn (Tubiane, Sa lIX & Kenesi, 1967; Coover e, '1967;Kovanc.Aaby. Hamil & Hardway, 1969). See table 3.10.

1 299-743168


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Table 3.2. Methods of ca]nJating approximate extent of bums over bod ~ul' facePercent

Surface a rea formulae

r ea . o f b od ysurface .Adult o r ch iIdover 5 yrs.oiage Rule of ninehild under5 yr Drage

Headnte rior trunkP tenor trunkBolh upp er armsBoth forearmBoth handsBolh [highs.inc! buttocksBoth legB O lh f ee l

618207. S 16.0 184.5

/9Il.O} /96.0

15/209II ]=18

1/ .2=/81/ eac.h=18

I I e a ch=?1/ each=l8

vi/Tee: Ph il li ps l ind uns ta bl e [undn tc d) .

deep burn of the limb which affect the circulation to the e trermtieArturson (1966} add to the cat,egory of evere burn those whieh are com-plicated in the fol lowing way: (a) oft ti ue wound and keletal damage;(b) complication of the respiratory pas age; (c) electrical bum ;.(d), imul-ta.neou radiation injury, and (e) burn wound due to white phosphorus,mu tard gas,or other chelni.cal .First degree burn have no ignificant mortality. Superficial second d -

gree bum. , however extensive, are rarely fa tall if orne medical careucha that sufficient to maintain an adequate fluid intake in a hot climate,i.avai lable, Thepercent ..age of deep second degree and third degree burnin a given individual can be combined for practical purpo e in e timatingprobabl:e mortallity, although the mortality from the third degree bumwill generally be greater. With adequate treatment, deep econd andthird degree bum. of les than IS per cent are unlikely to cau e death.whereas bum of over 50 per cent often do cf. Bull & Squire, (949). Wi thideal treatment young adult with burn of up to 85 per cent of the bodyincluding 70 per cent ful l thickne burn, havesurvived (Birke, Uljedah1 &Nylen. 1970).tn general, there is a tati tical relationship between the extent of the

bum and the mortality. which i sh wn in figure 3.3. The igmoid relati n-ship has been not d by a number of author .uch a Clark on & Lawrie(1946). It implie that even for relatively mild bum (e.g, 5-15 percentin adult. aged 15-44 year ) a few individual . Ie s able to withstand thephy iol gical tre e r ulting from burning will die. A imilar rei ti n-hip bas been noted in the case of some other biological phenomena,uch a the relation hip between mortality and the do e of t xi drug(cf. Gaddum, 1933). Acceptance of the idea of a igmoid relation hip be-no

Figure 3.3. ChaTacler.i t ic relat ionship betw en mortali ty and e ertt of burol!lMortalitytpercenn100

100

80

60. (1


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Table 3.3. LA~",fO.11some' . ll I rge I re aimeni sertes

Birk.e &Uijed'ah'l(1968)plasmaiJf,fJ/qJB.J 9 6 ( J . . . 6 ( )

Mg ,u re 3 .,4 ., T yp ie al : m or -C aU ty ,C lI ne s ~ de at h- : I n p er , ce nt ) f or b ur ne d p atl en t! l , Ba :o rd !l in g t o a ge and e xte nt o f buro'lA~ea bu:med'(par cent].100 _

!!'ruinel' al.Bull Bull , ( 1 1 9 6 4 )Ba lC. te r & ( 1 1 9 7 1 ) (1971) be/orehire Bull & be/ore after utpha-Ag e (1968) isher AI. ' 0'3. AgNO., m ION,[year l .~(JUf!'.!! !l954j 1944-64 /965-70 1 9 S ( J . . . 6 0

under 1 5 36 49 4 64 49I. .44 2 7 46 4 7 :5 6 5645-64 :lJ 27 2 9 ' 40 29over 65 7 1, 0 1 0 1 1 7

Birke &Liljedahl(1968)dextragroup A,1954- .59

75,6 45430

45436:1 3

Stmrc: Birke &. Liljedahl (19711.

produce de-ath in 50 per cent of the patient treated. The great advaatageof this method i'that it enables an asses ment of the effectivene .of treat-ment to be made by comparing the actual mo.r,tality with the p r . e c i i c l e c i,mortaliry from the probitanalys! c. Further e .Bull & . Squi re suggested tha tjustas the tOldcity ora drug is best expreed,in term of the doe needed 10 ' kill50 per cent of a. batch of experimental animals (U l Iallyknown asthe Lethal Do eof -0 per cent or L. D . 5 0). 01 we may assess tile treatmentof


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The limelak'en to,dieAll important con ideration i:n evaluating the suffer:ing resulting from dif-ferent weapon is the tim e taken to die. If a v ic tim , is going to, die he willin genera] suffer les if he die immediately tlian if he die Jowliy.1ilieimplicatton of the legal expres ion that weapons should not "render deathinevitable"is that weapons, where they d,o not. kUl. immedia.tely., shouldoffer the wounded persona h~gh probability of recovery ..So many factor . are involved in diffe rent wound. that it is difficul.t to

make meaningful com pari on . However, there are indi.cation that. whereadequate medical facilities a:reavaUable.. imple pelletr.ating and bla twounds iln general appreach the above humanitarian criterion. For ex-am ple , am dy .o f 450 94 U S A rm y casualties iill Viet-Na:m betw een 1965and 1'967 hewed tba t 5387 (U .9' per cem) were killed inac t ion, 623(lA per 'cent) died of wouads, and 39107 (88. m per cent) survived. Ofthose wl lo died of wound in hospital , 62..3 percent died within the fJrrst24 hours .and it was concluded that a h~ghproport io ," of th e e ,early deathsrepre ented casuahies which, in prevIous, wan with.out lUghlyeffec t i .vehelieopterevacuatian, would have been classified a "killed in action".O f the wounded in action 43 ..3 per cent were re turned liO du t. y w i th in th etheatre o f o p e ra t io n s within 3'0 days and 5 4.2 p er cent were evacuated fo rfur ther t rea tment (Whelan, Burkhalter &. Gomez. W968) .These figure in-dicate that .. whi.le conventional weapon are by no means "perfect",neverthele s, death tend to be relatively rapid or the chance . of re-covery relativelygood.There are indica t ion thar hum wounds, hy contra t,conform les toucha humanitarian criterion ..While there fs Iittle doubt that war bumshave a high early mortallity, in many cases death may not ensue for daysor even weeks. Ironically, the better the treatm.ent available, the moredrawn-out the period of dying may be. That there is evidence to Sl!IpPOr i l .such a concluaion may be seen. from thelDoUowling urveys ..

F jf tY ~ l1 e g ir l of the Hijiy am a High School in Hiroshima, J ap an ., w e reou rdoers in thechool gw und, Ie than one ki.lom etre from the explo -Table J..4. Day of death of .51 gir lS,. a l the Hiji'yam_B HJgh School, HLroshima, .!Iapan,.who r ,e c e hr ,e d sev e r e burusfrom the :atomJe: bomb explosionD a y a ll ie r t heexplosien D a iJ y d ea th r at eo fth e 5 1 g ir lsI234567

I' D715II45II

.ource: Ougil lerson & W a rr en ( 19 56 ).B4

T1Ibie3.5, Average da~ of death from burns ,In H : live-yearsuney .963-1 '967) ofhospita ls in Melbourne, A.ustraUs"

Hospital N um ber ofpat ienl N um ber ofdeathJ\yerage lpol-bu.mdayof dying

I234 .1'951 . 2 311 914 4

16III192 0

1711.418.82 0 1 . ' 9 The Originall da ta in cludes a furthe r 11 .1 patienta l fou r o ther hospitals. On ' l y li i :' I I, eo f t h esep a ti en ts d ie d .Source: Ma .c l. eo d ( 197 0 )' .

sioa of the ato mic b om b. They were all severely burned. and lMortaIDitywithin one week WaS 100 per cent. However, ooly lO of the girls died ODthe f irst da.y ; the largest Dumber died on tile third day (table 3 ..4) .. At theKameyasaa Hospital . a ID' in Hiro b:i1ll3,peak morta l i ty from bum, DC~curred on the fourth day. a:JtbonghanDther peak in deaths occurred inthe third and fourth weeks, when complications, including thoseassod~ated with radiation in jury. set in (Ough~ersol i1l& w.anen. [ '956).

11 1 IIrecent five-year s ur ve y of e ig h.1 hospitals in Melbourne. Australia,it was found that on a.v'ernge death from burn occurred to to 20 da.yafter the lqjury. depending on the quality of .he hospitca l trea tment (seetable 3.5) . .The author concluded;

T1lbl.e .3.6. D ay of deadl for .5eVfnly bUToedpatinls In Sl:O(kbolm Swed~en t lE N te nl o f bo{ly surfacearea burnedper cent

Age 'Pot-bum:Case }Ien! ': :> Total T h ir d d eg re e day ofdll.ingI. 2 2 10 0 98 1. 12 . 3 1 1 9S 90 73 34 '9 5 7 : 5 , 204 60 85 80 325 57 8 0. 7'j 96 47 75 70 137 44 75 70 1 08 75 70 1 70 II9 64 6~ 6 0 ' 6,

1 0 1 58: 6. 5 ( I I ) ! 14II 74 60 SO 19 '1 .2 74 45 45 15I3 7 9 45 40 38. T he o ri gi na l d a: la include an addiliiona.l SO pat ients, none o f whom died, Al l : pBt ie l l ls . we r eIl'e ate d w ith th e m ee em w arm dry a ir m eth od .Source: Birke &; Lil jedahl (l97n.

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. .. .2,0years ago 75%ofdealhs occurred f i "Omchock in the fir_t Ulreeday., [wherca 1omly. the rna l eVe"ely burnt now die atthis stage although over n!cen t years -the mt .erva l before deaihhas beenprol~onged . these has been lit tl e reduct ion inoverall mortality (MacLeod. 1970. p'. 776).Birke & Liljedahll (1'971)reported the til11.eof death f'Ora series of civilian

bum. patient in Sweden (table 3.,6), .In no case did death OCiCUif in les .thansix days,. and even for patients with a.very hiighpmbabiHt.y of dying, deathwas iin some cases drawn ,out to three weeks or one month . The , (USfBrookeArmy Medical Censer (1972: ) repo r ted that, fo r patients treated between1965 and 1'971, the average time taken to die was 14.9 days af~e'r thebum ..These i:ndication_ are no t conclusive, bn t they are suggestive of a. sig-

nificant difference between the time of deathcause


10/39

ions from the ti ue > even though there may be a higher concentration inthe (reduced volume of) bod.y fluids ..The balance of potas iumion is affected mewbat differently .. P otas-ium is normally f und in a higher concentration in the Intracellular fluid

rather than in the exrraceflular fluid. Whelll the cell are destrcyed byheat or by dis ea e , additional pota ium ion are relea edinto the bodyfluid '., Thu there may be an initiairi e in the concentration of pota iumion hyperkalaemia) following a bum. If the kidney continue to functionnormally they will remove orne of thi additional pota ium 0 that, athe ti ues are recon tituted, there may later arise a condition of hypo-kalaemia due to a hortage of potas iurn ion. In the fir t day or two oft reatment .it .i uuaUy unnece a:ry to replace lost potassium ion (PhilUp& Co table undated), but careful monitoring of electrolyte concentra-tionsin the b dy fluid: remain, nece ary for some time to avoid hort-age later. (Table 3.1 record one death from hyperkalaemia, and fourfrom hypokalaernla.)han e in blood protein level

The major component of the blood are pia ma---a f luid which containdis solved alts, protein (such a albumins. globulin and fibrinogen) andother comp unds-red blood corpuscles, containing the red iren-ri h pro-te i.n haemoglobin. and white corpuscles, who e principal function i to pro-tect the body again t the invasion of microorgani m .

Extensive deep bum m,ay re ult in the 10 of a much as 20 per cent,of the red c rpu de iljedahl, 1967). The red bl dell are brokendown, a proce known a haemoly is, releasing the haemoglobin into theplasma (a condition known a haernoglobinaemia), from which it maybe extracted and e excreted in the urine (a conditi n kn wn as haerno-gl binuri.a.) ... Removal of red corpu de from [he circulating bloe d mayal result from local thrombo i-the formation of a cl t of bloodwhich occlude a blood 'lie sel-in and around the area of burned ti sue ..Damage to . the capillarie in non-burned area a a re ult of thrombo iha been demon trated e perirnentally by Artur on (196]) and y Birkeand h :i colleagues (960).

In addition to the 10 f blo d protein by direct flow from the woundand by haemoly i,there are other large fluctuation in thelevel ,of bloodprot in , which appear to be related to change at the ite of the woundand to the greatly increased metabolic need of the burned per on, Sinceit i difficult toupply ufficient additional energy from eternal ourcethe body turn to meta lizing it wn protein. The re ult i a evereinitial decrease in the blood protein levels, which iln evere bum may ber duced to one-half of normal level (Liljedahl, 1967 . Sub equently, mill -de ti ue i.metabolized, and the patient' weight decline rapidly.althougbthe blood protein level return to. normal.13 8

Chan es in the kidney functionThe kidney have two. major func tions. They p lta y a m a jo r role in maintain-ing the water balance of the body. Se ndly, they e tract a range f wasteproducts from the blood and pa them int the urine which i thenex-creted. The kidney con it of large number of tubule. In the fir t partof each tubule, kn wn a the glomerulu , water and wa te PI1 ducts arefiltered 'Ollt of the circulating blood, In dl;e la t part ofthe tubule somewater is reab orbed into the blo d while the waste products and the re-maini,og water are pa ed into the bladder urine. The e proce es arereguts ted by hormone uch a tho' produced by the adrenal glanddjacent t the kidney.The decrease in the volume of the circulating blood, due to los from

the bum wound. h emoly is and thromboi induce con triction of theblood 'lie el which further decreases the flow of blood through the kid-ney . In the initial po tbum pha e, the flow f fluid through the kidneymay decrease by 30-50 percent. The amount of fluid filtered by theglomeruli i reduced by 40'-50 per cent, while the re orption of waterin the tubule increa e the b dyatternpt to maintain the fluid b lance .The higher concentration of wa ite products may block the fdtering actionof the tubule hindering the excretion of waste product int the urine.

he frequency of confirmed kidney damage resulting from larger burnwound varie between 9 and 12 per cent in varioutudie (Liljedahl.1967). Electrical and exten ive pulmonary bum are particularly liable tproduce phy iol gical di turbance ufficient to. re uH. in renal. damage(Birke, Liljedahl & Linderholm. 1958; Birke & .. iljedahl, ]966). Kidneydamage in patient witbe ten ive bum. greatlyc mplicate the prog-no i.even where an artificial kidney i available. Mortality in the ecase i high (Cameron,1969).

Damage to the dige tive ystemDuring the initial phase of the bum injury the muscle wan f the inte tinemay be paraly ed, sus p ending peri tal. i,the normal wa e of alternatecontraction and relaxation which cause the content of the alimentarytract t be propelled forward. Tbi may be followed by acute retention offood in the tornach, Change in the gatro-inte tinal tra t Im3Y cause ul-cer _, indicated by vomiting of blood and the pa age of dark. tarry-col-ured tool, due to the presence of blood chemically altered by the in-te tined juice . (melaena]. Gastric and duodenal: ulcers a n e in orne ca e .in t:he surf e and in other. a deep, acute ulcer kn wn a Curling'ulcer . The e ulcer may re ult in dangerou haemorrhage and perfora-tion . The pathogene i of uch ulcers i not ful ly ascertained althoughthe rna t widely accepted hypothe e include the effect. of hi tamine. ter-oids, hock, ga tric acid, rnicruemboli and endotoxin. a po ible causa-

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tive agents (Pri en. 1950; Moncrief, Switzer & Tepll tz , 1964. ; O'Neill .Pru i t t & Moncrief 1968) ,Even in later phase: of the bum iQjury , particularly wh re chron i in -

fection of the wound develop, difficuhiesir; dige tion may reate pr blernin maintaining an adequate IUl ltri liomd ta te.Changes in {he hormone balanceThe physiological tre due t the rmal inju ry t imulates the productionofa number of hormones. particularly those produced by the adrenalglaad (Biirkeel al.. 1 9 58 .; F e ll er , 1 9 62 ).Adrenaline. al 0 known a epinephrine, i released by the medulla of

the adrenal glands and timulate the heart inhibits the movement ofmuscle wall of the inte tine relaxes the bronchiole of the lungs and c n-t riers or di late the blood vessel s. NOl i3drenali .neec!ret ioni 3 1 1 0 in-creased; this hormone pm e e tbe excitatory function of adrenaline butnot the inhibitory function. The production of cortico teroid hormoneby th e adrenal g land also increa e .In me case, however, the tre of the rmal inj ury re ult in haemor-

rhage and aecro i. of the adrenal glands. whichin tum lead to a lack ofadrenal hormone uHicient to cau e death (Foley .Pruitt, Myer & MOIl-crief 1967).In the first hours after the wound occurs there is a large increase in theconcentrat ion of histamine in the blood. Hi tamine is a hormone whichi , Uberatedas a, re uli. of injury. It causes itdil:i,ng or pain, dilation of [heblood ve els, reddening of the kin, lowered blood pre ure, increasedga tric ecretion and may result. in shock-like manifestations. The libera-tion f large quantitie of histamine into the blood may be a po sible con-tributing factor to ga tric ulcer, and to the general capillary damage evi-denced inexten ive bum, njljedahl, 1967). Heparin Ita been used ex-peri mentally in the treatment of burns becau e of it tr ng anti-histamineeffect. Heparin appear to decrea e the ize of the burn, horten thhealing time, and ignificantly relieve the pain (Saliba, 1970; Saliba &Griner. ]970), although its use cannot be prolonged in e it inte rferewith the blood-clotting meehani m.The problem of hear lossOne of the major funct ions f the kin i to prevent the evaporation of thebody fluids and the 10 of heat. from the body ...Apart from the threat ofhypovolemic hock due to 1. 0 of fluid _. th e evaporation of each litre ofwater require 580 kilocalories of heat the latent heat of vaporizatlc n ofwater). Figure 3.5 bow that the rate of evaporation of water for varyingareas of burn wound may amount to many litre per day, compared with therate frcm the uahurned body urface. In an. attempt to maintain the normal.tempera ture of the body, the everely burned per on u es up large amounts14 0

86 per cent to ta ll ,._ _ . B O per cent thirddegree bum

___ ,30 per cent total,23 per cent thi rddegreeburn25 eerce nt lot.al,o per cent thirddegree bum

W,///h Normal rateW//;~ of evaporation

Figure 3.5. Rate of evaporation. of water In three patients wUb 8S 30 and 25per cent burn wounds compared wi th normal va lu _, durfng rtr t four weeks afterIrtjuryml/hr200180160140 \,120100

OL-~~ __~~~~~~~----~~~~2 4 6 8 10 12 14 16 18 20 22 24 26 28ource: :LiljedahII19TlJ,

d a y s

of energy .ome calculati n of typical energy requirements are given int able 3.7. It will be een that the verely burned per on may u e up totwice a much energy a normal ju t to compensate for the 10 . f heatby evaporation of water.Theincrease in the ba al metabolic rate as a re ult of burn w und wasreported by C pe, Nathan n, Rourke & Wil on (1943). Bi rke et al, 19 8)hawed that the ba aJ metabolic rate may increase by a much a 100 percent several weeks after the injury. Thi increased ra te of metabl ism

Table 3.7. Aerage daily rate of evaporation of water from bum woun~ or aryingextent and corresponding heat 10 due to fhl eaporation compared With the rateof wa.ter eva,poratJonfrom a normal :llduUmalerea of 'thirddegree burnper cent

, oss ofwate r byevaporation/ irTes/day

20-4fJ40-6060-901 - 23-45":7

ormal 70kg ma l e approx. 0.8 .ormaJ 70 kg male basal heat pr ductionmoderate activity

a The. latent heat of vllponiza.tion of water i580 k:ilocalorieource: iljedahl (1971).

Heat . .10I duetoevap ral ionGk il o ca l or ie s / da y80-1 160.1. 740.-2 3202900-4060

14 J


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pre ent a major pr bJem in treatmentv since the ever Iy burned per on,who frequently devel p .. cornplieati n in the digestive tract ha greatdifficulty 3'imi[ating ufi l ii :cien t qua:n t il . ie .of nutrient to provide 0 muchenergy.Where nly imple rnedi al facilitie are available II I a comm n e -

perience that tbe everely burned per on in fact u e up energy fa ter thanhe i able t replace it from food and a a re ult 10 e weight rapidly.Gestewitz (1968). for example report that for bum patient in NorthViet -Nam, weight 1 0 e may be a much a I kg per day and finallyaverage a 1 0 of I: per cent f the normal body weight. Thi: remarkableweight 1 gav ri e to the e pre i n "napalm int xification" and i verydifficult to cope with e cept in the most advanced treatment centres,"Roe et ( 1 / . (1.964, hewed that lowing down the rate of evaporationde rea ed the heat 1 0 and lowered the rate of rnetaboli m; thi findingled to the method reported by Liljedahl (19 7 whereby warm. dry air ipumped into the room in which the patienti treated. Thi increases therate of vaporation temp rarily, but the wound r-apidly drie . and aftertwo day the rate of evap ration, nd hence the increa ed rate f ba 1metabolism, decline COil iderably.Pathophysiology of "pulmonary burns"Inaddition to the urface bum de cribed above, fire may cause death orinjury by . ariou form of damage to the lung and re piratory pa -age . The e injurie are often re ferred t a . 'pulmonary burn ". Such'bum ., have; now been re ognized a one of the principal cause of deathby fire (cf.Phillip & Cope 1962: Shook, MacMillan & Alterneier 1968).It wa at fir t a surned thet the victim of pulmonary burn actually

uffered bum of the respiratory tract. and the lung . due t , the inhalation,of flame and hot air. It i ow realized that the term i omething of ami norner: thermal injury of the lower re piratory tract i rare, ince theflame. do n t pa beyond the no e and thr at. and the heat of the airisrapidly di iip.ated efore reaching the lung. 'Only where : t earni inhaleddoesthermal damage to the lung p ibly occur, . ince team ha a thermalcapacity 4000 time great r than that of dry if (Moritz. Henrique &M Lean, 1945}.However. there is no doubt that pulmonary complications are a ignifi-

cant cau e of death. In many ca e . pulm nary complication, ari e adirect equel to bum of the face. 110. mouth and throat. or theinhala-

H rn 11969) g.i es c i id account of such a p ro b le m in the People' Republi of hina:.. !u time when he most needed nourishment. the patient' appetue started to flag ...'i hen Ih i newsl eaked oul the chef of'. hanghai" famous restaurantsput their heads 1.0-gether , .. and sent a stream of delicacies 10 (he hospltal , .. " (p. 10 ). Ironi ally. [hem wer is not tempting dishes but the iniravenou admini t ration or an emulsion of oybeanoil and egg.yolk. tee below. page 169J.14 2

Table 3.8.. Major cause of d alb in 38 patients w o o died - II result or Inl lalaUoninjury"

umber o r pat ientswho diedPneumonia 1. 5iLarYUSOllfachcobronchili . 8Bum wound sep i~ 6Re p ir at or y tr ac t bur nPulm nary edema 2A.lelecta iMyocardial infarctionCardiac t rnponadeGa trointe t inal haem rrhageTollil 38, The data are gathered f rom the h spita l ~ecQrd- oflhe 2-97 patients treated for !berm~injurie at the US rmy In titute for urgical Re earch between 1956 and 1968. Sixty- Ipati ent were ident if ied wi th inhalat ion injur and of these 3 died.ource: DiVic.enti, Pruitt & Reckl:er (:1971.).tion of large amount of srn ke r fumes, particularly in a do ed pace.W,JiJJlilethe majority .f such injurie occur in confined pace, one tudyf 66 patientsshowed that eight patient u rained moke inhalation injury

fr m accident that occurred in open area (Di'Vicenti, Pruitt & Reckler,1971.). Mortality in the e ca e i very high. 'O f the 66 patient mentionedabove. 38 died. a mortal ity of57.6 per cent, Thi may be compared with anv rail morta lity of 9.6 per cent for thermal injurie treated at the arnein titution in the la t year of the tudy, The major cau e of death in thesepatients are shown in table 3.8.However, pulm nary complication frequently ac rnpany bum injurie

even where imrnedi reign f inhalation injury are n t vi u . A 20-yearuJ'veyat the Ma aehu 'e n General Ho piral showed that ;88 per cernf burn patients developed respirat ry c rnplication (Phillip & Cope,(962).10Pul:monary complicati n take' a number of forms [he most. importantf which are inhalation injurie due to make and to ic fum e pneumoniaand pulmonary oedema.Inhalation injury re ulting from m ke and to i cproduct of combustioni characterized by evere inflammation of the trachea and bronchi due

t the chemical irritation of the mu ou membrane lining the e re piratorypa age. Thisinflamrnation may lead tc severe breathing dim ult ies, Cli-nical indications include the pre ence of carbon particles in the putumwheezing, hoar ene and coughing. triking change may be vi ible n ache st X-r y. The patient with inhalation injury i particularly us c.eptibleto bacterial mfeetion of the tracheobronchial tree (Pruitt et al., 1 ' 9 7 0 ) , .eu Thi institution did n t u e mafenide acetate cream. which may lead I additl n Ire piratory complications. See page 1176.

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Suchinluriesere similar to those caused by the type of cllemi:cal warfareagent known a the lung irritant ( ee chapter 4).Pulmonary oedema m t commonly occur in patients with large bum,e pecially children and older patients, patient with a- -ociated renal fail-

ure, and patient to whom inappropriate amount of fluid were admini -tered at the, t ime of operation performed in their po tburn period (Pruittet al., 1970). Mortali ty inthe e case is high, althoughit may be accountedfor by the large average i ize of the bum and other as ociated factor . Apotentially fatal lung edema may occur with con iderable rapidity evenquite late in th recovery peri d (Walder et al., 1967). Thi in tum maylead to a weakening of the heart and decrea ed blo d circulat ion. Con-tinuou monitoring of blood pres ure and blood volume is required 0 that.if necessary, early mea ure can be taken to prevent decreased btood pres-sure leading to irrever ible ti ue damage of the heart and other organs.Pneumonia ia dise e of thelungs resulting from infection by bacteria.

The bum wound itself acts as a medium for the culture of bacteria whichmaysubsequently infiecttbe hmg . either through tbe blood or through theair. In one Judy of 70 burned patieru . who developed pneumomait wafound that 23 (33 per cent) were infected by airborne bacteria. while 47 (67per cent) were infected through the blood. In a ubsequent analy i of 113patients who were treated with an antibiotic agent it was found that 74(65 pe r cent) developed pneumonia from airborne bacteria and 39 (35 percent) from bacteria in the blood. Nine (13 per cent) of the patient in thfir t group, and 25 (22 per cent) in the econd group, died (Pruitt . DiVi.centi ,Ma on, Foley & F1.emma,I970).

The problem of lnfectionIn pile of many recent advance in medicine, the prevention and treat-ment of infection-c-entering the. body through wound from whatevercau e=remain a problem of great magnitude, Where advanced medi-ca) facilitie are available, enabling ucces ful control of the hypovolemicshock pha e, infectioni generally the major cau e of death followingbum.The deep bum i an id a I . ite for infection (Artz. 1964). The m isture

and warmth of th e body provide a near perfect medium for the growth ofa range of bacteria. which find abundant nutritive material in the deadti ue and multiply rapidly. Thrornbo i and 0 dernain the ti sue deere ethe fl w of blood and thereby inhibit the patient ' natural defence rnech-ani ms again t bacterial inva ion. P r the e rea ns, all deep bums becominfected to 3. greater or leer degree. A large bum wound may containthou and of gram of highly infected ti .sue, and organisms from thilis ue may enter the bl od tream or be breathed in by the patient, cau mggeneralized infection, or epticaernia ..When infection reache thi tage144

... he everity of a cutan U' bum wound depend not only upon t~e depth Of. theburn but al 0 upon the extent of the body surface a r ea . a ff e cl ic d . w:hl h de~erml~ethe los . ofbody fluid" and heat, and therefore the impact n the major phYclologlcaly te rn . of the body." (p. 126)"There i a direct relation hip etween the extent of a bum of a given depth andthe chance of urvial." p. 12 IT)"While there j linle d ubt thatar urn ha e a high immediate mortality, inmany ca es death may not ensue for day' or even week. ,. ( 1 " . 134)

10-743168


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"The everly bumed person, whofrequently develop c:omplicatio~in the dige tive tract .ha- great dlf-f ic :u ll ya s- im i la ti ns u ff ic ie nt q~an-titieo f nutrients (p. 142).. : Sinceit is diff icult to upply sufficient ad-dit ionaltenergy f rom eternal sour-ce . th body turn to metabolizingit own proteins . .. and thepati.ent' weight decline rapidly. . . ' ( 1 " 138 )

"There i n o . d o u bt t~at pulmonary complication are a. significant cause of death.In many ca es. pulmonary complication a n e a a direct equelte bum of theface, no e, mouth and throat. or tJhe 'inhalat ion of large amount of mokeor fume,particularly in a clo ed pace ... H. wever. pulmonary complication frequentlyaccompany bu rn injurie . e en wher immediate igns o f i n ha l at io n injury are no tobvieu ." (p. 14 2 fl)"Where there are igns of Lipper re piratory tract ob truction, large am unt ofliquid in the re piratory pa age or hallow breathing.tra heotomy=the operati nof making an opening directly in the trachea ( 'windpipe' ) 0 that oxygen may beadmini tered bytube-s-may be required. Thi hould only be done; where it i clearlywarranted by the ob erved ymptom . ine tracheotomy may be itself a factor inpulmonary infection." (p. 171)


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"8urn frorn napalm rno t typically OCCur n the unclothed a:rea of the bod .pa.r li cu la rl !y 't he hand_.head and face, and feel: and leg. Becau e of the thin layerof tis ue Over the areas napalm bum rapidly affect the underlying mu les, ten-don and bone which greatly compli ale, the urgieal problem. Recon tru ti e sur-gery t treat uch condition require a I ng erie" of Operation' 0 er se eral yearand i s unlike ! I. be available to rdina pe pi ill mot ocietie - in artirne COn-din a .: (p, 154)


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"Hypertrophie scar is ... thickened, raj eel ami grate que ... K.eloid ... mayprogres sivelyextend beyond the si te of the original trauma , .. kin cancer i muchmore prone to develop in car cau ed by burn than in normal kin." [p, 146fj)

"AIl full thickne burn heal withome degree of car ... (p. 146)


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"Contracture ufficient to cau s e eriou functional di abilityf requent ly OCCUrin the case of deep burn w unds or the hand-and the head and neck ... Burns in the e location are partic-ular ly common in the mili tary conte r ." (p. 147)

the chances of survival are not. great, According to Moncrief & Teplitz(1964) over SOper cent of late death fonowing bum result from epti-caemia.Large bum wounds are particularly pr ne to infection becau e of the

e tent of necrotic tissue. Infection of clean mechanical wound, for ex-ample tho e ,re ulting from low velocity bullet, i relatively ea y to con-tain. The bullet itself. or pie es of clothing or dirt carried into the wound.may infect it, but the area affected is generally restricted to the Immediatevicinity of the bullet path. Dum-dum bullet and very high vela ity bulletson the other hand. cau e an "exp!o ive-type' wound, where ti ue i dam-aged at a considerable di tance from the point of c ntact with the projec-tile i elf; and this type i much more liable to ec me infe ted due to themuch greater volume of necrotic ti ue acting a : a.culture medium for in -fective bacteria. Given that in general there i a direct relation hip betweenthe size of an open wound and the amount of infective bacteria whichgrow, it i.obvious thatthere are very large quantitative increa esin theamount of infection resulting from the entry wound of a bullet. whichiless than one squarecenfimetre in area the exit wound ofa high velocitybullet , which may be many square centimetres in area, and a bum woundwhich may. potentially, cover the total body area of approximately 1.5-2.0 square metres.The nature of bacterial infection i highly dependent upon the circum-tance and geographical location of the patient. In heavily populated andhighly cultivated area the likeUhood of infection from grit and dirt inwounds is greater. a major factor to con ider in combat condition . AWorld War n tudy of the bacterial infection of comparable woundshowed that only 30 per cent. of wound incurred in the Libyan de enwere infected with Clostridium welchii, wherea in . France 80 per centwere so infected (McLennan, cited in Cope, 1953. p.IS).The development and utilizati n of new antimicrobial agents during the

pa t 30 years have resulted in change in the type of rganism repon-. i ble fur fatal] infection of bum patient . Streptococcal and taphylococealepticaernia predominated prior t the availability of antibacterial agentseffective against thee organi m . Since the late 1950 . other organi illS.predominantly Pseudomonos aeruginosa, have emerged a the principaloffender (Pruitt & Curreri , 1971) .Thus, the exact nature of the bacI,eriall infection depends very much

upon the circum tance in which a particular patient find him elf, in-cluding the type of treatment available. Whatever the cause of infection.however, bum patients. tend to be particul.arly usceptlble, Thi i due tothe other effects of the bum on the body, including an initial 1 0 of cir-culating antibodies and decreased ability of whire bto d corpuscle to kiUbacteria. repre entinga decline in all f the body' normal defence mech-ani srn again t infect ion Lil jedahl, 1967).11-143168 14 5


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DlsabiUtJesresu]tlng from burnsSevere bum wounds usually resuh in di ability even art,er the w und hashealed ..The disabi:lity following the healing of the bum i due to a number of fac lor ...Therno !common .one . are d.i.abiUties due 10 car iiol':m'alioll,.to the development ofkel'old~. ~o ,c:ontrac tu~es in ge.neraJ, to lowered resitan.ce to oLi l ler di eases, to pychict rauma, to t ile de\lel'oJPmellt of unwanted emot iona l eomplexe , to inabili iyto as-ume fo rme l i to.l einoc:i ety, and theloss ,of s trength and activity (.AI~dric:h.I941,p.581).Sca_rnQg eccurs when the bum invoWves the f iwdW~hicknes of the skin

and u n de rl yi ng t is su e s . .AJl full! thickness bums heal w~th some degree ofcar ...SkillgJafts, . .if used, never perfectly match th e adjacent skill an d are

surrounded wiena rim of scar , espec.ial~y if graft ing Is delayed! or if E n .fecti .on prevents prompt heal i i lQg of the bum. Ilill a large bumthesewreasof sear are very ext,ensive and eon picllIous .Thi scarred tissue may develop a. number of abnormalities. Hyper-

trophic scar is defined as "a. pmk, wh it ,e . o r td'a.Qgtiect.atic ll scar w.hicbis hard, taut , unyieMjng, and more or less fixed to deep ' tlssues' (Wel ls& Tsuldfuj i, ]952. p.. 130). A ltho ugh the y may be thickened, raised andgmte que, they do not normally eX.t 'endinto ' undamaged skin, and if ten.sica is reduced by r ,e .lea.s ingcontracture, or if adequate'kin grafts . areapp.lj,ed, over the course of tlme they general!l)! . often an d become muchthinner .. K'e loidis a term introduced by Alibe.11 j ' l l : 1806 and has been de-til l l .ed as "a . l1 lovable,supemcialle ion. presen t ing an exuberant Jobula[ ,ed ,overhanwng profile, a.gli tenins, jnJ]!amed or acrocy.anoticll surface,. a r ub ~bery censissency, andlchar .acter iz ,edymptoma.tkal ly by a pricldy, burningit,eh", (,bid .), Keloid are cumulenve rna ses of cal' tissue that may pro-.gress lve]y extend beyond th e si te of the origina l traurea ; , charac te r. i t l eaUy ,if keloidsare ,e .xci ed , a larger keloid results. There ws therdlnean im-po.ttantsurgical distWrlct[onbetween the e two types of s ca r , .although ".dii f-f I cu l ti e s i !n c1inicaJ interpretation canan e whelill one approaches the: otherinappear :ance or when the twoexlr,emes coexi t In the same patient"(Ibid.).. In addition there ma.}! be scarring whicb present s: a raj ed or ir-regular surfa"ce"or a thlekness greater tban the surrounding normal skin,which is somewhatdi:tferent again from kel,oid Or hypertrophic. carri~asdefined above ..It Is g en er all y a gr ee d that the incidence of such abnormal scarring de-

pends upon th.e . 'ev,e .nr.y of th e initiall injuf)',tne madequacy 0 .1 ear lytreatment, t he i nc id en c e .of infection. and delays In .heaLing due ' 0 mal ...II. l~/Q~flgieC'taSi~ (from ~~~ ?reek 11!1.0s.e~d; aggeiQ!I,ves el: eklois, exten iO!l) lis thedlla~lQn.of 8l'OUps?i c-api lJanes: iorm!l1,g rn.!setil '. dark red, wart.like growth5;acmcyanQ.tic([romlne. Greek.a/(ron, exll\emJ.ly; k)lOIlO~i$, dark blue colour) mean d Is co lo u re dl b lu e ordark p ll .l :p le a tl he . f in ge r t ip s or O I he re x. lr ,e m it ie s, d ue ' to the presenee ,o f abnormal amo~! l lof reduced haemoglobin, in the blood. - .. - -146

aurritien or absence ,of -kin-graftillgand other factor ,(B~ock &!'III~uk~.1948: Wells & Tsuk.ifl iji ., (952 )" Such factors may ,explall il the Il l1ghmci-dence of kel.oids fbllowing the incelildiary and atomic bomb attacks onJapan, .althougb some author. suggest that rac ial ! characl .eri. tics may alsobe iin.vol.ve.d.A econdary factor is the known dispoi[ion for kel~idformalio~t? occur amongt .he:Japene e and ot: i1erclark- kil lnedpe pleas a racial cheracter is tic. Many spe~-tacular keloids, for example. were formed after th e heal.ing of bum . produce~ IIIthe incendiary bomb attack on Tokyo (US Depa:t tm.enl ,of Defense, 1.962.p. 70) .Keloid wbich are extremely rare in. the patient po.pul:ations typical of

most of the present-day medical literature, have been. noted in Vi.et~Namese bum vicllm_. by Liljedahl (l90n and Con table (1973).w e n & T sukifu jw 0 95 2) n ote d a [iendency fo.r abno rmal scar to dis-appear over a period of year.c unle provoked by illfecli~n,fo~eigo bodies,suchas retained fragments, contractures or abnonnal skin tension.C outrac tu re s are due to the: restri ct ion of undedymg; muscle and joiRt .bysuper i:mposed carol ' inadequ.ate grafts . ..Contracmre bandsof fibrobfas-tie ceUs are formed in the gran:llIlation tissue that builds up in 'the burnedareas. Thee centracture band may be very dense and. can produce mall.),untoward results, Conliractur;es suffic:ient: to cause erious functional dis-ability frequently occur in thecase of deep bum wound of the handand the head and neck, wbere they maycause hideous deformity. Bumsi~th~~e locations are paeticularly common in the mmtary context (table3.'9),D.isabilUie uch a centraetures and keloid, may nOI: develop until

week or month, after the wound ha healed .If uch cli abilities inrerfere with the movements of the body" it is impossible for theindiv idua l to a um.eall of hi former funct i ..ons and dutie . FrequenUy.contracture~a~ occur arounderiflees of th e body pr~venti.ng or inl,eriiering with. natura l fun.c-t ians such as defecation. urinationr. sexual interceurse and eveneau 'n .~. L:u.e.dls~abil. it ies are prone to produce a lack. of ociall adj,1I tment, UlIII havlfIga dl.recibearing 011 [he emeticnal stability.of the patient (A:ldric:b,1943. p'..582)...Such complication de man d a .long erie of recoastrue tive urgical oper-

ations coupled withphysio- and eccupational Ihe:rapy in . order to producea functional result. Thi proce __., pr:ead over many mnnth or even year ..is both painf td and stres ing- to thepatient, It places gre~u demand 0 1 : 1 .hospita.11 facilities. Asa resultadeqaate treatment may only be a~ai,lableto tho. e able to call upon con iderable economic reaourceaandi lea tlikely to be a vailable to' tho' e rna t.prone to such complication . . ...Further i:1 is at well established fact that skia cancer i.much more bable

to dev~lo~, in scars cain ed by bum than in nor:rnal.kin (~ang,.1925:Johnson, ]92,6; Treve & . Pack, 1930 ; Lawrence . 1952).. There Ievideecethat this is even more likely to. occur where bum wounds have Dot been

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n tper celli)Read Upper Lower urnberot'and b- extrerni- extrernl- Geni- wound, um ber ofWoundi ng : agent nCl;;k Thorax demen lalia, p e r ~ ge n l patients

BUlliS" 21,2 lJ.3 7.J 36,1 7,6 7,6 224S m all a rm 10.2 /2.8 II9.8 25.8 38.6 1 . 1 1 ' I093 8 2Mon:ar 16.1 15.6 6,9'Mfn,e 25.6 ,]2.1 1.3 II 728 1 17 0/7.7 10.0 6.8 263 ]5,8 1,2 I 061 ) 661 ) 'PUnji slake< 0.0 0.0 1. 0 9. 0 85.0 3.0Native" us Il.B 65 6. 51.0 34.0 36.0 1.0 68 44Other" 275 19.4 5.5 26.4 35.6 5..6 ,I 339 I014Al l WOUJlds /5.7 /1.2 7./ 26.1 34.8 3.9 57 , 3953N or ma ll p er c en tbody slJrface 9.0 l8.0 .18.0 UW 36.0 I , D '~1..JIle39~_pa:ljent5in :thL ~urY~y were~ou~d~d i~, II,total of.5 (7 bodyr,egion. dIal is, an average of~ o F ~ ~lIenL The d~la do,001Include killed IfI{J('II~n,.becau e I~I calegolj'is not brought 1(1ho pitals,e A . fire~';:8burns pallenu'68 5 7. 7 p e r cenl)were ~ICII,msofacc!de,~I,' ral;he!' than ofhostiJe action . .an d heav rdle lnh~d'_s~3.!pe~e~ blamboo fak~-,concealed 111 foliage. which :readily penetrates cnrnhat boots - -- , ~II }' co . m g. IQJ!.!ryUlg,ow,er ,clCtremllle. .._ - .: "Natlve_" ~~ r~ r s!~i1ijuries re o uhing from ueh weaaons a sa rrows and pike s.w~e /~: f ..~th: r~a t~gory II' Ic !udes398 non .~al t!e inj~red pa tient ; . the rema inder inc lude pat ients c~ e bl Y ~npec'l1ied mech!!msm :uc~a~ k mfi" cgn ,.p ho s:p ho ru s gre na de . ho me -m ade b om bs b la s;InJunes, unl t raurnavar ol .herwte uncla Ifred type Incldent.s" ,Source: Kovaric. Aaby, Hamil & Hardaway (1969).

gr-all.ed. a e an early tage, when il may well be that, in tead of healing,[he wound becomes ulcerou for a period of month or year. before be-comin~ cancer~u . ,Lawrence 1 9 5 2 ) record I W such case, with period ofulceration rangtng from 4 month. to 61 year ., The latent period beforetheon ft. of cancer may be:m any year andis inver. el:y correlated to the age ofthepe on at the time of bum injury. For example, a per on burned inchildho d may uffer from a caneerou growth of the car when he is 40 or50 year .'~I~.TId' kind of complicatioll.i now rare whe re modern treat-ment facilities are available but may be more 'freqll'ent wh e ,'I.. ,I': . "'.1' . - . '. . . ' " . . .... '" '.", , re' l ICl l ID~aC ' I . I-~le. ar~?ot available, fior ,exa.mplein uaderdeveloped countries. or i l l .mdust( ,lsl l!zed countrie , fol 'lowing mas des truction.A'~djt~onal ~Io~,g~ter .mpatb?phy iologicall! problem re ult from the .effect .

of hock. and 1IIIlfectl0l1,which may affect the kidney liver h" 11 nd[ . .. - , "e a ,anun~s,~esul'ting ina ~ermanent weakening of the individual!' ability toresls.t dll ea ,e, and facmg the victim of eriol! bums with a. further inter-mediate ,andlong.:term .haza.rd, Renal compllcarioes, such as nephriti.may have a permanent nlfluence on th e h ea ll h o Cll le patient and hi life~xpe ,ctucy, Prolonge~! Infecncn which il !li lJre the head may force the pa,t~lent Into a.sedentary htie.1~48

Pscbological effeets of burnsThe .immediate psychic impact of the bum wouad may 'be fnllowed byintermediate a'Rdlong~ter:m p ychologkal effect on the patientA number of faetorseontribure to a verysevere psychological burden on

the burned person (Hamburg, Artz, R.,e .i , Am pacher & Chambers, 195,.3;Hamburg. Hamburg & de Goza, 1'9-3). The event it elf, due to the rela-livel:y I ng time invclved in inflicti'ng a bum compared with. say, a bulletwound is likely lo have been particularly traumatic ..Extern ive econd de-gree bum. where the nerve ending are band but. not de troyed,.areexcrucias ingly paioful , and may give rl e to profound mentaland phyieslldisturbances .The problem of combating palin andiafection may themselve create

psychiatric problem :for the patient Easing pain by theadmiai tration .ofanalge ics Delli a morphine may create drug-deperrdency, and withdrawalfrom thee drugs maycause additional painand distres . Topical treatmentwith iliv,er nitrate" to prevent infection cause tbe h.ealthy kin totum black: thougil'll this is temporary it m ay be an additional eurce ofanxiety fO r thepat1i,enl and relatives ..

Pad:icuhurl.y In the case of a child, lhepa.t~ent who is isolatedand re-ceiv ing only occasional vi its by masked and robed hospitaJtaft' mustalsocope with re u[tingemoliona] problemWi,th ome tr epidation we havepermit ted nurses on our Chi ldren's Bum Serviceto work unmasked. The p yehologieal effect of rna-ked attendent- i unde irable,and [hu fa r we have observed noevidence 'o fa deleteriou effec l 'on the wound'"by having thenurse unmasked (P.hil.lip & . Constable ..undated),The psychological problem of isolation L exacerbated by the moreopbisti c.a ted tr eatment faci lit ie and i most ex t reme where the patient iscompleteliyisolated and observed bytelevisi .en 'cameras and remote rneas-uring intfument, he emotional-train of having to conlront alone thesight of one' own naked and burned body Iyin:g ona barep lasdc beJC I,andthe stench of one's own rotting fle h, cb erved only by t .hecold eyeefthe te levi .ion camera,. i.difficult for the ulililnitiat,ed to envisage."In many underdeveloped countrie It i cammon for ' the patient to beattended by hi family. thereby gaining considerably in pcychoIogica:1 re-a urance and emotional .upport-e-factcrs which may be overlooked inadvanced industrial societies. On the ather hand. [he limited method oftreatment availablatothe bum patient linmost underdeveloped eountriesgreatly dirnini 11 the pro pects of recovery, thereby muhiplyingahe at-tendant emotional strain that this impli .es,Thesum of the p - ychiatriceffect" upon the everely burned may be

II Se e p ag e 1 .7 6.13 'the e m ot io n al ' st ra in on the altending ' personnel : isal 0 enermou ' and even experiencedmedicalpersonnel h av e b ee n k no wn 10 ask for Ira n fer" from bu rn unit.

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overwhelming. At be t, the patient with extensive bum will be seriou Iyscarred in pite of all effort at reconstructive surgery. Many of th sedisfigured patient , even in cat e where 6unction ha been re tored, willp ychologicall.y withdraw and never make an adequate ecialreadiu tmenl.It j an unfortunate fact that little can be done to ease the p ychological

problem since it is to a large degree a function f the emotional hockelicited among the ocial contact of the patient by hi! evere di 6gure-ment, Burned per an may find them elve ociaUy tigmatized a in thecase of the _urvivor of the atomic bomb attack on Japan, wh e keloiddeformitie re ulling from burn rather than radiation mark them a .Mba-kusha, a. name connoting di ease, defect and di grace (Lifton. 1967).

Hl. Casualty effects of incendiary weaponsIn thi secti n a description of the known effect of incendiary weapon igiven. In th.i connection it hould be borne in mind that the. pecifie ef~fects of incendiary weapon depend up n the circum taace of u e, thequantity and type of agent u ed, and factor in the target population ucha age. general: health and nutritional tatus, degree of protection, andmedica] fa ilitie available ..Metal incendiuy burnThe metal ineend:iarie .are characterized by high burning temperature andthe tendency to splatter mall particles. of molten or burning metal on thevictim. These small particle may cause mall but deep bum . Such burnsare rare in civilian Jf fe; they normally occur only among workers inmunition factories and among per ions ubJec ted to . incendiary bombing(Artz & Moncrief 1969).Magnesium bum- produce ulcer which are mall at fir t but whichgradually enlarge to form extensive le ion. According to Wil on & Ege-berg (1942 the deeper part of the Ie ion i usually quite irliegllliar. Tis uedestruction may be increa ed by the formation of mall bubbles of hydrogenin the wound (US Army, 1968). The outer layer of the kin must be crapedunder Iocalanae the iasoon after i:njuryin order to remove the magnesium.However. depending 00 the ize of the particle magne ium may form arapid or a slow burning ember. If the larger slow-burning particle pene-trate deeper than the uterlayer of the kin they mu t be thoroughly ex-ci ed urgically (Artz & Moncrief, 1969).Burning thermite produce particle of iron which at the temperature ofcombu tion are molten. Thu , while not actually burning, the drops fmolteniron a re capable of causing small, deep burn until they cool andolidify. The e particle . mll t then be surgically removed. In practice the~50

hestand flame.f rom thermite clo e.enough to bed drops of molten iron na victim would probably have greater clinical effect . causing evere burnsor death from hyperthermia.Napa lm . b u rnsThe thickened oil incendiary agent. which are collectively group:"d underthe name "napalm" are intended to cau e bum by mean of dlre~l ad-hesion of the burning agent to the body and by instigating combutlon ofclothe heu e ,vegetation and 0on. Bumill.g hydrocarbon fue~ are char-acterized by the production of truck, black moke (carbon particles) co~-iderable heat and a tendency to produce c ar bo n m o no xid e un1es there Ivery goodventiIation. Thu the ca ualty effect of napalm~e due to. a.variety of can es, the ignificance of a particular cau e depending upon thecircumtance ofu e, ueh a the quantity fthe incendiary agent u ed, theamount of 0 ygen available. and 0on. ... ..The e factor are iUuskat.ed in a pilot experiment by Montz and hicolleagues (Moritz, Henrique Dutra & Wei iger, 1947 . They c~n luded

that expo ure to burning hyd~ carbon fuel in an encloed pace With goodventilation may lead to death within two minute at 600PCand five to ~x'. ute at 2S0C..Death may be due to . two mechan.i m . Fir t, sy tenucmm .~. . .hyperthermia (heat troke) result ~om the overheating of the ~lood du.nngit circulation through the superficial network of ubcutaneou blood 'lie -eX. Second re piration i prevented by severe burning of the mouth andpharynx, followed by an ob tructive oedema of the pharyn,_trachea andlung ..Where there i bad ventilat ion. the hydrocarb n fuel WIll bum morelowly and may even go out. This re ult in a lower tem~erature thanwhere there isgood ventilation and there i. therefore les .likelihood ofdeathfrom heatstroke. On the other hand, the bad ventilation increases the dangerfrom carbon monoxide and other toxic fume . .According to a US Army Field Manual, theca ualty effect of napalm

are as follows:Personnel CIi! ualtie re ult from B. number of fla!fle effects. Fir t ofcour e .~conta t with the burning fuel. Thickened f~el tlC~ .l~and bum hot o~. t.~~target. It i difficult (0et. inguish, lhu deterring the individual from accompli ~nghi combat mi ion. Caualtie are al 0 cau ed by the e t~me heat (I -~ F-I 400F), Inhalati n of Harne, bot vapour. carb n. mon~xlde. and unburnedhydrocarbon can al 0 pr duce ca ualties , Persoanel I'll a~IIJbo or othercloe~pace will uffer due to the withdrawal of oxygen from th a ir. The hock effect 0flame on the individual i. great US Army, 1960, pp. 3-4}.A Swedi h handbook state:

In addi.tion to an increase in the number of burn wound.' warco~ditio~ :a~oreduce an increa e in the proportion of burn .wound ~Jth a. ociat d LIiIJune_.p ft ti ue wound. fractures, etc.) and burns With a pecial aetiolegy. A _an ex0' . . d . he t ... 11 ery deep wounds cau ed byample of the la tter can be mennonec tne yp.IC Y vei _

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phospboruaana napalm. These agent a!. (I add the risk of 'y temic poi, oningfrom white pho.pl' loru and carbon mono ide, respectively (Artur on. 1 '966,p, 329;trim. from Swedi h).More p cifically, the variou ffect of napalm may e ummarized a

follow:]. Heatstrake (hyperthermia). Some evidence .ugge t that immediate

death from napalm attack. may be Ie frequent than has otherwi e been. uppoed, since the short duration of the firebail (about 6-110 second )! i_too short to cause heatstroke. However, the air temperamre cia e to theburning napalm rie to orne 800-I200C and perons exposed to thitemperature for more than a very few minutes may die rapidly fr m heat-. troke.2. Pulmonary burns. Tho e clo e to (he fire may uffer evere burning

of the no e. mouth and pharyn within a bort time a are ult of breathingin the hot air and fume. The phy ical damage to the ti ues, combined withthe oedema which thi produce, ob truer respiration and may cau e rapiddeath.The dense black sm.okefrom burning napalm and other incomplete

products of combustion may causede/ayed pulmonary oedema, even Inperson not apparenUy burned by the immediate fireball or by direct con-tact of napalm on the body. A noted above, such pulrn nary complica-tion have come t be recognized a . a major cau e of dea th in peacet imeexperience. and very likely contribute at least as much to death' fromnapalm attack.3. Carbon mono ide poi oning, Hydrocarbon fuel. uch a n palm,

produce carbon monoxide when they burn. Where a victim is confined in abadly ventilated pace containing carbon monoxide the proportion ofearboxybaernoglobln :inthe blood may reach a lethal concelltrati.on(66 percent: ee chapter 4), This circum tance i likely to occur relatively in-frequently in the ca e of attack by napalm from the air, but relativelyfrequently where napalm is projected y flamethrower into clo ed paceuch a pillbo e . The effect f carbon monoxide and other t ie ub-stance are di eu ed further in chapter 4.4. Oxy en starvation, Burning napalm u up large quantiti of oxy-

gen and in c nfined areas there i po ibility that the level of oxygenmay ink below that necessary to upport lite ( ee chapter 4),5..Shock .. Shock due 110 the 10 . of bodyf1uid is a functi n f the e _

tent of [he body urfaee area burned. A cording to Do Xuan Hop (1967),even. when napalm. burn do not exceed W per cent of the b dy surfacearea of the per on' affected. hock c ndition are neverthele u ual anderiou . Thi may be due to the fact that hypovolemic hock i c mplicatedby neurogenic hock as a re ult ofthe inten e pain r fear, inhalationinjurie and the to ic effect of carb n monoxide. benzene and pho phoru .]2

Ge tewitz '1968) report that 71.4 per cent of early death arc due toirreversible h ck0 acute carbon m no ide pining.6. Bum wound . Napalm is pread in clump of burning jelly, whichmay burn for up t me 10-15 minute at temperature exceeding OO"C.depending on the cornpo iti n ( ee chapter 2). Beneath the clump of na-palm. the temperature i relat ively low, unless slag ha been added to in-crea e the downward heat now. Unle s the victim inadvertently pread thenapalm in an attempt to remove orextingui h it, napalm bum are typicallyround. with an area of inflammation and welling around the bum and ale . damaged area in the middle, According 1:0 Hashimoto 0971) it habeen demon trated that the ti ue beneath the burned area remain abovethe normal temperature f r five or i minute after the fire i quenched.This cause further Ii ue damage and local thrombo iand necro i preadrapidly in the fir 1 h urand day. the wound becoming ea ily infected.Becau e of the high burning temperature and e tended burning time of

thickened ga oline fuel burn wound r e o ulting from them are typicallydeep and extensive. Ac ording to Do Xuan Hop 1,967) and Ha him to(1971) ome 7 per cent of napalm bum e tend into the .ubcutaneouti sue and involve mu clesand bone in afurther 1.0-15 per cent Thereport of Ge tewitz (1.'968) and Hashimoto (1.971, ugge t tbatome two-third of the victim have total area of bum of up to 25 per cent ofthe bodyurface area and ne-third have bum' ofm re than 25 per cent,7. Ph iological complication. The phy iological complication of the

burn injury a outlined above page 136-142) al 0 occur in the case ofnap tlrn bum. The c h r ac te ri tic weight 1 0 in the patient . may be a- muchas I kg per day. In the Democratic Republi f Viet -Nam burn iniurtehave been reported as in urring weigbt 1 0 e averaging 15 per cen t. of nor-mal weight (Gestewitz, 1968). This i due both to evaporation of water fromthe burned area and mobilization of the body' . fat and protein to com-pensate for the heat 10 re ulting from the evaporation. Such change arelikely t be particularly difficult to cornpen ate for in patient who areinitially undern uri hedand an ernie.The e metab Ii hange are frequently omplicated by injury to the

kidney and liver. ga tric ulcer . decrea e in the blo d protein level ,di -turbances of the hormone balance, psychiatric di turbance a nd o c n, adescribed above. uch development are particularly likely where onlyl imi ted medical f cilitie are available, a in many of the combat : i tuationwhere napalm weapon have been used.8. Infection. The area of dead ti lie cau ed by [he bum i. easi ly in-fected. Sep i of the wound may e tend the depth of the necrotic ti ue,converting a le eriou burn into a full thickne injury. Due to the generaldecline in the patient' phy iological and nutritional tatu a a re ult ofthe burn, infection i parti ularly Liable t devel p rapidly from 10 al ep i(0 generali ed epticaemia, threatening the life of the patient. A n ted

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above exceptional medical re our s are required to prevent and treat bumwound ep i,re ource which are unlikely to be immedia tely available in anembauledarea.It may b concluded that the exten ive tactical. u e of napalm in the

Pacific theatre in World War n, in Korea. in Indo-China andel ewhereha re u;llted iJ l a high mortal'ity mong tthe per on affected. Yet there itoo lit.tJe. p ublished informalion to enable an accurate asses ment of them rtality t be made. Some author , have gone 0 far a , to descr ibe napalmas an "all-or-nothing" weapon (Dudley, Knight, McNeur & Rosengarten,1968) .The eommonoffe.nive agent j napalm (jell 'ied petrol'eum) dropped from aircraft.However. Ih i i an ell-or -nothmg weapon and justa it wa not II ual to b calledupon to treat b ay net wound in World War I Or II (Taylor, 1953) it i rare 10 eenapalm burns: in 3 month we did nol encoumer a silngle i n l ance , (Dudley . Knight.Me eur & Ro engarten. 1968. p. 334Other author. uch a Do Xuan Hop (1967) and Ge tewitz 1968) . reporton the basi of tudies carried out in the Democratic Republk of Viet-Nam that 35 per cent of the per oasaffected died immediately,that is,within 1 to 20 minutes, Unfortunately, neither author give detaiJsa. tothe ci rcurm tance under which the vict ims were affected.)Tho e who' urvive the initiall infliction of eriou bum are faced with

a great variety of potentially fatal compUcatiol1s over a period of week ormonth. Do Xuan Hop 1967) rep rt that in addition 10 an average of35 pe r cent immediate mortality. a fur ther 21.8 pe r cent of victim die inhop.ital-a total of 56..8 per cent, After an investigation in the Demo-cratic Republic of Viet- am Gestewltz ( .1968) reported that 62 percentof affected per on die before th wound heal. Dreyfu (l971)ay; "1 donot have definitive stati tic- but it eem that only about 30 per cent ofthose wounded by napalm and not killed outright can be aved' (p. 1 '9 ) .The minority of vi tim who e live are avedare faced with varying

degree f phy i al di ability. characterized by ugly car and contraction .Bum from napalm rno t typically occur on Ul unclothed areas of theb dy, part icular l,y the hands, bead and face, and feet and legs. Becaueof the thin layer of ti ue ver the e are , napalm burn rapidly affectthe und rlying rnu cle , tendons and bone which greatly complicate theurgical problem. Recon tractive urgeryto treat lIch condition requirea long erie- f operation ver everal years andi unlikely to be availab. leto ordinary p pie in mo t ocietie in wartime condition. Thu in theDemo ratic Republic of Viet- am,a limited number of gra el burned person Ca n be treated in a. general ho pital,e ,pecia.lI,y In e in Hanoi , bU.I: the majority of victim are treated in the v.illagemater nity inf irmar ie and In c district h pita 1 where skin grafting i not: po ible.I!ns!ead of graft ing. wounds are lefl to neal by low kin exten ion from the woundperiphery. (Dreyfu , 1971.1'. I)Ii 4

.... .' . .. a wound which might. heal in two month w~ereIn the e condition ..... hi. ith iut grafting,graftingi carried out might tak a ..year. or more. to . ea W . l . thOUb'urn took,. . . done' yea.r after 'e' U . _A child who e entire : calp wa . an open woun .. '.'..., .lace wa . ob erved by Con table (pel' ona l c.ommu~,cauon? In a . out~P, h. ital, Do Xuan Hop (1967) reported that With the treatVier-Nam e e 0 p . ., 6'7.1.[ fment facilitie available in North Viet-Nam at that time. .. per cen or

. . . h l d within 3 months .19.8 pel' cent. between .3 and 6wounds 1 ! ' I l survl,vor ., ea.e .. . J. . , 14month ,and 13.1 per centtook longer than 6 mon~ .to heal. .Dreyfu 1.971 urn up the ituation f the urvivmg ca ualty of napalm

attack as foU w ; ,f - I 'I eriou after-effect .. Retractile. kin and .col1traCtlO'" ofPoor gra tmg a 0 eave ..


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W:hite ph~ phorus bums havecertasn eharaeterist ics ..Becau e [he par-IHc'lesof white phosplil.oru . are usually di-b"iibuled by an explosivecharge ..thee parti cle .rnay penetraee deepl ,y into Ute kin. Secondly" the phosphOlrllllmay continue to bum. for hours, and inome cases days, until it . i . ' neu-tr ali zed by some means. For thee reasons, phe phorus bum tend to bemade up of mall, deep, lesiees.

During World War n there were several report of death from thetoxic action of white phosphoru , contained ill tracer bullets fRabinowirch,1.943; Cope, 1953), which made up 2 per cent of all missile wound(C. G. Rob, in Porriu" 11953,), .P o rr it t ( 1 95 3 .) r ep o rt ed :WOllnddllcla incendiary or tracer bu lle ts need special m an agem en t becau 'e lhephocll~llorustheycontai:n cau e chemical destruction of th e tis ues , ear ly and pro-gl'essive ,hock, and 8l r i- 'k of fataJ hepatic and renal damage if not removedearly(Por r iU, 195J,p. 2.9).The 30~lb incendiary bombs dropped by the Bri!lish on Germany COIl-

tained white phosph.orus, and Bauer (citediin Bend, 1946) reported tha t"not only laymen butalo doeton called every burna phosphorus bum".However,. Bauer tales that "no ca e have been reportedin whi.cl1 organicdamage nLu~ting from the absorption of pho pheru through tli lekin ,couldbe proved".Thirty years ago any tox:icity ofphospheru in bum. woul~d probably

not have been observed since' everely burned pauenu usually died. SinceWorld Wa:r II, the treatment of bum bas improved considerably, wilh there u~t.that. the death ratein the bet modern cendition has decrea ed, Witht:his decline in mortality the everity of whit'e' pho phorus bums comparedwith wound. from other burning ubstances has become apparent frem anumber of recent studies, Because ,of it i;mportance the que tion of thetoxic~ty of white phosphoru weapon i discu sed in depth in chapter 4,while this ection is restricted to a de cription of'rhe bum wounds re uUingfrom the e weapon -..Many author. di t .i llguish between thermal bums, due to heat and flame,

and chemical: bum, due to theactionofa chemical! . u b ranee on the skin.Thi . terminnlogy is ambiguous, since the production of hea t and name isthe result of a c hem ic a] r ea ct io n. Nevertheles , for dlll.J.ca:.l purposes it iuseful to make the distwnction since, in general, flames must be extinguishedby the exc lusion ofoxygen, whereas chemical ubstances must be neut ral-ized or diluted.In the case of whitie phosphoru burns initial injury Is largely "thermal"

rather than "chemical", but elemental. pho phoru ., o r phesphoru corn-pound produced lin the wound, may be re ponslble fur ubseqsent com-pl:icatioli1. For IhL rea 'on, most. author cla ify white pho phoru bumsas ~hemical rather than pure ly thermal (for example, Curreri , Ach &P rU I tt , 1 9 70 ) .156

The I'.rin.cipa~difference between thermal and chemical burns, includingwhite pho .photllls. bum, i.the lengl.h . 'f time during which ti ue destrue-tien continues, since the ,chemical agenreemlnue to' cause damage untiiInactivared by reaction with the tissue. neutraliaing agents .or dilut ion withwater (Curreri, A ch &, Prui. tt , ) '97.0) ,.White phosphorus tend to bum h_w.ay through the skin and, even days after the original, injury ,.pont.aneu lyigniting particles may be found deep in the wound (Jane, Peter' & Ga ior,l '968).T:hail : is, white phosphorus buens are uually ef' second all' thirddegree, The e bum ar,e rna II : frequently localized 011 the arm, hand. thigh,lower leg and head. Becau e phosphoru i lipidsoleble it pread.rnpidlythrough the fatty tissue underlying the dermi (Summerlin, Walder & Mon-crief. ~967) and. the phespharus-derivedacids produced In the wound maycause further tissue damage (Rabinowitch, 1 9 4 3 ) 1 ,The most frequent. complication are contracture of the j oint s with re-

sultant functional IossvInjuries jn the head lead toa significantly highincidenee of eye c om pli ca tio n_ .. Other cemplication such as wnflamma.t ionof the cartilage' of the ear , gallgrene of the finger and pneumonia canbe ob erved in 1.0 per cent or more of the patient (Curreri.et'al ... 1970).

The estirnati ,n of bum depth by cllin.i.calobservation following chemicalinjury i difi:icult.. The evere fun thickness chemical burn may appear de-,cJep,tilvd.ysuperficial with onl.y a greyish-brown discolouraUon of intact kinduring the first few days. (Currer] et at. 1970).

Surv,eying the surgical Literature re ullin!! from World W.ar U, Copef l ,9S3) , reported cases of wounds caused by explosive bullet which depo ~t,edp ho sp ho llU .in deeper tissue . Hea[ing ef'these wound was lower than nor-mal l (Cope, 1953, p, 308).DurililgWorl.d w.a.r n phcsphcru was u ed in bombsa wda ill bultets

andheU. Cope (1953, ) , records the ca e of tw o children in ju red whileplaying with an unexploded phosphorus bomb:The two children. aged 7 and 8 wer accidentally burned whil~epliilying with aph o phorll bomb on Sully 2 7, 1943 .... C billd A had exten ive second degree. bu mon the backs ofthe legs.an.dthighs and a: patch offull thickness destruction ontheback of the left th igh about 4 in . quare .. C h:ild B Wi! mo r e s ev e re ~ l! y b u rn e d andbad J'ost the kin from thegrea ten pari . o f the back of the rigllt leg from the glutealreg ion to the a.nkl 'e and 0 1 1 1 the left side fliorn the glutealregien of the knee. Shea . l 8 0 ' had spla sh bum on the face and right hand ~lndarm , .. Tbern.(,e ?f healingwas s l~owin both case and multiple graft ing operations were done blllt lit wa mnuntil, D ecem ber ,o f the sam e year l ha le pi t' ll el ia li sa ti on w a s, complete, T he sca rswhich are e from the e bUl 1 l s were in both ca e keloidal an d un table, AClivecontraction took placeneces i :tat ing re-excj sion and Thierrch graft ing inane caseand Xray therapy in the other (Rook-down Hause Centre He pi. taJaceount, citedin CO , pe , 1 9 53 , p . . .] 10 ) .The longer time required to . heal. ph o phorus bums wa reported by

Obermer (~1943) and Sinilo 09M). _ his has been recently confirmed byCurrie'; et al. 0970), who,analy ed llleases of whi:te plilosphoru iand other

[57


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chemical bum patient admitted to the U _ Army In titute of SurgicalRe earch during the period fr m 1950 to 1968.The mean total body urface area of the burn wa 19.5 per cent as

compared with 28.5 per cent for al l bum patient, admitted during the arneperiod, although the mean area of third degree (fuUthickne ) bum was10.5 per cent f< r aoth group. The lower total bum area in the chemicalbum was reflectedin a 1 wer mortality: A per cent compared w.ithI9.3percent f or th e non-chemic I bum adrni in. However, Inger ho pitaliza-lion wa required for complete ki n healing of the chemical burn than forthe overall group: an average of 104 h pital day compared with 74. oran Increa e of 40. per cent.An average of 5...8 urgical eperaricnsper patient wa required. 78 per

cent involving homo- or autografting of third degree burn site . Table 3.10how the 2 2 . 7 complication that were recognized in the I . I I patient,the most f requent being c ntractur .. of j inc (52 ca e ). and c mplicationf the eye and eyelid (36 case ). Table 3.11 how the di tribution ofthe contracture ' which re ulted,Systemic complication uch a pneumonia lO ca e ). upper gastroin-

te tinal bleeding ( ev n ea e }.. epticaernia (five ca e I, acute renal fai lure(four ca e), jaundice (three case and urinary tra t infection (three c e)further complicated treatment. y temic complication re ulting from phphoru burns may be due t hypovolemic h k, or to the toxic effect ofphophoru ab orbed in the body fluid through the bum wound to toxiceffect of sub tances, uch a copper sul!phate, IJ ed to treat the wound, or tocombinati n of the e fact r .White pho phoru bum from e ploding munition are often a ociated

with other injuries such a laceration .fragment wound. traumatic amputa-tion of one or more digit. and fracture of the long bone. Table 3.12how the distribution of uch as ia~ed injurie in the US Army. tudy.In me ca e p rticle of pho phoru may penetrate deep into oft Ii ue

or into the che t or abdominal. cavi tie s. There i u.uaUy a need for radicaldebridement beeau e of the depth of th penetration nd it i extremelydifficuh to remove all the p rticle .. US Army recommendation. in Viet- amtate that re-debridernent hoald be planned after 6-24 hour ,by hichtime the continued burning of previou ly undetected p rti le will havecreated more clearly circum crib d area . of burned ti . ae, enabling theparticl to be I cated more rea

Thermal Effects of Incendiary Weapons on the Human Body

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