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Chemical agents that cause blisters or vesicles to form upon contact with the skin historically have been referred to as blister agents or vesicants. The three major compounds wimin this category are sulfur mustard, the nitrogen mustards, and Lewisite. Although the nitrogen mustards and Lewisite were initially synthesized as chemical warfare agents, only sulfur mustard has actually been used in conflict. A form of nitrogen mustard was used for many years as a chemotherapeutic agent. Sulfur mustard is also the only agent in this class that is stockpiled in the United States, and it is thought to be in the chemical arsenals of at least a dozen other countries as well.1 For this reason, the following discussion focuses on the medical effects, treatment, and unique pediatric concerns of sulfur mustard exposure.
Unfortunately, sulfur mustard has a long legacy of use against human beings since its introduction as a chemical warfare agent in World War I. In that conflict it was by far the single greatest cause of chemical casualties on both sides despite the relatively low mortality associated with its use against well-protected troops. Since that time there have been numerous instances in which it was allegedly used: Italy sprayed mustard in parts of Ethiopia in 1935; Japan used it during its invasion of China in 1938; Egypt is thought to have used mustard against Yemen in the mid-1960s; and more recently, the United Nations has confirmed the use of mustard on numerous occasions by Iraq during its war with Iran from 1980 to 1988, resulting in an estimated 45 000 casualties.1"3 More alarmingly, in 1988 the Iraqi government unleashed sulfur mustard on its own Kurdish minority population, exposing thousands of civilians, including children, to its toxic effects, thereby completing the evolution of the use of sulfur mustard from battlefield warfare to civilian terrorism.4"5
The suitability of sulfur mustard as a chemical weapon can be attributed to several factors. Although considerably less lethal than weapons such as nerve agents, mustard results in a significant degree of prolonged morbidity. For example, the average length of hospitalization for World War I sulfur mustard victims was 42 days.1 Local medical resources therefore quickly can become strained by a large number of exposed individuals. A second factor is the...