Annals of the MBC - vol. 4 - n' 4 - December 1991

BURNS AS A RESULT OF VIOLENCE AND SELF-INFLICTED INJURY

Lochaitis A., ]liopoulou E, Parker J.M., Poniros N., Panayiotaki D.

Department of Plastic Surgery and Burns, General Hospital of Attica (K.A.T.), Athens, Greece

SUMMARY. The relationship between accidental bums and those resulting from acts of violence has so far interested the medical world almost exclusively when the number of victims was large, as in the Circus Niteroi fire in Brazil in 1965, the fire in Los Alfaques in 1978 with 210 victims, or when it has been the result of terrorist action (Cooper et al. 1983), such as the bomb incidents in Northern Ireland and Great Britain. The relationship between accidental and self-inflicted bums has been well documented in psychiatric literature (Jacobsen et al., 1984; Snaith, 1987), where the emphasis was naturally on the state of the patient prior to the attempt rather than on the effect of the type and course of the bum. In this paper an epidemiological analysis of these two groups of bums is presented as encountered in our unit. Factors recorded and taken into consideration were as follows: age, sex, family status, financial status, educational level, medical history, the reason and cause of the bum, its extent, depth and location as well as treatment and complications. The outcome and social problems appearing during the burn course were also considered as well as several points of interest arising from the comparison of the two groups.

During a period of 30 months between 1987 and 1989, 601 burn patients were admitted and treated in our unit, of whom 24 (3.9%) belonged to the groups under investigation. In the first group (group A), of self-inflicted burns (Fig. 1) after attempted suicide, there were 16 cases of whom 13 were women (81 2%) whereas in the second group (group B), of bums as a spouse, lover or divorcee, while in 2 cases (25%) the assailant was unknown. The burns in all cases in group A (Fig. 4) were flame burns compared to only 4 cases (50%) in group B (Fig. 5). One case (12.5%) was a chemical burn from vitriol, one case (12.5%) was a scald with boiling oil and 2 cases (25%) were from explosions of Molotov cocktails. The groups differed considerably in the extent of the bums, with group A having extensive bums (over 50% TBSA) in I I cases (68.7%), whereas there were only 2 cases (25%) in group B. Both groups had bums in all cases in the head, neck and upper chest, with 14 (87.5%) cases in group A having full-thickness burns, compared to 3 cases (37.5%) in group B. The time-lapse in transportation of the patients to hospital was considerably varied, being much greater in the attempted suicide cases of group A where, with the exception of one case of only one hour, all arrived more than two hours post-bum. In group B, however, 7 of the 8 cases (87.5%) arrived in less than one hour. The outcome of these burns was as would be expected. In group A, where in general arrival was delayed, the depth and extent of the burns was greater, and the mortality rate was higher (56% - 9 cases). In group B the survival was better with a mortality rate of only 12.5% (1 case). result of violence (Fig. 2), there were 8 cases, of whom 4 were women (50%).
The ages of the patients in group A ranged from 20 to 80 years with an average of 45 years, with 5 cases over 50 years. In group B the range was from 17 to 55 years with an average of 35 years and with only one case over 50 years.
The family status of the patients showed the following characteristics: 10 patients (62.5%) in group A were married and 6 (75%) in group B.
The financial status of group A was poor or average in 13 cases (81.25%) and good or very good in only 3 cases (18.75%). In group B, however, only one case (12.5%) was poor or average and all of the others were classified as good or very good (7 cases: 87.5%).
Ten of the cases in group A (62.5%) had completed only primary education whereas 7 cases in group B (87.5%) had completed either secondary or further education.
The factors leading to this type of burn were, in group A, generally unclear with the exception of 6 cases where the patients had known medical history of mental illness or were under treatment with psychotropic drugs. There were also 2 cases not in this category who had, however, previously attempted suicide. In group B the main reason for assault was jealousy (6 cases), and criminal intent in the other 2 cases. In this group the assailant (Fig. 3) was known to the victim in 6 cases (75%), being either a relative.

The relationship between acts of violence and burns has always been of interest not only to Burns Units but to other related specialists as well (Bowden et al., 1988; Das Gupta et al., 1984; Eyles et al., 1984). However, the literature on this subject is relatively limited, usually referring,to the presence of mental illness and the use of drugs, presenting this as the most important provocative factor in the infliction of such burns. There is also a plethora of information (Purdue et al., 1988; Glasheen et al., 1983; Alexander et al., 1987; Wheeler et al., 1988) on such acts of violence committed on children who, according to Showers and colleagues, constitute a fairly large percentage of all children suffering bum injuries. In their series of 139 children assessed as abuse victims with burn injuries, these constituted 12% of all physical abuse cases and 10% of all admissions to the children's Burn Unit under consideration.
On consulting the Greek literature for epidemiological data (loannovitch et al., 1988), it was found to be almost non-existent for this category of bum injury and on comparing our data with that of the international literature it was found that burns caused by acts of violence, either self-inflicted or by assault, were considerably rarer (3.9%) in Greece than in most other countries. Brodzka et al., in a 5-year study, present a 20.9% frequency while Krob et al., in a 2-year study, present a 10% frequency. The relatively stable family unit in Greece, with regard to the self-inflicted bum group, and the relatively low rate of street violence with regard to the assault group, are contributing factors in the explanation of this phenomenon.
In the comparison of the social and financial status of these patients it was interesting to see that in group A of self-inflicted burns the majority were female (81.25%), poorly educated (62.5%) and belonged to the lower income bracket (81.25%), while in the assault group B there was no sex prevalence, the victims were on the whole better educated, with 87.5% having had secondary or further education, and they belonged to a much higher income bracket (87.5%).
Most authors report that previous psychiatric illness plays an important part in predisposition to self-annihilation (Hammond et al., 1988; Klasen et al., 1988; Davidson et al., 1985; Brodzka et al., 1985; Berry et al., 1984). Jacobsen and colleagues (1986) note that self-inflicted bums constitute a predominantly psychotic act and there is often a history of childhood arson and multiple previous attempts at suicide by burning. The mortality rate in this group is reported at 25% and most other authors report a significantly higher mortality rate than for accidental burns of comparable severity. In our equivalent group A the mortality rate was 56%, a reasonable percentage since 7 of the 9 fatal cases had burns over 60% TBSA. In 6 of the 16 cases in thi~ group there was a known history of previous mental illness and previous attempts at suicide in yet another two of the cases.
Within this group also, two cases showed a similarity to those reported by Zemshlany et al. in that they contained the element of mimicry which, according to their report, has caused outbreaks of attempted suicide both in mental institutions and also following the suicide of many famous figures. In the similar case of group A, a mother and daughter, whilst in a state of religious frenzy, set fire to themselves, one after the other. The result was burns so extensive that death followed very rapidly. It is interesting to note that the burns inflicted were almost identical in extent, depth and location.
With regard to group B an interesting report by Stone and colleagues shows an analysis of the social roots of such assaults with respect to living conditions, financial status, religious convictions and leisure-time occupations, which have a direct effect in many of these cases. The cause of assault in their study varied considerably but most patients were assaulted by their partners or members of their family. In the cases presented here, 6 of the 8 (75%) were due to jealousy, and 2 (25%) to unknown causes. The explanation for a greater number of cases due to jealousy within the family is probably that the Mediterranean family unit is still very strong and the people extremely temperamental; it is interesting to note that in 6 cases (75%) in this series too the assailant was either a relative or someone who had previously had an erotic relationship with the victim.
On examining the causative agents, the extent and distribution of the burns, a pattern evolves which has one or two noteworthy points. Death by burning was attempted in all cases by fire as one would probably expect in group A, but burns from assault were caused by a variety of agents since the death of the victim was possibly not the ultimate aim of the assailants and such agents as boiling oil or vitriol in non-lethal quantities were used. The extent of the burns in group A was also considerably greater, as was the time lapse in transportation to the hospital, than for the patients in group B. Further investigation into the history immediately prior to the attempted suicide revealed that these patients had hidden themselves to some extent before the act, choosing a time when they knew they would be alone so as to have a greater chance of success. This in itself led to some delay in discovery of the fire and thus to more extensive burns on the whole. Assault, on the other hand, tended to take place more publicly with thus less damage and quicker hospital transportation time.
Both groups, however, had one thing in common: the bums involved the head, neck and upper chest in all cases. The explanation in group A was that these patients all confessed to pouring the flammable liquid over their heads before setting fire to themselves, while in group B the burning agent tended to be thrown at the upper part of the body. Group B also had a high incidence of bums in the hands which would seem to have been raised in an attempt to protect the face from the assault.

This preliminary epidemiological report on burns which are either self-inflicted or caused by assault has revealed several interesting factors with regard to the incidence, distribution, causes and outcome of this poorly-documented category of bums in Greece.
The comparison of the incidence of burns in this category with that in the literature showed that they are considerably less frequent. Most of the attempted suicide victims were found to be female, middleaged, poorly educated and often accompanied by a psychiatric history. The assault victims were of a better social, financial and educational level. It would also seem that the victims of the self-inflicted burns were more seriously intent on taking their lives since the mortality rate was higher; the assault victims would seem to have a better fate. A comparative study, it is felt, encompassing other Mediterranean countries of similar culture would prove both constructive and enlightening.

RÉSUMÉ. Le rapport entre les brûlures accidentelles et celles causées par la violence a intéressé jusqu'ici le monde médical presque exclusivement dans les cas où il y avait de nombreuses victimes, comme par exemple l'incendie du Cirque Niteroi en Brésil en 1965, l'incendie à Los Alfaques en 1978 avec 210 victimes, ou dans les cas des actes de terrorisme (Cooper et al., 1983), comme par exemple les attentats à la bombe en Irlande du Nord ou Grande-Bretagne. Le rapport entre les brûlures accidentelles et les brûlures infligées volontairement à soi-même a été bien documenté dans la littérature psychiatrique (Jacobsen et al., 1984; Snaith, 1987), où l'intérêt principal concerne naturellement les conditions du patient avant le fait plutôt que l'effet sur le type et le cours de brûlure. Les auteurs présentent une analyse épidémiologique de ces deux types de brûlure qu'ils ont observés dans leur unité de brûlures, Ils ont étudié les paramètres suivants: âge, sexe, situation de famille, conditions économiques, niveau d'instruction, passé médical, la raison et la cause de la brûlure, étendue, profondité et siège, et en outre le traitement et les complications. Les résultats et les problémes sociaux observés pendant le cours de la brûlure ont été considérés, comme aussi divers points intéressants qui proviennent d'une comparaison entre les deux groupes.

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