Behera, C. MD*; Rani, A. MD†; Pradhan, M. MD†; Dikshit, P. C. MD†
A corrosive poison is one that corrodes and destroys the tissues it comes in contact with, by direct chemical action. The major classes of corrosives include acids (organic and inorganic), bases, and dehydrating agent.1 Examples of organic acids are acetic, carbolic, formic, oxalic acids, and so on, whereas sulfuric, nitric, and hydrochloric acids are included in inorganic acids. Alkalis commonly used as corrosives are ammonium hydroxide, sodium hydroxide, potassium hydroxide, and so on. The mechanism of action of acid is by production of coagulation necrosis by denaturizing protein and converting hemoglobin into acid haematin.2 Exothermic reaction occurs when a strong acid is dissolved in solvent and postulated to be the cause for eschar formation.3 An alkali causes corrosive effects by extracting water from the tissues and produces liquefactive necrosis, which results in penetrating damage due to saponification and solubilization of proteins.3 The severity of the corrosive burn is related to a number of factors including pH, concentration, contact time, volume, extent of body surface area involved, and physical form of the agent.3 When corrosive agents come in contact with body, they produce local effects that can be classified in 3 stages as follows: stage I: acute inflammatory phase (up to 7 days), stage II: latent granulation phase (1–2 weeks), and stage III: chronic cicatrization phase (after 2 weeks).3 Acute inflammatory phase is characterized by vascular thrombosis and cellular necrosis. In granulation stage, there is fibroplasia with formation of collagen. Perforation is most common during the latent granulation phase. Scar tissue and contracture are features of chronic cicatrisation phase.3 The skin burn by corrosive is usually accidental and can occur through mistaken identity, fall of containers over the body, rupture or leakage of inadequate containers, and improper storage especially at the workplace.4 Suicide by throwing corrosives on the body surface is rare as it is very painful. Cases of burn by throwing corrosive on the body of persons with intention of injuring or disfiguring them out of jealousy or revenge (vitriolage) are common.1 Although sulfuric acid is commonly used for vitriolage, any corrosive including organic acids, alkalis, and irritant plant juices may be used.3 Deaths due to corrosives usually occur when ingested, and the literature is replete with many reports. However, death due to body surface burns from corrosives is infrequent and rarely reported in forensic literature. The present study evaluated 13 cases of deaths due to homicidal corrosive burn injuries reported from Central Delhi, India.
MATERIALS AND METHODS
Central Delhi is an administrative district of National Capital Territory of Delhi, India, highly urbanized with population about 0.65 million. The Department of Forensic Medicine, Maulana Azad Medical College and Associated Hospitals, Delhi, caters the medicolegal autopsy of this district. Between the years July 1998 to June 2011, a total of 15 cases of death due to corrosive surface burns were autopsied. Two cases were due to accidental exposure, whereas 13 cases were homicidal in nature. The homicidal cases constituted about 0.1% of all autopsied cases (12,464) and 0.34% of all burn cases (3808) during the period. Detailed analysis of cases was based on the medical records and evaluation of autopsy reports.
The majority of the victims were male (61.54%) as compared with female (38.46%), with male-to-female ratio of 1.6:1 (Table 1). The most common age group involved was 21 to 40 years (46.15%) followed by the age group of 31 to 40 years (38.46%). Only 2 cases (15.39%) were reported in the age group of 0 to 10 years. There was no case reported in the age group of 11 to 20 years (Table 2). Face and thorax (Figs. 1 and 2) were involved in 100% cases followed by the upper limb (92.3%), abdomen (84.6%), lower limb (76.9%), and genitalia (7.7%) (Table 3). The percentage of burn ranges from 30 to 80 with average 56.69 of total body surface area. Sulfuric acid was used in all except 2 cases, where the nature of corrosives was not known. All persons succumbed to death at the hospital where they were admitted. The range of survival period was from 3 hours to 6 months; 46.15% persons died within 24 hours, whereas 53.85% survived for more than 15 days. Average survival period was 28.2 days (Table 4). Septicemia was the cause of death in 53.85% of cases (Table 5). In 6 cases, attack on the victim happened on the road, whereas 5 cases occurred at home. One of the victims sustained burn injuries at the workplace, whereas another sustained injuries on a train. The sources of sulfuric acid were known in only 2 cases. The intentions of attack were not known in 6 cases (Table 6).
In the past few years, there has been a huge increase in the acid attacks especially in Central and Eastern Asia, Europe, and Africa, and many such studies of corrosive burns have been reported. Sri Lanka reported 46 cases of acid attack in 2010, which represented 4% of the total number of burn patients and 57.5% of all chemical burns.5 In Iran, 59 cases of corrosive burn patients were reported in a 6-year study from 2004 to 2006.6 Bangladesh has been constantly reporting of such acid attacks since 1961 and reported 303 cases in 2002.7 In 2003, Tasmania reported 31 victims of acid burn injuries in a 10-year study.8 Uganda reported 17% of adult burns due to acid assault over an 18-month period in 2004.9
There are various motives for such act that are reported and consist mainly of marriage problems, revenge, jealousy, poverty, low socioeconomic class, larceny, and so on. Most of the acid attacks were committed to disfigure or maim the person, and usually there was no intention to kill.5,6
In our study, a total of 13 fatal cases of intentional acid burn injuries were identified, of which 8 cases (61.54%) were male and 5 cases (38.46%) were female, making a male-to-female ratio of 1.6:1. This is in contrast to most of the studies reported from Asia.5,7,8 According to Bahl and Syed,10 80% of victims of acid attacks were female. Our finding of male predominance concurs with some of the studies reported with male-and-female ratios of 1.1:1 in Uganda, 1.03:1 in Iran, and 2.8:1 in Sri Lanka.5,6,9
The studies reported were mostly on victims who have survived in the corrosive attack with consequent disfiguration, maiming, and blindness rather than actual death. As our study was autopsy based, only the fatal cases of acid burn injuries leading to death have been reported. Victims who have survived the acid burns admitted or treated in the hospital were not included in the study, suggesting the data might be only the tip of the iceberg of this problem. Hence, it can be said that the total incidence of acid burn victims would be definitely higher than what is reported and requires a wider study.
The numbers of female deaths in comparison to male were less, which suggest that females were attacked by corrosives mainly to cause disfiguration and not death. It was reverse in males, where motive was to kill and not disfiguration. In this study, the motive for the attack in males was revenge in 3 cases and denial of love in 1 case, and the motive was unknown in 4 cases. In females, the motive was denial of love and marriage proposal in 2 cases and domestic violence in 1 case, and the motive was not known in 2 cases.
Most of the cases reported was between the age group 21 and 40 years (n = 11, 84.6%). This finding is similar to the study reported from Sri Lanka, where 63% of the patients were between 21 and 40 years and from Iran where the mean age was 36 years.5,6 This age group belongs to the most active phase of life and out of impulse get involved in violent activities.
In 11 cases, the nature of corrosive was sulfuric acid, and except for 2 cases, the source and strength of the acid were not known. Sulfuric acid is a heavy, colorless, odorless, nonfuming hygroscopic liquid, which is widely used in chemical and leather industry.2,3 Commercially, it is usually available in concentration of 93% to 98% solution in water. It is also utilized in storage battery as an electrolyte. In one of our cases, the assailant used sulfuric acid of battery (battery acid), which is accessible to the public in India. Sulfuric acid is one of the most common chemicals to cause burns in the greater population and is being used as a weapon in countries such as Bangladesh, Iran, Uganda, India, and so on because of its easy availabilty.6,7,9,11 However, in some countries such as Sri Lanka, acid attacks are mainly by formic acid, which is more readily available because of its use in rubber latex processing.5
The pattern of injury over the body showed involvement of the face and thorax in all the cases (100%) followed by upper extremities (92.3%) and abdomen (84.6%). This pattern of injury is similar to most of the studies and suggests that the aim was to disfigure and cause intense pain and suffering.5,6,7 Similar pattern was found in both the sexes in our study. The average percentage of total body surface area burnt was 56.69%, which is comparatively larger than that reported from Sri Lanka and Iran, that is, 14.6% and 30%, respectively.5,6 In accidental chemical burns, the exposure is over a relatively small surface area and does not necessitate hospitalization; however, larger exposures as in intentional attacks (≥15% of total body surface) may require hospitalization and can cause death.12 With larger total body surface area injuries, patients are at risk for severe systemic toxicity. Acidosis may also occur because of severe tissue burns.3 The average survival period was 28.2 days, which is similar to the Sri Lankan study (4.5 weeks) and Iranian study (39 days).5,6 In this study, 6 of the victims (46.15%) died within 24 hours, and 7 of the victims survived for more than 15 days, which suggests that death can be either instantaneous or delayed in such acid attacks. Septicemia was the cause of death in 53.85% of cases followed by shock 46.15%. As acid burns involve wide area and full thickness of skin, nosocomial infections become inevitable in the burn wards, making septicemia a common cause of death. The common organisms causing septicemia are Pseudomonas and Staphylococcus as in thermal burns.5 The cause for shock can also be due to toxicity of the absorbed acid and acute renal failure.5
Intentional throwing of acid is a barbaric form of cruelty and crime. India has been facing this problem since long and is not a recent trend. The victims who survive suffer physically, mentally, emotionally, and socially. These acid injuries can be severe and fatal and even result in death. It is a huge social problem that needs to be recognized, and new and strict laws should be framed to curb this evil. The corrosives should be made less accessible to the general public, increase the existing punishment, and provide better health care and treatment for rehabilitation of the surviving victims, so that they can live without prejudice and social stigma.
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