bur n s 3 3 ( 2007) 149–154

available at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/burns

Review

Cases of chemical assault worldwide: A literature review

Ashim Mannan *, Samuel Ghani, Alex Clarke, Peter E.M. Butler

Royal Surrey County Hospital, Guildford, Surrey, UK

articleinfo
abstract
Article history:
Accepted 19 May 2006 We reviewed 24 studies of chemical burns by means of assault in the last 40 years. We
describe 771 cases of chemical assault in total. Jamaica had the largest absolute number of
Keywords: cases. Bangladesh had the highest reported incidence. Male victims were more common,
Chemical assault with the exception of Bangladesh and Taiwan. The youngest cohort was from Bangladesh.
Acid burns The role of gender, agents used and legislation were discussed. We identified two broad
Chemical burns motives; increases in violent crime and use as a crime of passion in disputes between men
Assault and women.
Epidemiology # 2006 Elsevier Ltd and ISBI. All rights reserved.

Contents

1. Introduction .......................................................................................................................................................................... 150

2. Material and methods ........................................................................................................................................................... 150
3. Results............................................................................................................................................................................................. 150
3.1. Patient characteristics ........................................................................................................................................ 150
3.2. Causes of chemical injury .......................................................................................................................................... 150
3.3. Motives ................................................................................................................................................................................ 150
3.4. Target. .................................................................................................................................................................................. 152
4. Discussion ....................................................................................................................................................................................... 152
4.1. Gender .................................................................................................................................................................................. 152
4.2. Agent .................................................................................................................................................................................... 153
4.3. Motives and role in crime .......................................................................................................................................... 153
4.4. Cultural and psychological factors............................................................................................................................. 153
4.5. Legislation ........................................................................................................................................................................... 153
4.6. Efforts to combat chemical violence; the non-government organisation (NGO) ...................................................... 153
5. Conclusion ...................................................................................................................................................................................... 153
References....................................................................................................................................................................................... 153

* Corresponding author.
E-mail address: ashim_mannan@hotmail.com (A. Mannan).
0305-4179/$30.00 # 2006 Elsevier Ltd and ISBI. All rights reserved.
doi:10.1016/j.burns.2006.05.002
150 burns 3 3 ( 200 7) 1 49–1 5 4
1. Introduction
Assault through the use of chemical agent, brings with it a
spectrum of complications, namely the onset of severe
scarring and deformities. The target is often the face in an
effort to maximise the impact of what is often an indelibly
easy weapon to obtain and use. In recent years, its uptake has
been most notable within the developing world, where
management is often difficult and limited.
In 1964, in the USA, Bromberg noted increasing use of
chemicals with intent to harm referring to the agents as ‘‘12-
cent pistols’’ propelled by ‘‘lye-throwers’’ who could be hired
out to carry out an attack [1]. The recent increase in
publications outlining chemical burns by assault reflects an
increase in incidence in certain countries [2–5]. The aim of this
review is to provide a comprehensive account of worldwide
occurrence and also highlight differences across the world
which may affect management and rehabilitation of this
difficult problem.
2. Material and methods
The medline database was searched to extract papers that
included data on chemical burn by assault. These papers
consisted of chemical assault (CA) as a single topic, or one
among other causes of chemical injury, or among other causes
of burn. The terms used for the search were ‘burns, chemical
burns, assault, violence and epidemiology’. Studies published
in English in the last 40 years (1964–2004) were included in the
tables if they reported at least 1 case of chemical assault
(Fig. 1).
The location of study, total number of cases of CA, %CA
among all burns %CA among just chemical burns and
mortality rates are presented in Table 1.
Fig. 1 – Cause of chemical burn (% of cases); incomplete data
documented in literature for India, Israel.
3. Results
A total of 24 studies met the criteria. They reported between 1
and 236 cases of CA each, with a total of 831 cases. Seven
studies were hospital-based reports of patients admitted with
chemical burns or burns. Nine studies were hospital-based
reports on patients admitted with deliberate burns/chemical
burns. Two studies focused upon chemical eye injuries. Three
studies were prospective studies including patients attacked
solely with sulphuric acid. Seventeen studies were retro-
spective, three were prospective. In two studies it was not
clear.
In Table 2, there is a comparison of various studies of
gender, age, TBSA% and length of hospital stay. The frequency
of different agents used in assault is compared in Table 3. In
this table, only papers outlining such details of a chemical
burns by assault group were included.
Table 4 describes the site of injury, and lists the number of
cases in which each region of the body was injured. Fig. 1
describes the causes of injury, and lists them within three
broad headings. Details of motives for chemical assault are
only available in a small number of articles and are discussed
further within Section 3.
The highest absolute number of CA in a single study (236)
was reportedfrom Jamaica overa 10-year period[6]. The highest
proportion of CA as a cause of burn admission was seen in
Uganda [2] (17% of all burns admissions). All of the eight casesof
chemical burns were due to assault as reported by Achebe and
Akpuaka [7] (Nigeria). In Bangladesh, in one study, 92% of a
cohort of 158 chemical burn admissions had been assaulted
with acid [5]. Eleven studies took place in developing countries,
and thirteen studies from developed countries.
3.1. Patient characteristics
The mean age varied from country to country. Bangladesh had
the youngest population in two studies: 22.5 and 20.4 years
[4,5]. The oldest cohort was found in New York, USA with an
average age of 44.5 [8]. Apart from Bangladesh and Taiwan, a
male predominance was reported among victims of chemical
assault. The highest male to female ratio was in the UK (6.14:1)
[9]. Bangladesh had the lowest male to female ratio (0.37:1,
0.15:1) in two studies [4,5]. When documented, the highest
mean length of stay in hospital was greatest in Hong Kong
(65.2 days) and Uganda (49.5 days) [10,2].
3.2. Causes of chemical injury
This is summarised in Fig. 1. Out of eight studies, four show a
dominance of intentional chemical injury. The other five show
either occupational or accidental causes.
3.3. Motives
There was a wide variety of motives for chemical injury via
assault. In Taiwan, financial and domestic disputes were the
dominant trigger in 80% of cases [11]. In Bangladesh, Bari
reported rejected romantic advances by a woman to a man as
the most common cause in 43% of cases [5]. In Jamaica, the
assailant is commonly a female with a significant number of
 bur n s 3 3 ( 2007) 149–154 151

Table 1 – Epidemiology of studies in chemical burning

Country, region Period Chemical Chemical assault% Reference
or town (number of years) assault—number among chemical
of cases burns

North America
USA (New York) 1957–1963 (7) 115 49 [1]
USA (Baltimore) 1976–1980 (4) 7 20 [16]
USA (New York) 15 [30]
USA (New York) 1975–1979 (4) 55 89 [8]
USA (Texas) ?–? (14) 18 No data [22]
USA (Washington) 1983–1985 (2) 8 No data [14]
USA (Louisville) ?–1996 (14) 13 62 [20]
USA (Georgia) 1978–2000 (22) 14 [27]
Jamaica (Kingston) 1981–1990 (10) 236 42 [6]

Asia
Cambodia (12) 20 83 [32]
China (Guangdong) 1987–2001 (5) 40 11.5 [31]
India (Chandigarh) 1984–1991 (8) 7 7 [28]
Hong Kong 1993–1999 (7) 10 7 [10]
India [34]
Bangladesh 1998 (1) 38 [4]
Bangladesh 1996–2000 (5) 129 92 [5]
Hong Kong 1992–2001 (10) 19 [3]
Taiwan 15 [11]

Africa
Uganda 2001–2002 (2) 15 [2]
South Africa (Cape Town) 1993–1995 (3) 30 100 [15]
Nigeria (Enugu) ?–? (3) 8 [2]
South Africa 1985 (1) 1 [23]
(Cape Peninsula)

Europe
UK (London) 1989 (1) 15 8 [9]

Middle East
Saudi Arabia (Riyadh) 1993–1999 (7) 3 5 [29]

Table 2 – Patient characteristics in studies of chemical burns

Country, region Age (mean) Male:female TBSA% Duration of Reference
or town ratio hospital stay (days)

USA (New York) No data 0.7:1 19–39 [1]

USA (Baltimore) 37 4.8:1 8.7 15 [16]
Jamaica (Kingston) 20–29 (most common) 1.6:1 8 [6]
India (Chandigarh) 21–30 (most common) 5.4:1 [28]
Saudi Arabia (Riyadh) 25 3.0:1 [29]
Israel (Negev) 29.6 [35]
USA (Louisville) 14 No data 9.5 [20]
Bangladesh 22.5 0.37:1 10.4 [5]
USA (New York) 44.5 1.64:1 19.7 [8]
USA (Texas) 34.2 3.48:1 20.4 20.5 [22]
USA (Washington) 37 1.7:1 14 19 [14]
USA (Georgia) 21–50 (54%) 2.0:1 24.8 [27]
Hong Kong 32.7 1.55:1 21.9 65.2 [10]
South Africa 32 1.9:1 [23]
(Cape Peninsula)
**
South Africa (Cape Town) 37 19 [15]
Bangladesh 20.4 0.15:1 [4]
Cambodia 20 0.54:1 [32]
China (Guangdong) 26 3.65:1 <10 22 [31]
Hong Kong 31 (median) 1:02 39 [3]
Taiwan 34 0.5:1 7.5 [11]
Uganda 33.1 1.1:1 14.1 49.5 [2]
UK (London) 32 6.14:1 [9]
152 burns 3 3 ( 200 7) 1 49–1 5 4

Table 3 – Different agents used in assault by burning and associated mortality

Country, region or town Agent used

Acid Alkali Scald Flame Contact Unknown Other Mortality% Reference

USA (New York) 6 208 3 39 [1]

USA (Baltimore) 15 9 7 6 [16]
Jamaica (Kingston) 0.5 [6]
India (Chandigarh) 68 52 4 20 0 [28]
Saudi Arabia (Riyadh) 11 44 4 [29]
Israel (Negev) [35]
USA (Louisville) 21 0 0 0 0 [20]
Bangladesh 129 0 0 0 1.5 [5]

Chemical burns
USA (New York) 24 18 9 4 1.3 [8]
USA (Texas) 81 46 8.7 [22]
USA (Washington) 25 6 3 14 [14]
USA (Georgia) 25 14 2 45 17.6 [27]
Hong Kong 6 12 2 16.7 [10]
South Africa (Cape Peninsula) 17 8 16.3 [23]
South Africa (Cape Town) 5 19.6 [15]
Bangladesh 38 0 [4]
Hong Kong 6 9 4 0 [3]
Taiwan 14 [11]
China (Guangdong) 230 122 24 0.7 [31]
Uganda 15 0 [2]
Cambodia 20 0 0.15 [32]

trends according to demographics/location, and also the year

Table 4 – Site of injury in chemical burns
of study.
Country, region Most Reference From the literature reviewed, the year of study appears to
or town commonly
predict whether the population group is derived from a
injured target
developed or developing country. In total, before 1980, four
USA (New York) Scalp [1] studies report a total of 192 cases of chemical assault in
USA (Louisville) Lower limb [20] developed countries (all in the USA), whereas after 1980, this
Bangladesh Face [5]
figure falls to only 55 cases. In developing countries, there is no
USA (Washington) Trunk [14]
record as to the number of assaults pre-1980, whereas since
South Africa (Cape Town) Face [15]
Bangladesh Face [4] 1980, 424 assaults have been documented in peer-reviewed
Hong Kong Face [3] journals. In association with a general lack of reporting
China (Guangdong) Lower limb [31] infrastructure within developing countries, this would seem
Cambodia Face [32] to represent an upsurge in the number of recorded attacks
Uganda Face [2]
within developing countries in recent years. Comparison
between continents suggests that chemical assault is less
attacks on other women on account of infidelity [6]. In Uganda, common within Europe and the Middle East, and far more
robbery and burglary accounted for 47% of attacks [2]. common in Asia, and North America although here, the
majorityofcaseswerederivedfromasinglestudy in Jamaica [6].
3.4. Target
4.1. Gender
The face is the most common site of injury from 6 out of 8
studies detailing site of injury. Injury to the eye and other Throughout the literature, there are trends that accord to
components of the head (scalp, neck) are also common. The gender. In Bangladesh, notably the act of chemical assault has
abdomen and buttocks are uncommonly injured. Injury of the been labelled as a ‘gender crime’ and there is a dominance of
genital region has been documented in several studies and female victims (ratio 0.15/0.37:1, male to female). This is
this is important in the context of gender crime/spousal abuse largely a representation of the uptake of acid as means to
[4,12,13]. disfigure women who refuse to marry, or refuse sexual
advances from male perpetrators [4,5].
In Jamaica, the gender ratio of victims was similar to the
4. Discussion general burn population although the assailant was more
likely to be female, a reflection of disputes often between
The use of chemicals in assault has a long history. Often the women over relationships with male partners [6].
result is severe extra facial/facial disfigurement with blind- Krob et al. showed a similar trend in a Western population
ness. It is a worldwide phenomenon which displays certain (Washington DC) where there was a dominance of female
 bur n s 3 3 ( 2007) 149–154
assailants in the context of domestic disputes [14]. Similar
findings were reported on the ‘battered male’; however, here
hot fluid was the most common agent of assault as opposed to
chemicals [15].
4.2. Agent
Previously, in cases of assault with the use of chemicals, lye
(extracted from household drain cleaner) has been a common
agent. Bromberg noted this in 1965 [1] and in another study in
1985, 43% of cases were due to lye [8]. This was more recently
demonstrated from data between the years 1976 and 1980,
where six out of seven such patients were attacked with lye
[16]. The uptake of lye as an agent of assault in the US is a
reflection of its availability at low cost.
More recent figures derived from data in developing
countries point toward the preponderance of acids in assault.
Whereas historically they have been attributed to uncommon
industrial injuries in America and Europe [17,18] in Bangla-
desh, sulphuric acids are responsible for almost all chemical
assault injuries [4,5]. Sulphuric acid is relatively easy to obtain,
a common source being the car battery [19]. This pattern is also
similar to Jamaica and Uganda. Bond et al. suggested that an
upsurge in the uptake of sulphuric acid as a mechanism of
assault in the 1983–1996 period in Louisville Kentucky, may
have been partly due to federal and state regulations
restricting the sale of firearms [20].
4.3. Motives and role in crime
Assault by chemicals has a relationship with patterns of
violent crime. This was documented in London in the 1986–
1987 period, where chemical eye injuries rose in parallel with
violent crime [8]. Wolfort et al. demonstrated a regional
predeliction for lye attacks over a 16-year period in Baltimore,
USA [21]. Robbery accounted for a large number of cases in
Uganda, [2] a typical example being where a motorcyclist or
car driver would have acid splashed over them before theft of
their vehicle. Alcohol abuse has been shown to be an
important predisposing factor in 50% of victims of burns in
New York, USA [8]. In one study, one-third of patients with
burns assault were intoxicated on admission [22].
Acid assault has been recognised as a crime of passion,
with particular reference to developing countries. Bari
demonstrated cases where the main trigger was refusal of
sexual/marriage proposals by a woman to a man [5]. In
Jamaica, relationship disputes are common where the
assailant is female [6]. Similarly in China, spousal attacks
are common with those involved in marital discord [11]. In
Cambodia, acid burns comprise 20% of all burns and tend
toward a female who attacks her unfaithful husband [24].
4.4. Cultural and psychological factors
In Bangladesh it has been documented that female victims of
acid burns suffer from societal ostracism, have a poor chance
of employment and will certainly never marry [19]. Social re-
integration is difficult and psychological morbidity may be
long standing and complex. This is a feature particularly
pronounced in developing countries.
153
4.5. Legislation
Purdue and Hunt recorded how only a minority of cases went
to court as a result of failure to press charges [22]. In another
series, it was shown how only a minority of victims pressed
charges [14]. Battery of men in particular predicted a lower
chance of judici al referral [14]. Problems with the judiciary
have been prominent in developing countries. Asaria et al.
suggested that strict regulation of sulphuric acid would
succeed in reducing the number of acid assaults [2]. However,
in Bangladesh the Acid Control Act of 2002 has not been shown
to achieve a sustained reduction in incidence [25,26]. In
Jamaica, civil courts have been unsuccessful in reducing new
cases, particularly due to an inability to collect punitive fines
from lower socioeconomic groups [6]. In Bangladesh, the death
penalty has been introduced for the crime and we have yet to
see exactly what long-term effect if any it has on the incidence
of acid attacks [19].
4.6. Efforts to combat chemical violence; the non-
government organisation (NGO)
With the upsurge in documented chemical attacks in recent
years attention has been drawn to paucity of dedicated
surgical and rehabilitation facilities in certain developing
countries [2].
In Bangladesh, the Acid Survivors’ Foundation (ASF), an
NGO set up in 1999, has made headway in development of
such modalities. The ASF reports the annual incidence of acid
assaults nationally in Bangladesh. It organises reconstructive
surgery for survivors and long term rehabilitation including
physiotherapy and psychological care. The ASF directs legal
proceedings in a country where the death penalty and a
number of acts of parliament have been introduced to curb the
number of attacks. The ASF is currently undergoing worldwide
expansion, and regional centres will be delivered in countries
such as Uganda.
5. Conclusion
The reported incidence of chemical assault is on the rise in
many developing countries worldwide. This often involves
the use of sulphuric acid to incur disfigurement. Motives
vary, however the resultant physical and psychological
sequelae constitute significant morbidity. Some progress
has been made in the form of new legislation and input from
dedicated NGO’s, in both prevention of and tackling of this
problem.
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