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Main Page > Vol-26 No- 2 > Paper 4 (you are here) LinkedIn X (Twitter) Facebook Copy link Share Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology Volume 26 Number 2 (July - December 2025) Received : May 17, 2025 Revised manuscript received ; May 28, 2025 Accepted : June 10, 2025 Ref: Dalua P, Behera C. Reluctant to Give: Exploring Youth Attitudes Towards Organ Donation in Delhi. Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology [serial online], 2025 ; Vol. 26, No. 2 (July- December 2025): [about 6 p]. Available from: https://www.anilaggrawal.com/ij/vol-026-no-002/papers/paper004 Published: June 16, 2025 DOI: 10.5281/zenodo.15708613 Email: drchitta75@rediffmail.com Click here to access PDF. ( All photos can be enlarged on this webpage by clicking on them ) Reluctant to Give: Exploring Youth Attitudes Towards Organ Donation in Delhi Abstract Introduction: India continues to grapple with a notable imbalance between the demand for and their actual availability of transplant organs, despite of concerted efforts in creating public awareness through mass campaigns and policy driven initiatives. While biomedical solution to this problem asks for more efforts for cadaveric or living donors as a viable way for addressing this challenge, the persistence shortage indicate existence of deeper and complex interrelationship between medical and socio cultural factors. Aim: This paper critically examines the socio-cultural factors influencing the reluctance to organ donation among youth in Delhi, the capital city of India. Material and Methods: Using online surveys and telephonic interviews this study has identified four thematic frameworks that converge together and shape the youth reluctance regarding organ donation. Result: By examining the ways in which youth today navigate in between the complex moral framework and societal values, this paper reframes the organ donation refusal not as a simple irrational act of the youth but as a conscious and contextually grounded act of resistance that are often been shaped by their cultural norms and institutional structure. Conclusion: Organ donation reluctance among the youth must be viewed as a culturally embedded decision-making process rather than a lack of awareness, calling for approaches that engage with the socio-cultural realities of contemporary youth. Keywords: Organ donation, youth, values and attitudes, cultural beliefs, transplantation Introduction There is an established tradition of empirical research in sociological and anthropological literature on organ donation and transplantation, arguing that it goes well beyond medical technology and is reflective of the psycho-social wellbeing of donors, families, recipients that is deeply interwoven in their socio-cultural specificities.1 In other words organs, viewed from a social life approach appear to be having a social life of their own.² Understanding the reasons behind either the eagerness or reluctance requires examining the social and cultural factors that influence it. While there has been scholarly empirical researches on this topic in India from a biomedical or health perspective, relatively scanty literature exists in India taking into account its cultural and social concerns baring few.³ Biomedical perspective to organ donation rests on the organ transplantation ethos of ‘saving life at any cost’ is a problematic affair owing to the fact that it emphasises too much on the market logic, individual choice while ignoring the socio-cultural insights about the importance of understanding death, bereavement, the body, organs and its transfer to others , claim scholarly studies.⁴⁻⁷ Ben-David⁸ emphasizes the social and emotional dimensions of organ exchange are frequently dismissed when organs are viewed merely as commodities governed by supply and demand. He argues it is necessary to define what constitutes the body and its parts in the context of organ transplantation. Studies that recognise socio cultural dimensions of organ donation are extensively present in international domain. For instance Lock and Crowley-Makota⁹ in a comparative analysis of the United States, Mexico, and Japan, noted that both donating and receiving organs should not be understood as the "autonomous choice" of an individual but rather as based on moral positions and obligations again reiterates the socio cultural dimension of organ donation and transplantation. The metaphor of the 'gift' or reciprocity is frequently emphasized in organ transplantation discussion , but this is to some scholars an oversimplifies the concept. For many involved, this 'gift' can evoke feelings of coercion, extending beyond simple health implications and healing, as noted by Scheper-Hughes¹⁰, Siminoff and Chilag¹¹ and Margaret Lock² explored the contrasting cultural and historical reasons for organ donation across countries. In the United States, organs retrieved from post-mortem donors are generally accepted without hesitation, while in Japan, the practice faces significant obstacles due to deeply rooted beliefs about death. Lock pointed out that definitions of death are culturally constructed within modern medicine. Hogle¹² discusses how medieval beliefs about the diffusion of life essence throughout the human body complicate organ donation in multicultural Germany. Despite the state’s political narrative of ‘solidarity’ being used as a powerful metaphor in East Germany, and Christian notions of ‘charity’ being employed to encourage organ donation at the state level, the process remains fraught with difficulties. Additionally, based on extensive fieldwork, Crowley-Matoka⁹ illustrates how organ transplantation in Mexico is often viewed as a family matter, particularly concerning kidney donations among living relatives, contrasting with the practice of seeking donations from strangers that is more common elsewhere. These broader discourse under the socio cultural perspective therefore acknowledges that organ transplant discourse is a complex socio cultural matter and cannot therefore only be understood with the overused concept of ‘gift’ metaphor alone which many see as a ‘politically loaded and non-neutral concept’ to make sense of this act.¹ This is so because the gifts entail a complex and contradictory meaning in itself and if taken into account then it demands a through exploration of meanings behind such thoughts. These studies recognising social and cultural construction of organ donation frame the tone of argument of the current study on youth refusal to organ donation in Delhi. Considering young adults as key representatives of future donation system, it becomes more pertinent to understand their reluctance or apathy towards organ donation. While substantial discussion exists on this topic among health practitioners and policy planners in India, there has been a lack of academic focus on this issue from social scientists, particularly sociologists. Drawing from the empirical study, this paper seeks to elucidate the underlying reasons for the refusal of organ donation among undergraduate students in Delhi within a broader critical theory framework. A Socio-medical History of Organ Transplantation in India: Organ transplantation in India has a relatively short history compared to the developed world. The first case of Kidney transplantation in India dates back to 1970s. During the 1980s and early 1990s, although this activity became more widespread, it was largely restricted to live donors in selected urban centres. In the 1990s, kidney transplants became much more visible with the establishment of additional transplantation centres. According to NOTTO¹³ sources, there has been an increase in number of transplants cases from 4,990 in 2013 to 16,041 in 2022. Extensive studies in India exists exploring organ transplantation issues from legal perspectives or from a rational choice perspective. For instance, reports from the National Organ Transplant Programme indicate, an increasing demand for human organs in India. The figures stated by the organization are as follows: As per Director General of Health Services, Govt. of India, an estimated 180,000 people suffer from renal failure every year; however, the number of renal transplants performed is only around 6,000. Approximately 200,000 patients die of liver failure or liver cancer annually in India, and about 10-15% of these could be saved with a timely liver transplant. Therefore, about 25,000-30,000 liver transplants are needed annually in India, but only about 1,500 are performed. Similarly, about 50,000 people suffer from heart failure annually, but only 10 to 15 heart transplants are performed each year in India. In the case of corneal transplants, about 25,000 are done every year, against a requirement of 100,000.¹⁴ Viewed from this perspective existing studies mainly focus on the motivations or barriers components of organ donation process noting the low level of awareness.¹⁵,¹⁶ Studies conducted in India also underscore the inadequacy of regulatory mechanisms to prevent illegal trafficking of human organs.¹⁷⁻¹⁹ Several studies also document mistrust and misinformation surrounding organ donation as significant barrier to organ donation in India.²⁰,²¹ The structural factors such as economic disparities are highlighted is some studies.¹⁷,²² Few studies also propose stringent mechanism to regulate illegal trade of organs, implementing educational programmes while examining correlation between awareness levels and willingness to donate.¹⁶⁻²³ Many do also emphasise on government and private stakeholder intervention in these critical matters.²⁴ These studies while elucidating the complexities surrounding organ transplantation from a positivist or biomedical perspective, fail to consider the perspectives of the donors themselves especially when they express their reluctance towards the acts of donation. In other terms, this discourse tends to depict the process of donating body parts as primarily an informed decision based on empirical knowledge of the donors and interpret donors who show their reluctance as ignorant and lack information . This surely undermines to capture individuals’ profound socio-cultural and symbolic dimensions associated with life, mortality, and human corporeal form. Moreover, providing a critical understanding in this context that goes beyond biomedical comprehension of the issue is more important for creating an inclusive and culturally aware public health policies. MATERIALS AND METHODS This qualitative study aimed to explore the reasons for refusal or reluctance toward organ donation among youth in Delhi. The research specifically sought to examine how this reluctance is expressed within the broader public discourse that frames organ donation as a life-saving act and promotes it as a "gift of life." Participants for the study were recruited through snowball sampling, initiated via the researcher's social media networks, including WhatsApp, Facebook, and Instagram profiles. Individuals who consented to participate were selected for the study. From these virtual platforms, a purposive sample was drawn to complete a questionnaire consisting of both closed- and open-ended questions, followed by one-on-one telephonic interviews. All participants were undergraduate students who drawn from across different states in India. In total, twelve in-depth interviews were conducted. These individuals were drawn from a broader pool of seventy-nine respondents who had completed the online survey via Google Forms intended to know their general knowledge and attitude towards organ donation. A hermeneutic approach was utilized to analyse the interview data, allowing for an interpretative understanding of the participants' perspectives. To guide the analysis, typologies of reluctance toward organ donation developed in previous studies were employed as ideal types. Pfaller et al.,²⁵ proposed a fourfold typology based on their research in Germany, identifying key factors such as (1) information deficits, (2) mistrust, (3) objections to killing, and (4) concerns regarding bodily integrity, noting the potential for these categories to overlap. Similarly, Saxena et al.,26 developed a typology relevant to the Indian context, identifying mistrust of the donation process, fear of responsibility, emotional reactions such as shock and grief, challenges in obtaining familial consent, concerns about the post-mortem appearance of the body, and religious beliefs as critical influences on reluctance. This study framed four types of frameworks to interpret the forms and expressions of refusal and reluctance among the sample respondents. This framework is being designed on the basis of existing literature and recurring theme that emerged during the course of data collection. A tabular representation is provided below. Table 1: Workflow of the study Component Details Objective To explore reason for refusal or reluctance towards organ donation among youth in Delhi Population Undergraduate students studying in Delhi Recruitment Method Snowball sampling through social media network (WhatsApp, Facebook, Instagram). Data Collection Methods Online questionnaire (Google Forms, including closed- and open-ended questions) One-on-one telephonic interviews. Sample Size 79 questionnaire responses; 12 in-depth interviews with participants expressing uncertainty, scepticism, or negativity toward organ donation. Analytical Approach Hermeneutic analysis (interpretive understanding of participant narratives) and critical analysis of power and organ donation. Typologies Developed from Interviews Mistrust Social conformity Familial authority and bonding Spiritual world views Findings and Discussion: Four recurrent themes emerged from the study’s extensive telephonic interviews regarding respondents beliefs about organ donation and ideas around it. Though these four thematic frames are not exclusive categories of concepts but rather they are indicative patterns which help in understanding the reasons for youth reluctance to be a donor. These are: Mistrust Social conformity Familial Authority and bonding Spiritual World View I. Mistrust During the investigation, the researcher encountered personal opinions of respondents mistrusting the process of organ retrieval and donation. This mistrust was created either due to lack of information or due to mis representation of the processes involved in it. Though many of the respondents were not completely hostile to the process, but they expressed their concerns in various ways often by linking it to the institutional facilities or scary stories heard over the media. As a. result few respondents preferred not to accept to be a donor . For instance, Aparna (a pseudonym), a third-year undergraduate student, said: “Yes, I have heard about it advertisements and large hoardings near hospitals. But I don’t have complete knowledge about it as to how it happens; the idea of retrieving human organs sounds so scary! Death itself scares people, and separating body parts from a dead person sounds scarier. It’s a topic I would rather not deal with. May be I would be more open to it if I understood it better.” Nirmal is a second year graduation student, expressed similar concerns by asking, ‘I want to be an organ donor, but I am just worried that if something happens to me in the process, who will be held responsible for it? I am the only child of my parents. Social work can wait, but not my parents. Will the medial team do everything possible to save my life? I have heard stories of medical negligence, thus my fears are real, I am not just apprehensive only’. Adding to this, another respondent, Shruti, age 19, said reluctantly, “ I am so young and have never thought about death and donating body parts after death would surely not come to my thoughts. Anyway, if I had to decide right now, I would surely say ‘no’. Who would want to be cut into pieces?” (frowning her eyebrows). “I want my body to remain in one piece not in pieces after my death. ” Shruti’s beliefs have something deeper in its meaning her beliefs and reluctance are not just casual reflections of an younger person but rather it reveals how the younger adults are socialised into thinking about the ritual impurities, integrity of the body and more over how the fear of death is internalised in the subconscious minds of younger adults who are thought generally to be so open. Shruti’s view also construct death as an age affair. Death being a natural process comes only through aging. Similarly, Smriti (a pseudonym), a second-year political science student, said: “We were working on a classroom project about human trafficking. While searching for relevant articles, I came across with how kidney rackets and organ theft happens in India involving health professionals like doctors and nurses. This is so frightening! whom to believe then? One really cannot say ‘yes’ strongly if such things are happening and getting flashed in newspaper stories so often. Even if you want to participate in a noble cause like saving others’ lives, who knows who are the beneficiaries of your organs!” Pragati aged 20, was very authoritatively asserted, “It does not matter whether one is saying yes or no to participate in it . Reliable and motivating stories need to reach out to them in order to think about it. One need to be also sure that lives of all individuals are given priority not just the ones having more money. There are instances of how human organs are sold for money even if these are donated for all the needy” Pragati had never heard of possibility of donating body parts while being alive. She said she would consider to be a donor in only to her family or to a known one and not to strangers. Her refusal to organ donation is conditional and is due to her mistrust in the institutional structure aiding organ retrieval and transplantation. II. Social conformity Social conformity is the process in which individual members of the society adjust their behaviours and actions in accordance with the prevailing norms and values of the society. Those who don’t confirm to certain societal moral or value standards, society often treat them as deviants. This analysis is rooted in the concept of collective conscience coined by Durkheim. Therefore, conformity towards prevailing norms has always been emphasised in societies to maintain solidarity and to avoid chaos argues Durkheim in his scholarly work. In the present study while assessing younger generations beliefs towards organ donation, few of the respondents showcased their stronger conformity towards their family or community values which was negatively associated with motivations to be a donor. Particularly they confirmed that’s the judgments from peers and distant family members do affect them. These judgements are mostly based on the idea that donating body parts for saving life is a noble idea but these are not part of a normalised behaviour as their meanings are fused with beliefs about life and death. One respondent shared that relatives' opinions matter, especially if one is closely associated with them. Decisions about death rituals are collective affairs and involve consultation with both close and distant family members said Shalini a 20 years old girl. She added: “ This is a big decision! The decision to register or not register for organ donation cannot be made by me alone. Does not matter that it sounds good to me to save someone’s life but it’s about life and death not about donating money as charity.” She became emotional remembering how her younger uncle’s face got distorted after his cornea retrieval. His death was already a shock for all of us but his face was even more shocking for those who came for paying last homage. She added, “The decision was made when everyone was in shock due to his death, and not everyone was consulted about his cornea donation. We don’t know what happens after death, but if there is a belief that spirits never die, then extracting body parts is not a great idea. That belief needs to be changed first to make it happen without guilt. His body has already undergone through pain and later by removing his body parts we surely did not do good to him” Shalini’s narrative highlights how decisions about organ donation after death are influenced by collective beliefs about the body and about life and death. ‘ Separating body parts is linked to disrespect’ , she asserted. Conformity to family values, religious or traditional belief about bodily integrity therefore are significant factors influencing donors reluctance. III. Familial Authority or bonding Familial authority refers to the structured power dynamics within the familial domain that influences individual’s decision making process. In the context of India, family remain still a pivotal institution of power shaping individual’s decisions, actions and values bypassing the personal autonomy. The decision to donate organs is therefore not a rational one for the member of a family. It is a collective one. To some respondent’s family support is needed for all kinds of organ donations living or non-living. Akriti (a pseudonym) said, “ What if I decide to go for it, but my family does not approve? I am educated and well-informed, studying in a big city like Delhi, but my parents are not exposed to these new aspects of medicine. For them, it’s a weird ‘city thing’. They would put all the blame on my education, if even I try to convince on this. ” Akriti’s hesitation to be a donor is rooted in her deeper submission to familial authority and moral obligation. Her apprehension is real as she does not want to disturb the social cohesion and stability within family by making such a decision about something which is completely unknown in her family history. Another respondent Deepika, added to the above position in a similar line, “ I cannot decide on this sensitive issue. Death cannot be discussed so casually after all. My parents have greater control over my life; I cannot make this decision on my own. Donation, saving life of others sounds good but when it comes down to a persona and a family … there are a lot of things to consider, my family won’t approve of it and I can’t go against them. ” Fear of death came out as a real fact in her narration along with the importance of familial authority for younger adults in India. Deepika’s anticipation of disapproval or rejection from her parents was also echoed in Sreemant’s narration. Sreemant, a native of Bihar (a pseudonym) while remembering his brother who died in a road accident said, “ These kinds of campaigns are only prevalent in big cities. In rural areas, death does not bring an end to our memory , we still feel as if our beloved departed person is still around us whenever we think of them, so it is not be acceptable to impose an additional burden on grieving family members by forcibly convincing them and blackmailing them to go for organ donation. ” Sreemant’s narrative signify how the reluctance to be donor is rooted in one’s emotional experiences with the departed person in the consideration for organ donation. The role of family in these revelations suggests that acts of organ retrieval and transplantation go beyond medical rationalization theories that view the body as a machine and organ donation need is a universal rational act. IV. Spiritual World View Death is not a clinically determined condition but rather is socially and culturally constructed. For instance Mampe²⁷ argues a good death is a normative idea of living and dying well and is constructed socially and culturally by studying marginalised communities of transgenders. Haddow²⁸ argues that new inventions and discoveries in modern medicine during the 18th and 20th centuries have further complicated these beliefs by demonstrating that individuals previously thought dead could now be revived. Organ transplantation system is therefore gripped around certain ambiguates which need to be elaborated only though people’s lived experiences and though their beliefs and practices not through ‘methodological nationalism’ -an apt terms used by Jamieson.²⁹ Organs as ‘gift of life’ therefore goes contested when one looks at the everyday experiences of individuals , their beliefs on it. Understanding life and death is connected to the concept of organ donation, though they may appear different themes altogether. Scholars argue that ideas about life and death are significant in understanding people’s perceptions of organ donation in cases of brain death or accidental death. Fear of bodily mutilation often arises in these discussions as contradictory ideas not supporting the idea to be an organ donor. As Sanner³⁰ argues, families of such individuals “generally are not able to imagine a difference between the living and the dead. The dead body was ascribed qualities that only a living individual possesses”.²⁸ In this context then, a spiritual world view can significantly shape one’s reluctance to be a donor. For few respondents, the dead should be respected and that any act of mutilation, such as organ retrieval, can mean a form of disrespect. The body is not a biological entity rather is a spiritual entity. Therefore, body and self are inseparable in their view. Ruby (a pseudonym) stated, “ We see others through our eyes; the same logic applies to the dead. If there is an afterlife thing then it’s a crime! Seeing their face before cremation is the last memory that we create before cremation. If their eyes are gone, that last image will never leave one's mind. It’s not something you would do to your loved ones after all.” Shikha age 20, an undergraduate student at the University of Delhi questions the contradictions involved in the idea of organ donation and one’s spiritual world view. She said, “ Deciding to donate organs is not just any casual matter; parents would surely be hesitant to allow us. I am not a very religious person but am sure all do follow rituals of death and birth in their families. It’s so strange that we want to ensure that the soul is resting in peace but how is this possible if organs are gifted to other persons and that person is still alive. Is it not a contradiction? ”. Her refusal was clearly indicative her dilemma that is rooted in a rational and logical thinking and a spiritual world view that she adhere to as a member of society. CONCLUSION The current article aimed to elucidate the ‘rational’ reasoning of young adults in their ‘irrational’ decisions to decline their participation in organ donation within a specifically selected demographic of young adults in Delhi. While existing literature pertaining to this topic has specified numerous factors contributing to the reluctance for procuring organs from the deceased donors, this research paper particularly aimed at analysing the data using a fourfold framework based on the responses of respondents drawn from a qualitative study in Delhi. These categories are not entirely distinct; conversely, they are all interrelated to each other. Despite the limitation of a small sample size, the study revealed deep-seated doubts and apprehensions among respondents regarding organ removal and transplantation. Within the scholarly critical discourses on Organ donation, the biomedical process of organ donation and retrieval is often understood through the lens of exercise of power. For instance Foucauldian disciplinary power ³¹ conceptualisation may help in understanding how romanticising organs as gifts campaign are rooted in the creation of a disciplined body, normalised citizens to control and exercise power over bodies for purported betterment. Agamben ³² would argue in the similar line to say that through this process exercise of power over bodies are performed for creating a normalised body which is the aim of the sovereign power of the state. Feminist scholars like Butler ³³ from a critical perspective therefore are interested in showing that how this biomedical technology that generally aims to safeguard the life of some, puts few selective others , mostly the vulnerable population at the brink of death or exposes them to the corporeal harm involved in organ theft or illegal organ removal process that is based on manipulation, persuasion, deception etc. ³⁴ From a critical theory lens reluctance to donate organs can be interpreted not as an irrational act of the youth but rather this mode of reasoning is a rational one that may have been rooted in the often assumed irrationality of family authority, customs, spiritual world views etc. It is a rational response because is a mode of resistance to the disciplinary powers of biomedical and institutional apparatus. The discourse on organ donation therefore moves beyond the organic life of biological bodies rather they are rooted in individual subjectivities, a symbolic world that sees and imbues diverse meaning to the very act of organ donation. The cited narratives of the young individuals depicts these diversities by disallowing their subjective selves to submit to the politics of biopower argued from a Foucauldian perspective. Refusal attitude therefore means the rational act of resistance that construct the life worlds of these young adults in a meaningful way away from bio ethical rational models. Rather than understanding refusal as an irrational logic, attention need to be paid on understanding the reasons of their reluctance as valid expressions of their rational decision. This also reveals how the narratives of organ transfer caught in between the complex and contradictory structures of life and death. The study has certain limitations and is acknowledged by the researcher due to smaller sample size. Although the study is based on a limited number of respondents, however it did not prevent it to explore and theoretically explain the cultural embeddedness of organ donation among a sample of youth population in Delhi. The study recommends macro-level empirical research to explore the link between individual factors and social determinants such as caste, class, education, and ethnic identities in shaping attitudes toward organ donation to the future researchers. Conflict of Interest There is No Conflict of interest in the paper References Shaw , R., Bell, L & and Webb, R. New Zealanders’ perceptions of gift and giving back as participants of organ transfer procedures. Kōtuitui: New Zealand Journal of Social Sciences Online 7, 26–36 (2012). Lock, M. M. Twice Dead: Organ Transplants and the Reinvention of Death. (University of California Press, 2002). Fox, R. C. 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Intimacy as a Concept: Explaining Social Change in the Context of Globalisation or Another Form of Ethnocentricism? Sociological Research Online 16, 151–163 (2011). Sanner, M. A. Exchanging spare parts or becoming a new person? People’s attitudes toward receiving and donating organs. Soc Sci Med 52, 1491–1499 (2001). Foucault, M. The Subject and Power. Critical Inquiry 8, 777–795 (1982). Agamben, G. I. HOMO SACER: Sovereign Power and Bare Life. in The Omnibus Homo Sacer 1–160 (Stanford University Press, 2017). Butler, J. Precarious Life. Verso Link Roy P. Organs and their travels: an analysis of organ donation and transplantation(unpublished). *Corresponding author and requests for clarifications and further details: Dr. Chittaranjan Behera, Professor, Department of Forensic Medicine, AIIMS, New Delhi, 110029 Email ID - drchitta75@rediffmail.com

Main Page > Vol-26 No.- 2 > Paper 3 (you are here) LinkedIn X (Twitter) Facebook Copy link Share Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology Volume 26 Number 2 (July - December 2025) Received : April 28, 2025 Accepted : June 18, 2025 Published : June 18, 2025 Ref: Kumar J, Khan IA, Reyazuddin M, Haroon A, Khan FA. Proposing a Single centre as a Drug and Toxicology Unit for Complete Care of Substance Abuse and Poisoning Patients at Tertiary Care Centers. Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology [serial online], 2025 ; Vol. 26, No. 2 (July - December 2025): [about 17 p]. Available from: https://www.anilaggrawal.com /ij/vol-026-no-002/papers/paper003 DOI: 10.5281/zenodo.15708358 Email: dr.jitendrak2@gmail.com Click here to access PDF. ( All photos can be enlarged on this webpage by clicking on them ) Proposing a Single centre as a Drug and Toxicology Unit for Complete Care of Substance Abuse and Poisoning Patients at Tertiary Care Centers Abstract A Registered medical practitioner is qualified to manage all the cases of poisoning and substance abuse after passing their graduate medical education. The qualification of managing poisoning cases comes from Toxicology taught to them under the subject "Forensic Medicine and Toxicology". At tertiary care centres, the post-graduates in Internal Medicine manage poisoning and substance abuse cases under emergency care based on the knowledge they received during their undergraduate studies. However, the Teacher who taught the subject is practically not involved in managing such patients, i.e. preaching without practice. This results in a gross deficiency in the quality of care for poisoning cases. To overcome this, we propose one centre as a Toxicology unit at every tertiary care centre, corroborating Medicine, Forensic Medicine, Pharmacology, Psychiatry and various other disciplines dealing with all the aspects of Substance abuse and Poisons. With the help of this unit, we can run a single centre catering to the management of poisoning and substance abuse patients, their mental health, diagnostic centres for drugs and poisons, drugs and poison information centre (DPC) including drugs de-addiction and treatment centre (DDAC), an integrated rehabilitation centre for addicts (IRCA), Outreach and Drop-in centres (ODIC), De-addiction drug pharmacy and various training courses to the health care professionals. Keywords: Toxicology, Poisoning, Substance abuse, Mental health, Suicide Introduction Suicide is one of the preventable forms of death. Suicide is not only a personal tragedy that takes the life of an individual prematurely, but it has a continuing ripple effect, affecting the lives of families, friends and communities. The global burden of death due to suicide is more than seven lakhs per year (1). Suicide is among the top 20 leading causes of death in the world (WHO) and among the top 10 leading causes of death in India (NCRB data) (2). Although we don't have actual data on the suicide attempters, as per WHO, for each suicide, there are likely more than 20 suicide attempts (3). In that way, if we consider suicide as a preventable disease, then this will become the most prevalent disease in the world, and 2nd commonest will be far behind. Sadly, 77% of global suicide occurs in middle- and low-income countries. Suicidal behaviour is a complex phenomenon that demands a holistic approach of care and support by multiple agencies. Mental Health Care Act, 2017 and India Under Indian Penal Code (IPC) section 309, the attempt to commit suicide is a criminal offence and is punishable with one-year imprisonment with or without a fine. With the implementation of the Mental Health Care Act 2017 (4), Section 309 of IPC was decriminalized, and it was stated that "Any person who attempts to commit suicide shall be presumed, unless proved otherwise, to have severe stress. And the appropriate government shall have a duty to provide care, treatment and rehabilitation to a person having severe stress and who attempted to commit suicide to reduce the risk of recurrence of attempt to commit suicide”. This has changed the approach of every stakeholder towards suicide patients. Although suicidal behaviour was seen as a mental illness, treatment for the same is provided by the Psychiatry department of the hospital for a long apart from their regular treatment (5-9). But with this commendatory step taken under the Mental Health Care Act, every attempt of suicide shall now be seen as a disease rather than an offence for which the appropriate government and healthcare provider will provide proper care, treatment and rehabilitation as per the standard guidelines. Poisoning and Mental Health It has been observed that most of those patients who survive suicide and get admitted to the hospital, the majority of them are with poisoning incidences, and poisoning is the most typical method practised. Also, it has been reported that most of the poisoning cases are suicidal (More than 75%), followed by accidental (10, 11). In view of this, the majority of cases of poisoning need care of their mental health. Substance Abuse, Mental Illness and Toxicology Substance abuse, i.e., the harmful or hazardous use of psychoactive substances, including alcohol and illicit drugs, is a form of toxicity itself and is an essential part of pharmacology and toxicology. They are taught to undergraduates under the drug dependence chapter of Forensic Medicine and Toxicology. The emergency care of such patients is done at casualty by post-graduates in Internal Medicine and further care in the Psychiatry department. At present, we don't have substance abuse testing labs in hospitals. Essential care of such patients in a routine manner is avoided due to medico-legal reasons. Substance abuse is a shared Medicine, Pharmacology, Forensic Medicine and Psychiatry domain. So, a multi-disciplinary approach is essential for proper care of such patients. Pharmaceutical Drugs, Environmental Poisons and Toxicology lab Indiscriminate use of drugs without proper prescription is rampant in the society. This results in toxicity, resistance, chronic renal diseases and various other pathologies. We don't have toxicology labs even at the tertiary care centre for the testing of chronic drug toxicity. Similarly, air pollution, water pollution, household poisons, and other factors resulting in chronic diseases and ill health are totally ignored areas of toxicology management. We need toxicology labs and research in this part to provide proper care for such cases. Present practice in the care of Poisoning cases and Forensic Medicine and Toxicology Understanding of the management of poisoning cases is developed among Indian medical graduates through their teaching of the Subject "Forensic Medicine and Toxicology" during their second or third professional. However, Forensic Medicine and Toxicology faculties are not practically involved in the care of poisoning patients. They develop their training only theoretically. Poisoning cases at tertiary care centres are dealt mainly as emergency cases. Post-graduates in Internal Medicine provide emergency symptomatic care to the patients along with other routine emergency patients. At our hospital, ACMO (Assistant Casualty Medical Officer, mostly Post-graduate students of different disciplines posted temporarily in the casualty) sees all patients coming to casualty first, including poisoning cases. In poisoning cases, ACMO takes the patient's history, notes vitals, and categorizes the patient as stable or unstable. In case of an unstable poisoning patient, he gives a distress call to Anesthesia. The Anesthesia team does resuscitative measures and accordingly takes to a ventilator or stabilizes the patient. Once the patient is stable, Gastric lavage is done, and the patient is referred to the Medicine unit in case of an adult. Most antidotes for poisoning are unavailable. Routinely, Normal saline and sometimes charcoal are used. In the Medicine unit, routine blood testing for non-critical poisoning cases includes CBC, LFT, KFT, ABG and ECG (sometimes) are done. If nothing abnormal in the above parameters, only symptomatic supportive treatment is given, and the patient is observed for up to 24 hours and then discharged. In case of any abnormal parameters, the patient is managed in the ICU or CCU ward. In most cases, no MLC is prepared, and neither gastric lavage is preserved for MLC purposes. Also important to note is that all the care related to poisoning is done along with other emergency or ward cases. Poisoning cases in government or private are medico-legal cases, whether accidental, suicidal or homicidal. This becomes another reason for the cold approach in the care of such patients. Proper Medico-legal formalities are not done, and cases are usually sent to the home after recovery without proper medico-legal formalities. Also, the doctors of Internal Medicine don't get any separate training for poisoning cases, but they manage patients like other routine emergency cases based on the knowledge of Forensic Medicine and Toxicology taught long back. So, overall, poisoning management is developed more theoretically than practically, i.e. preaching without practice. This results in a gross deficiency in the quality of care for poisoning cases. Most tertiary centres face the unavailability of toxicology management related medicines like activated charcoal, various antidotes, etc., as well as the availability of other resources and space constraints. To overcome this, Faculties and Residents of Forensic Medicine and Toxicology need to be involved in managing poisoning patients and dedicated centres for the care of Toxicology patients are the need of the hour, particularly at the tertiary care centres. Since toxicology care is multi-disciplinary, we propose a Drug and Toxicology unit. Drug and Toxicology Unit We are proposing one single centre as a Drug and Toxicology unit at every tertiary care centre, corroborating Internal Medicine, Forensic Medicine and Toxicology, Pharmacology, Psychiatry and various other disciplines dealing with all the aspects of Substance abuse, Drugs and Poisons for better care and compliance with such patients. It shall be established near the hospital's emergency department for better patient care and to admit patients of the above categories after their emergency care. The unit shall have The Drug and Toxicology Division and the Substance Abuse and Mental Health Division. The following parts shall be attached to each division, as shown in Fig. 1. Figure 1: Different centres under the Drug and Toxicology Division and Substance Abuse and Mental Health Division Drug And Toxicology Division Substance Abuse And Mental Health Division Drug and Toxicology out-patient department Drug and Poison Information Centre (DPC) Diagnostic lab (Drug level estimation) Diagnostic lab (Poison level estimation) Drug and toxicology ward (Min. 20 bed) Antidote Bank Substance abuse out-patient department Drug de-addiction centre and treatment (DDAC) Outreach and drop-in centres (ODIC) De-addiction drug pharmacy Integrated rehabilitation centre for addicts (IRCA) Objectives A single centre dealing in all aspects of Drugs, Poisonous Substances, Substance abuse and mental health for the convenience of the patients and administration. Human resource and workforce development by training medical undergraduates, post-graduates, research scholars, and other staff in all aspects of drugs and toxicology for better running of such centers. Benefits The facility will support the hospital and the public in better diagnosis and management of drug-related events, poisoning cases and substance abuse cases. It will have a Drug and Poison information centre that will provide knowledge about all the aspects of Drugs, Poisonous substances and Substance abuse to the public and health care providers, which will save the lives of many. All the drug and toxicology-related investigations shall be available in the Drug and toxicology unit. The earliest diagnosis of the Poison can help save the lives of many and support the investigating agencies in regulating the availability of such poisons. Unit shall estimate the drug levels through therapeutic drug monitoring (TDM) in case of life-threatening events and low therapeutic index drugs. De-addiction and treatment centre (DDAC), an integrated rehabilitation centre for addicts (IRCA), and Outreach and Drop-in centres (ODIC) will be beneficial in the prevention and management of Substance abuse cases. A de-addiction pharmacy and antidote bank will provide de-addiction drugs and poison antidotes that will be very helpful in patient care and compliance. De-addiction drug pharmacies will be very supportive of patient of substance abuse to avail their prescribed drugs at ease with following norms as per the NDPS Act, 1985. Teaching and training medical undergraduates and post-graduates in clinical pharmacology and toxicology can be imparted. Various courses like DM (Pharmacology), DM (Toxicology), DM (Psycho-pharmacology), DM (Addiction Psychiatry) along with PhD programs, MSc, DMLT and other related courses in clinical pharmacology, toxicology and Substance abuse may be undertaken. New Research avenues may be inculcated through this unit. We can collaborate with institutes of high eminence for further enhancement. We can also generate good revenue from various sources, as mentioned in Table 1. For substance abuse management and care, the Department of Social Justice and Empowerment provides massive funding to such centres. Table 1: Revenue for the above unit can be generated from the below sources Drug And Toxicology Division Substance Abuse And Mental Health Division Ward admission charges OPD charges Drug and poison estimation charges Therapeutic Drug Monitoring charges Different academic and training courses Antidote bank charges Ward admission charges De-addiction pharmacy EEG Bio-feedback MBT (Aversive Therapy) Motivational enhancement therapy Social skill Training Funding by department of Social justice and empowerment. Our Proposal under HEFA Higher Education Financing Agency (HEFA) is a joint venture of the Ministry of Education, Government of India and Canara Bank to finance the creation of capital assets in premier educational institutions in India. This idea of the Drug and Toxicology unit evolved from inter-departmental activity that started while preparing such proposals that will be a revenue-generating model. HEFA provides funds for infrastructure and equipment, with the condition that they return 10% of the amount in 10 years. In brief, we have proposed an infrastructure with the Ground and first floors having the Drug and Toxicology division and the Second and third floors having the Substance abuse and Psychiatry division (as shown below in Fig. 2-5). Figure 2 : Layout plan for ground floor Figure 3 : Layout plan for first floor Figure 4 : Layout plan for second floor Figure 5 : Layout plan for third floor Tentative Cost And Revenue Generation We estimated the cost of infrastructure and equipment separately as per government norms for both divisions, along with tentative revenue generation as shown in Table 2. Table 2: Tentative cost and revenue generation for the Drug and Toxicology unit as calculated forour proposal under HEFA Drug and Toxicology Division Substance abuse and Mental health division Tentative cost Building (Ground + First floor) = 6.07 crores Instruments/Lab=20.30 crores Total cost= 26.37 crores Building (Second + Third floor) = About 6 crores Instruments/ Lab= 6.35 crore Total cost= 12.42 crores Tentative revenue About 3150 patients were considered per month as per the current hospital load. Ward admission + OPD Charges + Lab investigations (Drug and Poison analysis + TDM) may generate a revenue of about 28.23 lakhs per month and approximately four crores per year. About 750 patients were considered per month as per the current hospital load. Ward admission + OPD charges + De- addiction drug pharmacy + EEG + Biofeedback + MBT + Motivational enhancement therapy + Social skill training = 7,47,500 per month and 89.7 lakh per year further funding by the Ministry of Social Justice and Empowerment approximated to be about 1.46 crore per year for DDAC's, IRCA's, ODIC and Nasha Mukti Abhiyan. Total revenue generation = About 2.5 crore Similar Successful Projects As per our information, we could not find any such unit that incorporates drugs, toxicology and Substance abuser care under one centre all over India. However, many centres run separately for each division, with limited facilities. Drug and Toxicology Division All India Institute of Medical Sciences, Raipur, has started caring for poisoning patients under the Forensic Medicine Department and is also running a DM course in toxicology with two intakes per year. They are taking patients with poisoning cases after the emergency stabilization. The Poison Information Centre is being run at various centres, mainly under the Pharmacology department like AIIMS, New Delhi, which runs the National Poison Information Centre with toll-free (1800 116 117). Amrita School of Medicine, Cochin, runs the Poison Control Centre and Clinical Forensic Medicine with an Analytical toxicology laboratory attached and accredited by the NABL under the Forensic Medicine department. They are not directly involved in the treatment of patients. Substance Abuse and Mental Health Division National Drug Treatment Centre, Ghaziabad (NDDTC), under AIIMS, Delhi, has been established as the apex centre for the management of drugs and substance abuse disorders in India. The centre provides clinical care to patients through community-based OPD and In-patient care, speciality clinics, wards, etc. Health education & preventive measures for substance abusers are done on a community basis. The centre works as a nodal centre for evaluating the prevalence of addiction in society. The centre is involved in staff training and human resources development to cater to such services nationwide, apart from testing, documentation and research in substance abuse disorders. PhD Programme and DM in the area of Addiction Psychiatry running under this centre. Also, they are designated as a WHO Collaborating Centre on Substance Abuse (12). Further, 90 DDAC, 95 ODIC, and 375 IRCA are running under the Ministry of Social Justice and Empowerment all over the country at present (13). Conclusion Healthcare management is interdisciplinary and involves teamwork rather than individual activity. Both the poisoning patients and patients of substance abuse need the care of their mental health. All the poisoning cases and substance abuse cases are medico-legal cases and need the support of Forensic Medicine and Toxicology for Management and other formalities. Hence, the proposed Drug and Toxicological unit at tertiary care centres, with the collaboration of the Departments of Internal Medicine, Pharmacology, Forensic Medicine & Toxicology and Psychiatry for effectively managing substance abuse and poisoning patients, can be paramount. Also, their support in estimating the drug and poison level will help adequately plan healthcare management. Such centres can be nodal centres for the training and research on all aspects of substance abuse and toxicology, including general, pharmaceutical, occupational, environmental, household and others. 1. What is already known on the topic? Answer: Poison information centre is a known concept where the diagnostic facility is also provided at many centres run under Pharmacology and Forensic Medicine. Various centres for the care and management of Substance abuse are also running under the various social initiatives by the WHO and the Government of India. 2. What this study adds? Answer: The paper puts forward a concept of a single centre for the care and management of poisoning cases, substance abuse cases and accessibility of all the aspects of toxicology under a single umbrella, like a One-stop center in case of sexual assault cases. This will improve the quality of care of poisoning and substance abuse case. Also, this paper highlights the need of involvement of Forensic Medicine and Toxicology Department in the management of poisoning cases. 3. Suggestions for further development. Answer: Such a Toxicology unit may be proposed under the different health schemes and government policies to be established at tertiary care centres for streamlined management of poisoning and substance abuse cases. References World Health Organization: WHO. Suicide. Who.int . Published July 8, 2019. [ Link ] . Sharma S. The top 10 causes of death in India. https://www.hindustantimes.com/ . Published September 30, 2017. Accessed April 10, 2019. [ Link ] World Health Organization. “Suicide.” World Health Organization, World Health Organization: WHO, 28 Aug. 2023, [ Link ] The Mental Healthcare Act, 2017|Legislative Department | Ministry of Law and Justice | GoI. [ Link ] . Carrigan CG, Lynch DJ. Managing Suicide Attempts: Guidelines for the Primary Care Physician. Prim Care Companion J Clin Psychiatry. 2003 Aug;5(4):169-174. doi: 10.4088/pcc.v05n0405. PMID: 15213779; PMCID: PMC419387. Sarkhel S, Vijayakumar V, Vijayakumar L. Clinical Practice Guidelines for Management of Suicidal Behaviour. Indian J Psychiatry. 2023 Feb;65(2):124-130. doi: 10.4103/indianjpsychiatry.indianjpsychiatry_497_22. Epub 2023 Jan 30. PMID: 37063624; PMCID: PMC10096207. Wasserman, D., Rihmer, Z., Rujescu, D., Sarchiapone, M., Sokolowski, M., Titelman, D., . . . Carli, V. (2012). The European Psychiatric Association (EPA) guidance on suicide treatment and prevention. European Psychiatry, 27(2), 129-141. doi:10.1016/j.eurpsy.2011.06.003 Hill, N.T.M., Shand, F., Torok, M. et al. Development of best practice guidelines for suicide-related crisis response and aftercare in the emergency department or other acute settings: a Delphi expert consensus study. BMC Psychiatry 19, 6 (2019). [ Link ] Jacobs DG, Baldessarini RJ, Conwell Y, et al. Assessment and Treatment of Patients with Suicidal Behaviors WORK GROUP on SUICIDAL BEHAVIORS.; 2006. [ Link ] Das A, Datta A, Nath A, Bhowmik A. Profile of poisoning cases treated in a teaching hospital of Northeast India with special reference to Poison severity score: A cross-sectional study. J Family Med Prim Care. 2022 Nov;11(11):7072-7076. doi: 10.4103/jfmpc.jfmpc_1076_22. Patel NS, Choudhary N, Choudhary N, Yadav V, Dabar D, Singh M. A hospital-based cross-sectional study on suicidal poisoning in Western Uttar Pradesh. J Family Med Prim Care. 2020 Jun 30;9(6):3010-3014. doi: 10.4103/jfmpc.jfmpc_306_20. “National Drug Dependence Treatment Centre.” AIIMS NEW, [ Link ] . Accessed 31 Oct. 2023. Department of Social Justice and Empowerment National Action Plan for Drug Demand Reduction (NAPDDR) Nasha Mukt Bharat Abhiyaan (NMBA): Annual Action Plan (2021-22) for 272 Most Affected Districts. [ Link ] *Corresponding author and requests for clarifications and further details: Dr. Jitendra Kumar Assistant Professor, Department of Forensic Medicine, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, UP Email- dr.jitendrak2@gmail.com

Main Page > Vol-26 No.- 2 > Paper 2 (you are here) LinkedIn X (Twitter) Facebook Copy link Share Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology Volume 26 Number 2 (July - December 2025) Received : Jan 25, 2025; Revised : manuscript received; May 22, 2025 Accepted : June 18, 2025 Published : June 18, 2025 Ref: Mukesh R, Toi PC , Chaudhari VA, Pandiyan KS, Kumaran M. Death due to Clinically Undiagnosed Hematolymphoid Malignancy: An Autopsy Case Report and Review. Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology [serial online], 2025 ; Vol. 26, No. 2 (July - December 2025): [about 16 p]. DOI: 10.5281/zenodo.15708004 Available from: https://www.anilaggrawal.com/ij/vol-026-no-002/papers/paper002 Email: mukeshfmt22@gmail.com Click here to access PDF. ( All photos can be enlarged on this webpage by clicking on them ) Death due to Clinically Undiagnosed Hematolymphoid Malignancy: An Autopsy Case Report and Review Abstract B-cell lymphomas, a type of hematolymphoid malignancy, constitute 90% of all lymphomas. We report an autopsy of a 33-year-old male with a clinical history of hypothyroidism and anemia brought unresponsive to casualty. The body exhibited no external injuries. Sparse and fine hairs were present in the face, chest, axilla and pubic region, with reduced right testicular size and scrotal volume. The thyroid gland was grossly not palpable and internally untraceable. The spleen was enlarged and softened with a wedge-shaped infarct in the cortical region and a hilar abscess. Under microscopy, the liver showed periportal chronic inflammation, bridging fibrosis and focal interface hepatitis. Acute tubular necrosis with thyroidization of tubules and focal tubular atrophy was reported in the kidney. Lymphoid infiltrates were found in the testis, brain parenchyma, pituitary, and liver, positive for markers like Tdt (Terminal deoxynucleotidyl transferase), CD34, and CD79a. The cause of death was opined as acute tubular necrosis due to septicemia secondary to B-cell lymphoma. After tissue or organ infiltrations, B-cell lymphomas are frequently linked with immunosuppression and multiorgan dysfunction, leading to death. Postmortem immunohistochemistry has helped in finding the key diagnosis in this case. In cases of unexplained anemia or endocrinological abnormalities, autopsy surgeons should rule out hematolymphoid malignancy. Clinicians must include the workup for hematolymphoid diseases in cases with atypical presentation. Keywords- B cell lymphoma; Splenic infarction; Thyroidization; Immunohistochemistry in lymphoma; Hypothyroidism; Thyroid Dysgenesis; life threatening anemia Glossary Bcl: B-cell lymphoma, a general term for lymphomas affecting B cells. ● CD: Cluster of Differentiation, a system used to classify different types of white blood cells. It was suggested in 1982. ● CD34 – CD 34 is a cell surface protein that is commonly used as a marker to identify hematopoietic stem cells (the cells that give rise to all other blood cells) and endothelial cells. ● Clone QBEnd/10 -A specific monoclonal antibody that targets the CD34 protein. Q is a designation given by the laboratory or company that developed the antibody. BEnd: indicate the target [end part refers to endothelial cells]. CD34 is commonly used to identify endothelial cells. 10 represents a sequential identifier, indicating that this is the 10 th clone developed in a series. ● DIC - Disseminated Intravascular Coagulation ● DLBCL : Diffuse Large B-cell Lymphoma, a common type of Non-Hodgkin Lymphoma. ● ECG: Electrocardiogram ● HLM: Hematolymphoid Malignancy ● IVBCL: Intermediate-grade B-cell Lymphoma, another type of Non-Hodgkin Lymphoma. ● Ki: Ki-67, a protein marker used to assess cell proliferation. ● MUM-1: Multiple Myeloma 1. It plays a role in the differentiation of B-cells into plasma cells. It is often used as a marker in immunohistochemistry to identify certain types of lymphomas and myelomas ● NHL: Non-Hodgkin Lymphoma, a type of cancer affecting the lymphatic system. ● PAX: PAX genes - a family of genes involved in the development ● RBC - Red Blood Cells ● Tdt: Terminal deoxynucleotidyl transferase, an enzyme involved in DNA synthesis. It is a specialized DNA polymerase. TdT is primarily expressed in immature, pre-B, and pre-T lymphoid cells, as well as in acute lymphoblastic leukemia/lymphoma cells ● Thyroidization - Thyroid like appearance in renal tissue Introduction Natural deaths due to disease and senility may be unexplained, where the cause of death is not known or unclear to the treating physician[1,2]. "Sudden unexplained death" refers to an unexpected and sudden death in an individual older than 1 year [3]. Unexplained sudden death (Intrinsic Factor(s) Identified) is a type of cause of death statement when the causality of death can be determined. However, intrinsic natural abnormalities like known intrinsic risk factors for sudden death or those of unknown significance are present. Trauma and other unnatural etiologies are properly excluded in such cases [4,5]. In a study, about 6-12% of cases subjected to medicolegal autopsies were determined to have died of natural causes [6]. About 35% of brought dead cases were reported to have a natural cause of death at autopsy [7]. About 8% of adult cases revealed clinically undiagnosed malignancy in autopsy [8]. About 20% of the clinically unsuspected malignancy was detected at the time of autopsy, while 16% presented with metastasis. Among the autopsy-diagnosed cancers, the primary cause of death was malignancy in 16% of such cases, which also includes hematolymphoid malignancies [9]. Hematolymphoid malignancies (HLM) are primary cancers affecting blood, bone marrow, and lymphoid organs, originating from either myeloid or lymphoid cell lines. Lymphomas, lymphocytic leukemia, myelomas and other plasma cell dyscrasias arise from lymphoid cell lines. In contrast, acute myeloid leukemia (AML), chronic myeloid leukemia (CML), myelodysplastic syndromes (MDS) and other myeloproliferative disorders (MPD) are myeloid in origin. Immunohistochemical markers like CD1a(Cluster of Differentiation 1a), CD3 (Cluster of Differentiation - 3), CD7 (Cluster of Differentiation 7), CD8(Cluster of Differentiation 8), CD20 Cluster of Differentiation 20), CD30 (Cluster of Differentiation 30), CD 34 (Cluster of Differentiation - 34), CD 79a (Cluster of Differentiation -79a), TdT (Terminal deoxynucleotidyl transferase), MIB (Cell Proliferation Marker), LCA (Leucocyte Common Antigen), etc. are used in the biopsy diagnosis of various types of HLMs with their expressivity in staining. Organ infiltration from leukemia, lymphoma, myeloma, and related conditions is less likely to be symptomatic than from carcinoma. Patients with HLM are at risk of complications from the neoplasm and treatment [10]. We present an autopsy case report with a postmortem diagnosis of lymphoma in the deceased, who was brought dead to casualty in our hospital after a brief period of hospitalization in another health care center. Case Report We conducted an autopsy of a moderately built 33-year-old man. The deceased allegedly had anemia and hypothyroidism and was suffering epigastric pain along with reduced urine output for 3 days prior to death. As per the clinical records, prior to death, he was admitted to a hospital for management for 13 days. The lab values during the admission period were as follows: Hb-4.5g%, WBC- 12800/mm3, Neutrophils - 67%, Lymphocytes - 29%, Eosinophils - 4%. T3- 46.96 ng/dl (Normal- 70-204 ng/dl)), T4- 2.6 microgram/dl (Normal- 4.6-10.5 microgram/dl), TSH - 1.76 microIU/ml (normal - 0.4 - 4.2 microIU/ml), Blood urea - 40 mg/dl, Serum Creatinine- 1.2 mg/dl, Blood sugar - 87 mg%. ECG showed T wave inversion in V1-V3. The treatment included diuretics, iron supplementation, packed RBC transfusion, antibiotic prophylaxis, and thyroxine supplementation. On external general examination, the body had no injuries, measuring 165 cm in length and 55 kg in weight. The conjunctiva was pale, while fingernails and toenails had nail paint. Natural orifices were free without any discharges. Sparse and fine hairs were present in the face, chest, axilla and pubic region (Figure 1A, 1B, 1C). The volume of the scrotum appeared relatively reduced (Figure 1C). Fig 1. Immature & sparse hairs: Face (A), Axillary region (B) and Pubic region (C) hairs. Reduced testicular size (Arrow mark in C) On internal exploration, the thyroid was not traceable in the anatomical or reported ectopic locations. In front of the arch of the aorta above the tracheal bifurcation, there was a solid grey-white mass measuring 1.5cm X 0.8cm X 0.8cm situated in the superior mediastinum. The adjacent muscle tissue was flabby and more softened. The spleen was soft with an intact capsule measuring 18cm X 11cm in frontal view and 750 g in weight. The cortex showed a coalesced pale infarct involving the entire organ and a wedge-shaped advanced infarct (Figure 2A). A splenic abscess measuring 3cm X3 cm had developed in the hilar region. Liver was congested with intact capsule. Lungs were congested and edematous (Figure 2B). Most segments were firm in consistency. There were multiple petechial hemorrhages in the right atrium and at the base of great vessels, and coronaries were patent. Examination of the kidneys revealed fatty infiltration with renal pelvis hemorrhage (Figure 2C). The right testis was smaller, measuring 4cm X 2cm X 2cm. Left testis appeared grossly normal. The thoracic cavity contained straw-brown colored fluid estimated to be about 750ml (Figure 2D). Fig 2. Significant internal findings In Figure-2 2A Infected pleural fluid in thoracic cavity (Arrows) 2B Frothy edematous fluid in lungs & trachea (Arrow Heads) 2C Infarcts in spleen (asterisk - advanced) 2D Infarcts (Asterisk) & hemorrhagic extravasation with necrosis (arrow head) in kidney Under microscopy, the lungs showed dilated alveoli with interstitial congestion, chronic inflammatory cells with bacterial clumps, and hemosiderin macrophages. The liver showed chronic inflammation, fibrosis, and sinusoidal dilatation with lymphoid cells. The testes showed atrophy of seminiferous tubules and immature lymphoid cells in the interstitium with thickened tunica (Figure 3A). The thymus showed hyperplasia and thick-walled vessels (Figure 3B). Kidney tubules showed acute tubular necrosis, thyroidization, and atrophy with tubular hyaline casts (Figure 3C). Tonsil showed increased lymphoid cells, while lymph nodes showed reactive changes (Figure 3D). The brain showed dilated vessels filled with lymphocytes and parenchymal lymphocytic infiltrates (Figure 3E). The pituitary showed diffuse infiltration of immature lymphoid cells, highlighted with CD79a. The left ventricle showed pericardial fat with chronic inflammation, interstitial oedema, and lymphoid aggregates. The right ventricle of the heart showed thick- walled vessels and lymphoid aggregates. The aorta shows atherosclerotic changes along with lymphoid aggregates (Figure 3F). The unidentified thick mediastinal mass from the thorax showed interstitial spaces and lymphoid aggregates in the background of skeletal muscle cells. The suitable tissues were subjected to immunohistochemistry. Fig 3. Microscopic examination (Hematoxylin & Eosin) showing lymphoid infiltrates in various oegans: A- Testis (10x) B- Thymus (40x) C- Kidney (10x) D- Tonsil (4x) E- Brain (40x) F- Aortic wall (4x) Immunohistochemical staining with primary and secondary antibodies (PathnSitu Biotechnologies) was performed using Ventana platform for CD3 (clone Polyclonal), CD20 (clone L26), CD34 (clone QBEnd/10), CD79a (clone HM47) and TdT (Polyclonal Rabbit Anti-Human TdT Antibody (Abcam, Cat# ab19515)) in a dilution of 1:200 with standard operating protocol. The moderate intensity of DAB chromogen in the slide image was considered positive expressivity. On immunohistochemistry, Tdt, CD34, and CD79a highlighted the immature (probably blast) cells in the pituitary, liver and testis. CD3 and CD20 were negative in the immature B cells. Hence, the possibility of B cell leukemia or lymphoma was reported from histopathological impressions. Blood and sterile fluid culture showed the growth of Escherichia coli. Toxicological examination did not detect any poison or drugs in this case. The cause of death was opined as acute tubular necrosis due to septicemia as a complication of B cell lymphoma. Discussion More than 30% of HLM cases diagnosed in autopsy, were earlier clinically undiagnosed [10,11]. Diffuse Large B cell lymphoma is the most common type of NHL (Non-Hodgkin Lymphoma), frequently observed in adults, and so is indolent lymphoma [12]. The mean age range of autopsy confirmation of HLM is about 36-46 years [10,11,13], whereas the age of the deceased was 33 years in the present case. Lymphoma may be localized, and it may later tend to be rapidly progressive. Diffuse Large B Cell Lymphoma (DLBCL) involves nodal or extranodal sites, including the Waldeyer ring, lung, bone marrow, spleen, liver, and gut, manifesting as a rapidly growing mass [14,15]. Intravascular B Cell Lymphoma (IVBCL), a rare type of non-Hodgkin lymphoma, primarily invades blood vessels and presents with neurological or hemophagocytic symptoms depending on the variant [16]. The spectrum of clinical features in lymphoma includes low- grade intermittent fever, nausea, oliguria, anorexia, abdominal pain, weight loss, oedema, pallor, progressive dyspnea, cognitive decline, painless lymphadenopathy, splenomegaly and lactic acidosis [17-24]. Lymphoid malignancy may be further clinically associated with anemia, hypertension, hypothyroidism, paraplegia and multiorgan failure [25,26]. The present case had an antemortem diagnosis of anemia and hypothyroidism. T wave inversion in lead V1-V3 ECG is a normal variant in children but indicates cardiac pathology in adults [27], which does not exclude secondaries or lymphoid infiltration in the present case. In aggressive cases of lymphoma, autopsy may reveal septic and disseminated intravascular coagulation- like picture bone marrow hyperplasia and hepatosplenomegaly [18,19]. The correlation of gross autopsy features with histopathological findings remains crucial for diagnosis, especially in cases with atypical presentations of HLMs [17,18,29]. Generally, painless lymphadenopathy is found in most HLMs [17]. Enlargement of peripancreatic, mesenteric, hilar, paratracheal, paraaortic and mediastinal lymph nodes have been reported [10]. In cases of NHL, diffuse infiltration by tumor cells causes complete architectural effacement. In our case, lymph nodes showed reactive changes, which could be attributed to infection. Tonsils, in HLM, may show monomorphic proliferation of large lymphoid cells, distinct plasmacytoid features, eccentrically placed nuclei, thick nuclear membranes, variably prominent nucleoli, clumped chromatin, and copious pyroninophilic cytoplasm [36]. In the present case, diffuse infiltration of immature lymphoid cells was found in the tonsils. Diffuse infiltration with angiotropic features, CD20 positivity and decreased ACTH immunoreactivity in the pituitary with associated hypogonadotropic hypogonadism has been reported [37,38]. Diffuse infiltration of lymphoblast cells is found in the pituitary gland with associated hypogonadotropic hypogonadism. Hatem reported diffuse lymphoid infiltration of skeletal muscle in multiple cores with pseudo-glandular structures and sheets observable in low-power microscopy [39]. Skeletal muscle exhibited immature lymphoblast infiltration, with features like large cells, irregular nuclear contours, vesicular chromatin, prominent nucleoli, and moderate cytoplasm in high-power microscopy. Thyroid dysgenesis, which includes thyroid agenesis, hypoplasia and ectopic thyroid, amounts to 80-85% of congenital hypothyroidism [40,41]. Acute leukemia is linked to autoimmune thyroid diseases like Graves' and Hashimoto's thyroiditis, with hypothyroidism being a common outcome of thyroid lymphoma [42]. Also, secondary hypothyroidism is most commonly associated with pituitary disorders/abnormalities [43, 44]. A case study by Foresti showed a cause-effect relationship between leukemic infiltration of the thyroid gland and hypothyroidism, with progressive reduction in thyroid hormones and increases in TSH levels [45]. In our case, there was no trace of thyroid in the neck or mediastinum. Clinically, the thyroid profile has shown decreased secretion of thyroid hormone levels, suggesting the possibility of ectopic thyroid. However, no glandular tissue was identifiable or appreciable in the usual reported areas of ectopic thyroid during the autopsy [46]. A mediastinal unidentified tissue excised in an autopsy suspected of ectopic thyroid also did not show any histological components of thyroid tissue; only lymphoid aggregates were found in the background of skeletal muscle cells. This is similar to a study by Waghmare TP et al. where 18% of the NHL cases had soft fleshy yellow-white mass [10]. The thymus showed hyperplasia with a preponderance of immature B cells in our case. Lymphoma may cause thymus enlargement either by primary involvement or secondary infiltration following the invasion of adjacent lymph nodes. Medullary B-cell lymphoma in the thymus is found in 2% of cases with NHL [47]. Malignant lymphoma in the thymus can resemble hyperplastic thymus. Histologically proven invasion in the thymus was not revealed even in advanced imaging methods like FDG or chemical shift MRIs.[48]. Petechial hemorrhages in the ventricular subendocardial region and cardiac hypertrophy were reported in the literature [10, 49]. The tumor cell infiltrates are reported in the myocardium, epicardium, conduction pathway [49,50], cardiac septum and valves [10]. In the present case, the heart displayed petechiae, inflammation with interstitial oedema, lymphoid aggregates, thick aortic and vessel walls, myxoid changes, and enhanced fibrosis. Pulmonary nodules, mostly calcified and peripheral lung oedema, have been reported [18,19]. Doran reported extensive neoplastic infiltration, generally filling vessels and spilling out into the alveoli while associated with thrombo-embolism and infection (pneumococcus, aspergillus) in the lungs [51]. Microscopic examination of the edematous lung, in our case, revealed dilated alveoli with interstitial congestion with chronic inflammatory cells with bacterial clumps and hemosiderin macrophages. Reported findings of lymphoma in the liver include neoplastic infiltration, fibrosis, cancerous nodules, necrotic areas, Reed–Sternberg cells, hypocellular regions, diffuse organ filtration by leukemic cells, profound infiltration of CD30 (Ki-1) positive lymphoma cells [11,52,53]. Enlarged hemorrhagic lymph nodes at porta hepatis were also reported by Waghmare TP et al. [10]. Infiltrates in sinusoidal and periportal regions with nodular aggregates were recorded. Liver, in the present case, periportal chronic inflammation with bridging fibrosis, focal interface hepatitis, sinusoidal dilatation with large lymphoid cells, despite normal hepatic architecture. Hemorrhagic splenic infarcts involve vascular congestion, hemorrhage, and necrosis, while septic infarcts involve acute or chronic inflammatory infiltrates. Lymphoma-induced splenic infarctions result from blood flow interruption and hence bland infarcts are pale, wedge-shaped, and subcapsular. Septic infarcts have suppurative necrosis and large depressed scars during healing. Splenic abscesses show chronic inflammatory infiltrates and necrotic cells [54]. In our case, the spleen was enlarged with massive pale infarcts, implying the possibility of splenic vessel thrombosis. About 10% of splenic infarcts progress to bacterial abscesses in immunocompromised individuals [55,56]. In the present case, there was a progression into a splenic abscess in the hilar region. Renal enlargement and deposits are reported in HLM [10], while renal pelvic hemorrhage was found in our case. The microscopic findings include acute tubular necrosis, thyroidisation of tubules and focal tubular atrophy with hyaline casts. Tubular atrophy involving broader areas and delineated interstitial fibrosis along the medullary rays forming a striped scarring pattern suggest chronic ischemia. The thyroidization pattern is often seen in urinary reflux or chronic pyelonephritis [57]. Testicular infiltration in leukemia cases is typically bilateral but asymmetric in severity, starting in one testis before affecting both. Specific size measurements of affected testis were hardly found in autopsy-based literature. Its severity is similar to other sites but can be second only to marrow, lymph nodes, and spleen involvement. Microscopic infiltration is most common in acute leukemia, less common in chronic leukemia, and less frequent in lymphoma [58]. Atrophy of the seminiferous tubules with immature lymphoid cells with thickened tunica was observed in our case. Abnormally small testes, smaller than the 50th percentile for age, can be caused by congenital or acquired factors.[59]. Waghmare & Moller reported leukemic infiltrates in the brain parenchyma, meningeal and Virchow robin space [10,60]. Thirunavukkarasu reported patchy myelin pallor in subcortical areas without over-demyelination due to lymphoma cell infiltration [61]. In our case, cerebral vessels were dilated, along with increased vascular and parenchymal lymphocytic infiltrates. Immunohistochemical studies help to type the tumor cells infiltrating various organs like the lungs, liver, spleen, pituitary gland, ovaries, uterus, and bone marrow. Diffuse large cell B-cell lymphoma (DLBCL) tests positive for CD20, CD79a, bcl-2, and MUM1 but negative for CD3, CD5, CD10, CD 56, bcl-6, and cyclin D1 [20, 26]. Reportedly, diffuse CD20 positivity is found in lymphoid cells in sinusoidal and interstitial sites with a Ki-67 index of about 80% to 90% [26]. The CD20 negative subtype of DLBCL is rare and aggressive, with lesser survival rates [62]. B cell lymphoblastic leukemia also tests positive for TdT, CD34, CD79a or PAX5 [63]. IVLBCL exhibits strong intravascular CD20 and CD45 positivity [21]. In the present case, immature B cells in the pituitary, liver and testis tested positive for Tdt, CD34, and CD79a and negative for CD3 and CD20, suggesting B cell lymphoma or leukemia as a final impression on immunohistochemical confirmation. Following flow cytometry, fluorescence in situ hybridization (FISH) analysis is the method of choice for confirmatory diagnosis [64]. CD34 is a transmembrane phosphoglycoprotein found on cell surfaces in humans and animals, used to identify and isolate cancer stem cells (CSC). It is positive in leukemia, breast and lung cancer, and other types of tumors [65]. Terminal Deoxynucleotidyl Transferase (Tdt) is a DNA polymerase found in high levels in the thymus, low levels in normal bone marrow, and absent in normal peripheral blood leukocytes. In adult leukemias, the Tdt level is elevated primarily in lymphoblastic leukemia and low in myeloblastic leukemia [66]. CD79, pan B-cell marker, is a dimeric, transmembrane protein, which, along with surface immunoglobulin, is expressed from the pre-B stage to the plasma cell stage of differentiation. It is found in B-cell lymphomas, B-cell lines, most acute leukemias of precursor B-cell type, megakaryocytic lesions and certain myelomas [67]. Hematological malignancies exhibit a dynamic spectrum of infections among the affected patients [68]. Most of the infections were either systemic or pulmonary [69]. Klebsiella pneumoniae, Escherichia coli and Pseudomonas aeruginosa were the most frequent organisms isolated, resulting in mortality rates up to 48% in diagnosed cases of HLMs [70]. Escherichia Coli is isolated from blood and fluid culture in the present case, forming the primary foci for septicemia like in other cases [70-73]. The specific subtype of B-cell lymphoma may also influence the primary cause of death [10,74]. The progression and transformation into aggressive subtypes, such as diffuse large B-cell lymphoma, has an unfavourable prognosis and increased mortality rates [20]. Complications from the disease, treatment-related side effects and comorbidities contribute to mortality [28, 75-77]. Death was commonly caused by Disseminated malignancy followed by fatal respiratory illness or complications [10,71]. Any infiltrative diseases involving the spleen can also lead to spleen rupture, causing intraperitoneal bleeding, shock, and death [78- 80]. Other causes of death include infection, hemorrhagic shock, hemoperitoneum, thromboembolism, increased intracranial tension with cerebral oedema and conduction abnormalities and associated congenital heart disease [10,20]. Significant autopsy findings in cases of septicemia include pulmonary oedema, diffuse alveolar damage with micro- thrombosis, inflammation & ischemic necrosis of cardiac tissues, acute tubular necrosis, cholestatic jaundice, liver necrosis with sinusoidal aggregates, partial liquefaction of spleen, hemorrhagic adrenal gland, cerebral petechiae, sub-serosal or submucosal hemorrhages in the gastrointestinal tract and features of disseminated intravascular coagulation [81]. In the present case, death is attributed to septicemia secondary to B cell lymphoma in its advanced stage involving multiple organs. Multiple conditions, including syndromic abnormalities like hypogonadism and Kallmann syndrome, were in consideration before concluding the autopsy cause of death in this case. However, the findings from ancillary investigations of the tissues and fluids, in corroboration with the gross features of the case, directed the focus of causality towards B cell lymphoma. Conclusion The unexpected discovery of B-cell lymphoma in this 33-year-old man with a history of anemia and hypothyroidism demonstrates th e potential for these conditions to remain undetected until postmortem investigation. The gross findings, extensive lymphoid infiltration observed across multiple organs on microscopy, and immunohistochemical findings provided crucial evidence for diagnosing B-cell lymphoma. Septicemia, the common fatal complication of B-cell lymphoma as in any HLM, had caused death in this case. The case report highlights the importance of comprehensive autopsy examinations in identifying clinically undiagnosed malignancies, particularly HLMs. Limitations The spleen and bone marrow were not subjected to microscopic studies using cytomorphology, histomorphology, and immunohistochemistry, thereby posing difficulty in locating the lymphoma's primary origin. Suggestions For Autopsy Surgeons: The case highlights the importance of autopsy in medical education, quality assurance, and disease understanding. Postmortem diagnosis of B-cell lymphomas can be challenging due to heterogeneity and limited tissue samples. Understanding gross autopsy findings in HLM is crucial for prompt recognition and management. In unexplained anemia or endocrinological abnormalities, an autopsy should also rule out HLM. For Clinicians: The case report emphasizes the importance of clinicians detecting underlying malignancies in cases with atypical presentations or unexplained deterioration. Advancements in diagnostic techniques like noncoding RNAs, Next-Generation Sequencing, and radiomics provide new insights into disease pathogenesis and development, while tissue proteomics and digital pathology can enhance early detection [82-86]. Conflicts of interest The authors have declared no conflict of interest in the submitted work. Funding/services All authors have declared that no financial support or service was received from any organization for the submitted work. Ethical Approval & Informed Consent This article does not contain any studies with animals. This is a retrospective case report of a medicolegal autopsy. The case data has been completely anonymized with proper de- identification of contents in this report. References Hanzlick R, Hunsaker JC, Davis GJ. Guidelines for Manner of Death Classification. Atlanta. GA. National Association of Medical Examiners. 1st ed. 2002. Available online from: Link Our role in investigating deaths [Internet]. Scotland. Crown Office and Procurator Fiscal Service. 2023 June 9 [Updated on 2024 July 16. Cited on 14 September 2024]. 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Detection of elevated levels of tumor‐associated microRNAs in serum of patients with diffuse large B‐cell lymphoma. Br J Haematol. 2008;141(5):672-5. https://doi.org/10.1111/j.1365-2141.2008.07077.x Gillies RJ, Kinahan PE, Hricak H. Radiomics: images are more than pictures, they are data. Radiology. 2016;278(2):563-77. https://doi.org/10.1148/radiol.2015151169 Griffin J, Treanor D. Digital pathology in clinical use: where are we now and what is holding us back? Histopathology. 2017;70(1):134-45. https://doi.org/10.1111/his.12993 Zheng GX, Terry JM, Belgrader P, Ryvkin P, Bent ZW, Wilson R, Ziraldo SB, Wheeler TD, McDermott GP, Zhu J, Gregory MT. Massively parallel digital transcriptional profiling of single cells. Nat commun. 2017;8(1):14049. https://doi.org/10.1038/ncomms14049 *Corresponding author and requests for clarifications and further details: Dr Mukesh R, Assistant Professor, Department of Forensic Medicine & Toxicology,JIPMER, Pondicherry. Mail at: mukeshfmt22@gmail.com

Main Page > Vol-26 No.- 2 > Paper 1 (you are here) LinkedIn X (Twitter) Facebook Copy link Share Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology Volume 26 Number 2 (July - December 2025) Received: March 12, 2025 Revised Manuscript Received: June 1, 2025 Accepted: June 16, 2025 Ref: Tsranchev I, Timonov P, Toneva I, Fasova A, Dzhambazova E, Uchikov P. Forensic Interpretation and Importance of Pathologic Findings in an Unusual Case of Hanging . Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology [serial online], 2025 ; Vol. 26, No. 2 (July - December 2025): [about 6 p]. Available from: https://www.anilaggrawal.com/ij/vol-026-no-002/papers/paper001 Published: June 16, 2025 DOI: 10.5281/zenodo.15708563 Email: tsranchev@inbox.ru Click here to access PDF. ( All photos can be enlarged on this webpage by clicking on them ) Forensic Interpretation and Importance of Pathologic Findings in an Unusual Case of Hanging Abstract Hanging is one of the most common methods of suicide worldwide, accounting for more than 50% of the population regardless of gender. In addition to being a method of suicide, hanging may also occur postmortem as an attempt to conceal a crime. Therefore, it is important to carefully examine the body and search for typical signs of this type of mechanical asphyxia, as well as for specific pathologic indicators confirming the exact cause, mechanism, and manner of death. The presented case report shows that a concealed homicide must be considered in every hanging victim, which requires a thorough investigation of the scene of death, which could give crucial information about the circumstances, with further important autopsy examination of the body externally and internally, and additional toxicological and histological examination, helping coroners to resolve the case and confirm the exact cause, manner, and mechanism of death. Keywords hanging, suicide, obstruction of orifices, concealed homicide, cause of death, manner of death Introduction Asphyxia generally refers to the deprivation of tissues and organs of oxygen due to mechanical or chemical factors, accompanied by an accumulation of carbon dioxide [1,2]. Mechanical asphyxia is caused by obstruction along the respiratory pathways, which can occur by neck compression, chest compression, obstruction of airway paths, or lack of environmental oxygen [3,4]. In cases of neck compression, there are three main types of asphyxia: hanging (most common in suicides), ligature strangulation (most commonly associated with attempted murder), and manual strangulation (typical homicide) [5,6]. The last could be in combination with other mechanical asphyxia – obstruction of the mouth and/or nose of the victim. There are no pathognomonic signs for the different types of mechanical asphyxia. Still, the correct interpretation of all findings that are specific to one or another type of mechanical asphyxia collected from the crime scene and the corpse examination allows coroners to make an accurate conclusion about the cause, manner, and even mechanism of death. The following case report illustrates the points discussed above, demonstrating how the presence of classic external and internal features in hanging could be crucial in determining whether death was due to obstruction of the mouth and nose or hanging. Case Presentation The body of a 60-year-old man was found hanging in the basement of his house in a block near the town of Pazardjik, Pazardjik district, Republic of Bulgaria. The cellar was locked from the inside with a key that was installed on the lock; no signs of foul play were found at the scene. A white rope was hung from the ceiling of the cellar, and a ligature was made of it, encircling the deceased's neck. The body was hung so that the face was pressed against the surrounding wooden shelves, which were part of the room's interior (Figure 1). No suicide note was found at the scene, but according to relatives, he was depressed due to severe financial problems. The body was sent for a routine autopsy in order for the cause, manner, and mechanism of death to be established. The following findings were present during the external examination of the body: well-developed and fixed lividities, situated mainly on the lower parts of the body and encircling the lower limbs. The neck examination showed the presence of two ligature marks (Figure 2). Figure-1 showing the position of the corpse at the crime scene Figure-2 showing both the ligature marks around the neck region Figure-3 showing the traumatic changes over the lower lip The upper ligature mark was well presented, situated above the level of the thyroid cartilage, with a point of suspension located on the left occipital area of the head. The second ligature mark was presented as an additional furrow situated below the first one, again above the level of thyroid cartilage, visible on the frontal and right aspects of the neck. A slit-like laceration was present on the chin, measuring approximately 3 cm with a depth of 0.5 cm. The margins of the wounds were irregular, bruised, and abraded. Tissue bridges were found in the depth of the wound. Multiple irregularly shaped abrasions were found on the skin of the lower lip (Figure 3). These abrasions had dry, reddish surfaces and did not have scab formation. On the mucosa of the upper lip, two blue bruises with oval shapes and equal size (1 x 2 cm) were visible on the left and the right, while on the lower lip, there were four slit-like lacerated wounds following the line of the dental crowns (Fig. 4). Figure-4 showing the lacerations on the mucosa of the lower lip Figure-5 showing fractures in both the upper horns of the thyroid cartilage and the hyoid bone Figure-6 showing 1. Amussat’s sign and 2. Simon’s bleeding In the left cheek area, there was a patchy bruise measuring 6 x 4 cm. The oronasal passages were not obstructed and clear. The right elbow had a patchy abrasion with a dry reddish surface, measuring 1 x 1.5 cm. A similar abrasion was noted on the middle third of the right forearm. On the front of the left knee, there was a bluish bruise measuring 2 x 2.5 cm. No other traumatic injuries were present on the deceased body. Internal examination: The internal examination of the neck showed that the upper horns of the thyroid cartilage and the hyoid bone were fractured bilaterally, with haemorrhages in the surrounding tissues (Fig. 5). Subcutaneous haemorrhages were observed beneath the ligature mark. Well- defined haemorrhages of the neck muscle (superficial and deeply situated ones) were present. Amussat's sign (arrow 1 in the figure) was represented by linear transverse tearing on the intima of the right carotid artery (see Figure 6) in combination with Simon’s bleeding (arrow 2 in the same figure). Both lungs were congested and oedematous with multiple dot-like subpleural petechial haemorrhages. The toxicology results were negative for alcohol and drugs. No other traumatic injuries were observed over the body, externally or internally. Samples from internal organs were taken, glass slides with H-E staining were generated, and additional microscopic examination was performed with a Zeiss PrimoStar microscope with zooms of x10, x40, and x100. Organs showed well- presented stasis, oedema, and petechial haemorrhages. Skin samples from ligature marks showed evidence of vitality – haemorrhages into the true dermis with inflammatory white cells in depth. Based on all autopsy findings and all performed additional examinations, the cause of death was determined as mechanical asphyxia due to hanging. Discussion There are no pathognomonic signs to distinguish the different types of mechanical asphyxia. Hanging can result from homicide, suicide, or an accident. Cases of suicide by hanging are the most frequently described in the literature, accounting for around 95 % of all cases. In contrast, cases of homicide by hanging are rare [7]. The reasons for committing suicide vary – mental disorders, personal dissatisfaction with life, or the onset of a malignant disease threatening the patient’s life. These rare tumours often appear at a young age [8]. It is more typical to see the concealment of a committed murder, where the victim is hanged after death in an attempt to simulate suicide. Accidental cases are usually seen in cases of autoerotic asphyxia [9-13]. The determination of whether death is the result of homicide, suicide, or accident is based on findings at the scene (the position of the body related to the surrounding interior), specific autopsy findings, and additional toxicological results. In the presented case, the presence of two ligature marks and only one ligature material could be explained by the body slipping during the convulsive phase, typical for death caused by mechanical asphyxia, or as an alternative possible mechanism of production - by an initial incomplete process of hanging attempt in a close time interval. The cause of death was attributed to mechanical asphyxia due to hanging. The conclusion was made by the presence of the following characteristics of vital injury: bilateral fracture of upper horns of the thyroid cartilage and hyoid bone, bruising of the neck muscles, and tears in the intima of the carotid arteries (Amussat’s sign). Another possible finding that could be observed in cases of hanging is the so-called “Simon’s bleeding”, referring to stripe-like haemorrhages on the ventral surface of the intervertebral discs of the lumbar part of the spinal column [14-17]. All these vital morphologic features seen over the cadaver during the coroner's examination play essential roles as evidence for the vitality of the occurred mechanic asphyxia and as predictors of the exact mechanic asphyxia type – especially hanging, not mechanic obstruction of orifices [18-21]. The abrasions and bruises on the limbs and traumatic changes around the face and oral cavity are a result of the body interacting with the shelves during the convulsive phase. Some injuries, especially oral lacerations, could be, in rare cases, incompatible with life due to following aspiration of blood, and the patient would not survive even if found alive due to a hypoxic state. The changes occurring in the damaged tissues are irreversible, and they lose their function [22]. Imaging studies are also highly informative regarding the type and mechanism of the injury [23]. The presence of typical vital markers for death occurring by hanging in combination with all other features, achieved by the crime scene examination and additional microscopic and toxicologic analysis, excludes another type of asphyxiation in the recent case and confirms the mechanism, manner, and cause of death. Given the scene findings, autopsy findings, and additional laboratory findings, the hypothesis of suicide is accepted from an expert point of view. Conclusion Determining the manner of death in a case of hanging is not always such an easy expert task. The presented case report shows that a concealed homicide must be considered in every hanging victim, which requires a thorough investigation of the scene of death, which could give crucial information about the circumstances. Knowing and searching for the classic external and internal morphologic signs of death by hanging still plays a vital role in determining the expert answers about the cause, mechanism, and manner of death in doubtful clinicopathologic cases, while the correct forensic diagnosis plays its crucial role in the process of crime investigation by a criminal point of view. References Stoicho R. Forensic Medicine and Deontology, 2006 Gautam B. Review of Forensic Medicine and Toxicology. 2012 Wyatt JP. Oxford handbook of forensic medicine. Oxford: Oxford University Press; 2011. Hausfeld JN, Yanagisawa E, Pensak ML. Sudden Airway Obstruction Due to Pedunculated Laryngeal Polyps. Annals of Otology, Rhinology & Laryngology. 1983 Jul;92(4):340–3. Biliana Mileva, Kiryakova T, Nikolov D, Alexandrov A. NEONATICIDE – LIGATURE STRANGULATION OF A NEWBORN. DOAJ (DOAJ: Directory of Open Access Journals). 2019 Dec 1; Nikolov D, Brainova-Michich I, Goshev M, Alexandrov A, Hristov S. 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Mileva B, Goshev M, Valcheva M, Alexandrov A, Braynova I. Forensic Interpretation and Importance of Simon’s Bleeding, Amussat’s Sign and Other Typical Findings of Hanging as Diagnostic Signs. Cureus. 2024 Apr 8; Hejna P, Bohnert M. Decapitation in Suicidal Hanging - Vital Reaction Patterns. Journal of Forensic Sciences. 2012 Nov 5;58:S270–7. Clément R, Redpath M, Sauvageau A. Mechanism of Death in Hanging: A Historical Review of the Evolution of Pathophysiological Hypotheses. Journal of Forensic Sciences. 2010 Sep;55(5):1268–71. Tattoli L, Buschmann CT, Tsokos M. Remarkable findings in suicidal hanging. Forensic Science Medicine and Pathology. 2014 Apr 7;10(4):639–42. Tumram NK, Ambade VN, Bardale RV, Dixit PG. Injuries over neck in hanging deaths and its relation with ligature material: Is it vital? Journal of Forensic and Legal Medicine [Internet]. 2014 Feb 1 [cited 2021 Nov 12];22:80–3. Available from: https://www.sciencedirect.com/science/article/abs/pii/S1752928X13003454 Anastasova VN, Georgiev AA, Zanzov EI, Velkova KG, Krasteva ES. High-Intensity Focused Ultrasound Thermotherapy for Scar Treatment. PubMed. 2023 Mar 1;36(1):63–7. Georgiev AA, Desislava Tashkova, Lyubomir Chervenkov, Anastasova V, Kitova T. Primary synovial sarcoma of the shoulder: Case report of the “triple sign” on proton density magnetic resonance imaging. Radiology Case Reports. 2022 Dec 26;18(3):943–7 *Corresponding author and requests for clarifications and further details: Ivan Tsranchev, Medical University of Plovdiv, Republic of Bulgaria, Europe Email- tsranchev@inbox.ru

Main Page > Vol-27 No- 1 > Paper 1 (you are here) LinkedIn X (Twitter) Facebook Copy link Share Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology Volume 27 Number 1 (January - June 2026) Received: March 20, 2025 Accepted: June 16, 2025 Ref: Tsranchev I , Timonov P , Yancheva S , Hadzhieva K , Gudelova T , Sotirova M , Fasova A , Dzhambazova E , Uchikov P. Posttraumatic Ischemic Brain Stroke After Sharp Neck Injury: A Case Report Based on Autopsy. Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology [serial online], Vol. 27, No. 1 (January - June 2026): [about 11 p]. Available from: https://www.anilaggrawal.com/ij/vol-027-no-001/papers/paper001 Published as Epub Ahead: June 25, 2025 DOI: 10.5281/zenodo.15743623 Email- tsranchev@inbox.ru Click here to access PDF. ( All photos can be enlarged on this webpage by clicking on them ) Posttraumatic Ischemic Brain Stroke After Sharp Neck Injury: A Case Report Based on Autopsy Abstract Neck injuries usually are emergency medical conditions which require special medical attention. Several complications following neck trauma could be fatal, if they are not correctly treated and diagnosed. Present case is of a 56-year- old male patient sustained sharp neck trauma, who was immediately admitted for hospital treatment, with following surgical reconstruction of the left carotid artery. Two days after the surgical intervention, the patient showed clinical signs of coma and sudden respiratory and cardiac failure, resulting in a lethal outcome. Autopsy and microscopic findings revealed a life-threatening post-traumatic complication following such type of trauma. In each case of sharp or blunt neck trauma, the diagnosis “post-traumatic ischaemic brain stroke” must be ruled out as a possible serious complication by a detailed examination, including laboratory, ultrasonography, contrast angiography and various specific imaging methods. All these medical actions as standard medical algorithm can save the patient’s life. Keywords: Neck injury, posttraumatic brain stroke, sharp force trauma, fatal outcome, medico-legal case Introduction In routine forensic practice, various types of trauma can contribute to neck injuries, potentially leading to severe consequences or even a fatal outcome for the patient. Death could be directly attributed to the source of the injury or as a result of a complication following such a neck injury [1]. One possible cause of death can be a post-traumatic ischaemic brain stroke after blunt or sharp neck trauma involving blood vessels in the neck, which supply the brain with blood, which in turn can be a reason for blood clots and/or emboli, causing critical cerebrovascular blood flow blockage and death of brain tissue. In these emergency cases, if such an injury to the arteries can be diagnosed at the time after the trauma, a patient could be treated with different types of anti-clotting medications to prevent thrombosis and potential stroke formation, thus saving the patient's life. Case Presentation Fig.1 showing the neck region represented with a zigzag wound A 56-year-old male patient after excessive alcohol consumption fell to the floor in a bar and injured his neck on pieces of a broken glass. Immediately after, he was transported by emergency medics to the University Hospital "St George", Plovdiv, Bulgaria. After a detailed emergency room assessment, he was transferred to the Department of Vascular Surgery with the diagnosis of an "incised wound in the neck region with severance of the left carotid artery." An emergency reconstruction of the vessel wall was performed. Two days after the surgical intervention, the patient presented with clinical signs of coma and sudden respiratory and cardiac failure, resulting in a lethal outcome. After death, the body was transferred to the Department of Forensic Medicine for routine forensic examination. During the examination of the cadaver in the autopsy room, it was observed that on the frontal surface of the neck, in its upper third, just below the tip of the chin and slightly to the left, a slit-shaped incised wound was found, which had been surgically treated and stitched with 4 sutures. The length of the wound was 5cm. The edges of the wound were relatively clean and smooth; the edges were sharp. On the left half of the frontal surface of the neck, in the upper, middle and lower thirds, a large zigzag wound was found, stitched with 15 sutures. The length of the wound was 17 cm. The edges of the wound were also relatively smooth and clean, slightly congested, with scattered necrotic areas (Fig. 1). The wound was additionally assessed by performing several deep surgical cuts. A slit-shaped wound, 1 cm long and treated with one stitch, was found 2 cm to the left of the zigzag wound in the middle third of the neck. Fig.2 showing the left common carotid artery and inserted prosthesis inside with a greyish-reddish dense thrombus The skin in the neck area was carefully dissected, and the zigzag wound was examined in depth. The muscles in the left half of the neck were diffusely blood-soaked with a dark reddish colour. The middle third of the sternocleidomastoid muscle had impaired integrity and had undergone surgical suturing. The muscle was dissected, and the left carotid artery was reached. It was found that a 2.5 cm long section from the common carotid artery to the carotid sinus was replaced by an artificial Dacron-type prosthesis. The left common carotid artery was opened during the autopsy, and at the upper end of the inserted prosthesis, a greyish-reddish dense thrombus was found inside, adhered to the prosthesis-vessel transition (Fig. 2). The thrombus occluded the lumen of the carotid artery by about 90%. Along the course of the external carotid artery at its beginning, two transverse tears in its intima with lengths of 0.2 and 0.4 cm were found. There was a tear in the wall of the left jugular vein at the level of the described carotid artery prosthesis. The tear is sutured. Its length was 0.5 cm. During the internal examination of the cadaver, all soft tissues forming the scalp were intact, with a moist surface and a pale pink colour. The bones of the cranium were intact. The dura mater was pearly in colour and had a smooth surface. The cerebral gyri were smoothed, and the sulci were narrowed. In the left parieto-temporal region, there was a section of the cerebral cortex, sunken below the level of the surrounding brain tissue, with a pale greyish-yellowish colour, sized 4cm by 3.5 cm. We fixed the brain in a 10% formaldehyde solution for 48 hours before conducting a detailed examination. Fig.3 showing the infarction of brain matter over the left cerebral hemisphere The cerebral vessels at the base of the brain were well developed without malformations. A detailed examination revealed a hard, greyish-reddish thrombus occulting the left middle cerebral artery. Consecutive sections of the brain were made. In the left parieto-temporal region of the brain, a large area of softening with a livid-greyish colour was found, with peripheral reddish haemorrhages (infarction) around it. The border between the grey and white brain matter was obliterated (Fig. 3). This area measured approximately 8 cm x 7 cm as dimensions on the surface of the left cerebral hemisphere with depth measured 7 cm in the left cerebral hemisphere. The left middle cerebral ventricle narrowed, and the left cingulate gyrus (gyrus cinguli) was shifted to the right. In the hypothalamus in the left cerebral hemisphere, a dark reddish round haemorrhage measuring 0.5 cm x 0.5 cm was also found. A similar haemorrhage was found in the basal nuclei of the left hemisphere, measuring 1 cm x 0.5 cm. Along the course of the brainstem (pons and medulla oblongata), numerous dark reddish haemorrhages measuring from punctate to 0.5 cm in diameter were found. In cross-section, the cerebellum was clear and normally developed. Fig. 4 showing multiple haemorrhages and oedema in the left frontal and left parietal cortex. H-E staining. Samples from brain matter were taken, and further microscopic examination was performed with H-E staining under Primo Star Zeiss microscopes with enlargements of 10x, 40x, and 100x. The detailed microscopic examination showed haemorrhages, oedema and multiple massive punctate haemorrhages in the left frontal cortex with multiple massive punctate haemorrhages in the left parietal cortex (Fig. 4), in combination with hyperaemia of blood vessels in the arachnoid layer. Additional microscopic findings were stated during this examination as follows: corpus callosum – mild oedema, hypothalamus – massive punctate haemorrhages and mild oedema, pons – areas with haemorrhages and severe oedema, medulla oblongata – severe oedema, cerebellum – oedema, cortex – mild oedema 2. Carotid artery vessel wall – part of a vessel with mixed thrombus (fig. 5). Other samples from internal organs showed no significant pathologic changes. Fig.5 showing the carotid artery vessel wall – part of a vessel with mixed thrombus. H-E staining Discussion Ischaemic strokes resulting from carotid artery thrombosis following open and closed head and neck trauma have been recognised with increasing frequency recently, and these cases involve not only adults but even children [2-6]. They can lead to life-threatening consequences or even a fatal outcome if they are not diagnosed correctly [7-10]. Ischaemic strokes resulting from carotid artery thrombosis are observed in both blunt and sharp injuries, such as in the case report described above. Carotid artery thrombosis is a rare but potentially devastating complication that can follow even reconstructive surgery of any major traumatised blood vessel of the neck region [11, 12]. The non-traumatic genesis of carotid artery thrombosis, which can lead to ischemic stroke, should also be considered in such cases. The most common cause of non-traumatic carotid artery thrombosis is atherosclerosis [13]. In the presence of an unstable atherosclerotic plaque or an ulcerated atherosclerotic plaque, the endothelium of the arteries is compromised. In these cases, coagulation factors are activated, which predisposes to the formation of thrombi. In our case report during the autopsy, no atherosclerosis of the carotid arteries was detected. Other factors, of a non-traumatic nature, also predispose to the formation of thrombi in the body, such as obesity, pregnancy, smoking, arterial hypertension, and hyperlipidemia. Our case lacks previous patient history on whether the patient had any of the above-listed diseases based on medical documentation, and no pathological changes or malformations of the vessels in the brain were identified during the autopsy and on microscopy. Other causes of ischemic stroke are emboli. Most often, emboli form in the heart in the area of a post-infarction aneurysm, in the left auricle of the heart in patients with ventricular fibrillation, and in patients with bacterial endocarditis. No such conditions were found in our case report. Taking certain medications, such as oral contraceptives, can cause blood clots to form in women. Different mechanisms can cause traumatic internal carotid artery thrombosis, including direct traumatic force delivered to the neck, the head, or the oral cavity, resulting in trauma to the soft tissues or even to the cranial bones, other possible mechanisms are whiplash trauma, seatbelt trauma or even procedures in the neck region [14]. Studies have shown that factors significantly increasing the risk of developing carotid thrombosis due to carotid artery injuries include non-penetrating head injury, basilar fractures of the skull, facial fracture, cervical spinal fractures and thoracic injuries [15], with the non-penetrating head injury being the most common single associated injury. In the literature is suggested that combined injuries to the upper part of the body /head and neck injuries especially skull and spinal fractures and combined injuries to the head and chest/ increase the risk of damage to the carotid arteries. In our case the patient did not sustain any other trauma, except to the neck. In this case, we concluded that the cause of death is an ischaemic brain stroke caused by vascular injury resulting from sharp force trauma to the neck. He sustained a reconstructive operation on the traumatised section of the common carotid artery, which was replaced with an artificial Dacron-type prosthesis, despite additional anticoagulation therapy. During the autopsy, a thrombus was found adhered to the prosthesis-vessel transition. The macroscopical and histological examinations determined ischaemic brain stroke.These results imply that the carotid artery damage location is where the thrombus originated. It is therefore very likely that the thrombus formed as a result of an intimal tear in the carotid artery caused by the sharp force trauma. The patient died three days later, with clinical signs of coma and sudden respiratory and cardiac failure. In summary, for patients admitted for treatment as a result of neck trauma caused by a sharp object, it is important to monitor them, especially in the first few days, for the appearance of neurological symptoms [16]. It is known that in the early stages of development of an ischaemic stroke of the brain, changes may not be visualised with standard imaging techniques like a CT scan. Therefore, numerous tests have been developed that can provide an early evaluation of a neurological condition, such as the MMSE (mini mental state examination) or Folstein test, the Hodkin-son abbreviated mental test score. Highly sensitive imaging methods have also been developed, such as diffusion-weighted magnetic resonance imaging (DWI or DW-MRI), which is highly sensitive to the changes occurring in the lesion and revealing subclinical neurological changes. These imaging-specific methods could be used in combination with specific biochemical markers, proving the diagnosis [17]. CT angiography is also a highly sensitive and informative imaging method which could be in helpful use for the correct diagnosis. Conclusion Different diagnostic methods, clinical assessing tests and biochemical markers could be used in cases of sharp force neck trauma to diagnose this type of life-threatening post-traumatic complication in trauma patients. In each case of sharp or blunt neck trauma, the diagnosis “post-traumatic ischaemic brain stroke” must be ruled out as a possible serious complication. A detailed examination, including laboratory, ultrasonography, contrast angiography and various specific imaging methods with the rich patient’s history, periodic neurologic consultation and physical examination, must be performed as a standard algorithm for medical action in such types of clinical cases. That could prevent fatal complications and can save a patient’s life. References Tawil I, Stein DM, Mirvis SE, Scalea TM. Posttraumatic cerebral infarction: incidence, outcome, and risk factors. J Trauma. 2008 Apr;64(4):849-53. doi: 10.1097/TA.0b013e318160c08a. PMID: 18404047 Yılmaz S, Pekdemir M, Sarısoy HT, Yaka E. Post-traumatic cerebral infarction: a rare complication in a pediatric patient after mild head injury. Ulus Travma Acil Cerrahi Derg. 2011 Mar;17(2):186-8. PMID: 21644101. Chaturvedi S, Sohrab S, Tselis A. Carotid stent thrombosis: report of 2 fatal cases. Stroke. 2001 Nov;32(11):2700-2. PMID: 11692038. Moulakakis KG, Kakisis J, Tsivgoulis G, Zymvragoudakis V, Spiliopoulos S, Lazaris A, Sfyroeras GS, Mylonas SN, Vasdekis SN, Geroulakos G, Brountzos EN. Acute Early Carotid Stent Thrombosis: A Case Series. Ann Vasc Surg. 2017 Nov;45:69-78. doi: 10.1016/j.avsg.2017.04.039. Epub 2017 May 5. PMID: 2848362 Caldwell HW, Hadden FC. Carotid artery thrombosis; report of eight cases due to trauma. Ann Intern Med. 1948 Jun;28(6):1132-42. doi: 10.7326/0003-4819-28-6-1132. PMID: 18864120 Hockaday TD. Traumatic thrombosis of the internal carotid artery. J Neurol Neurosurg Psychiatry. 1959 Aug;22(3):229-31. doi: 10.1136/jnnp.22.3.229. PMID: 14402209; PMCID: PMC497379 Schneider RC, Lemmen LJ. Traumatic internal carotid artery thrombosis secondary to nonpenetrating injuries to the neck; a problem in the differential diagnosis of craniocerebral trauma. J Neurosurg. 1952 Sep; 9(5): 495-507. doi: 10.3171/jns.1952.9.5.0495. PMID: 12981571. Moulakakis KG, Mylonas SN, Lazaris A, Tsivgoulis G, Kakisis J, Sfyroeras GS, Antonopoulos CN, Brountzos EN, Vasdekis SN. Acute Carotid Stent Thrombosis: A Comprehensive Review. Vasc Endovascular Surg. 2016 Oct;50(7):511-521. doi: 1177/1538574416665986. Epub 2016 Sep 19. PMID: 27645027 Julia C. Schmidt, Dih-Dih Huang, Andrew M. Fleming, Valerie Brockman, Elizabeth A. Hennessy, Louis J. Magnotti, Thomas Schroeppel, Kim McFann, Landon D. Hamilton, Julie A. Dunn, Missed blunt cerebrovascular injuries using current screening criteria — The time for liberalised screening is now. Injury, Volume 54, Issue 5, 2023, Pages 1342-1348, ISSN 0020-1383, https://doi.org/10.1016/j.injury.2023.02.019 Macdonald S. Brain injury secondary to carotid intervention. J Endovasc Ther. 2007 Apr;14(2):219-31. doi: 10.1177/152660280701400215. PMID: 17488181. Setacci C, de Donato G, Setacci F, Chisci E, Cappelli A, Pieraccini M, Castriota F, Cremonesi A. Surgical management of acute carotid thrombosis after carotid stenting: a report of three cases. J Vasc Surg. 2005 Nov; 42(5):993-6. doi: 10.1016/j.jvs.2005.06.031. PMID: 16275459. Iancu A, Grosz C, Lazar A. Acute carotid stent thrombosis: review of the literature and long-term follow-up. Cardiovasc Revasc Med. 2010 Apr-Jun; 11(2):110-3. doi: 10.1016/j.carrev.2009.02.008. PMID: 20347802.] Torvik A, Svindland A, Lindboe CF. Pathogenesis of carotid thrombosis. Stroke. 1989 Nov; 20(11): 1477-83. doi: 10.1161/01.str.20.11.1477. PMID: 2815181. Karnecki K, Jankowski Z, Kaliszan M. Direct penetrating and indirect neck trauma as a cause of internal carotid artery thrombosis and secondary ischaemic stroke. J Thromb Thrombolysis. 2014 Oct; 38(3): 409-15. doi: 10.1007/s11239-014-1077-2. PMID: 24748050; PMCID: PMC4143597. Hayakawa A, Sano R, Takahashi Y, Fukuda H, Okawa T, Kubo R, Takei H, Komatsu T, Tokue H, Sawada Y, Oshima K, Horioka K, Kominato Y. Post-traumatic cerebral infarction caused by thrombus in the middle cerebral artery. J Forensic Leg Med. 2023 Jan; 93:102474. doi: 10.1016/j.jflm.2022.102474. Epub 2022 Dec 24. PMID: 36577210 Fisher M, Paganini-Hill A, Martin A, Cosgrove M, Toole JF, Barnett HJ, Norris J. Carotid plaque pathology: thrombosis, ulceration, and stroke pathogenesis. Stroke. 2005 Feb;36(2):253-7. doi: 10.1161/01.STR.0000152336.71224.21. Epub 2005 Jan 13. Erratum in: Stroke. 2005 Oct; 36(10): 2330. Capoccia L, Speziale F, Gazzetti M, Mariani P, Rizzo A, Mansour W, Sbarigia E, Fiorani P. Comparative study on carotid revascularisation (endarterectomy vs stenting) using markers of cellular brain injury, neuropsychometric tests, and diffusion-weighted magnetic resonance imaging. J Vasc Surg. 2010 Mar; 51(3):584-91, 591.e1-3; discussion 592. doi: 10.1016/j.jvs.2009.10.079. Epub 2010 Jan 4. PMID: 20045614 *Corresponding author and requests for clarifications and further details: Ivan Tsranchev, Medical University of Plovdiv, Republic of Bulgaria, Europe Email- tsranchev@inbox.ru

Main Page > Vol-27 No- 1 > Paper 2 (you are here) LinkedIn X (Twitter) Facebook Copy link Share Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology Volume 27 Number 1 (January - June 2026) Received: May 20, 2025 Revised Manuscript Received: June 8, 2025 Accepted: June 20, 2025 Ref: Hamzah NH, Osman K, Nadarajan N, Tham JC, Khairuddin N, Sabri MI, Nasir AM, Isa NM. Can Lip Prints Change Overnight?: A Study of Lip Print Stability Across Day and Night as a Forensic Identification Tool. Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology [serial online], Vol. 27, No. 1 (January - June 2026): [about 9 p]. Available from: https://www.anilaggrawal.com/ij/vol-027-no-001/papers/paper002 Published as EpubAhead: June 26, 2025 DOI: 10.5281/zenodo.15743496 Email: khairos@ukm.edu.my Click here to access PDF. ( All photos can be enlarged on this webpage by clicking on them ) Can Lip Prints Change Overnight?: A Study of Lip Print Stability Across Day and Night as a Forensic Identification Tool Abstract Aim Lip prints have long been considered unique and stable over time, causing a boost of cheiloscopy research to understand the potential of lip prints for forensic identification. While studies looking at lip print stability over time are common, this study investigates the stability based on the day and night phenomenon. Methodology Lip prints were taken from 200 participants from the campus population using the standardised paper technique, wherein lip prints were made on A4 papers then digitised using a high- resolution scanner. Lip prints similarity percentage were formed by comparison of the prints collected at the morning and evening, then analysed using Contrastive Language-Image Pre- training (CLIP) image analysis model. Statistical analysis included repeated-measures ANOVA to compare the lip print similarity percentage obtained at Day 1, Day 7 and Day 14. Intra-class correlation coefficient (ICC) is used to test the reliability of the CLIP model to analyse lip print images. Results Repeated measures ANOVA indicated significant variation in lip prints similarity percentage obtained at Day 1, Day 7 and Day 14. The intraclass correlation coefficient (ICC) was rated 0.649, between fair and good. Conclusion The study concludes that lip print morphology may not be as stable over short time intervals as previously assumed, and this variability should be considered in forensic evidence collection. Keywords Cheiloscopy, Lip Prints, Deep Learning, Digital Analysis, ICC Abbreviations CLIP Contrastive Language-Image Pre-training ICC Intra-Class Correlation SD Standard Deviation SPSS Statistical Package for the Social Sciences Introduction Lip print analysis raises questionable potential for forensic identification, known as cheiloscopy, and faced a turning point after the study by Tsuchihashi in 1974.[1] Lip prints are considered relatively stable over time and unique, similar to fingerprints. [2-5] However, the assumption of temporal stability has not been sufficiently challenged, particularly over short-term intervals such as within the day and night of the same day. Previous studies have primarily assessed long-term consistency of lip prints and their uniqueness among populations over long time intervals. [6,7] However, these studies are conducted with manual observation and no quantitative analysis was utilised to measure lip print similarity, thus invalidating efforts to ensure lip prints can adhere to the Daubert’s standard of evidence. [8] This study aims to explore the short-term variability of lip prints across different times of day using a novel digital approach. We employed Contrastive Language-Image Pre-training image analysis model (CLIP), a deep learning model capable of analysing images and calculating similarity percentage based on the potential changes of lip print patterns from day to night. Our hypothesis is that the lip print morphology may vary during the morning and evening due to natural biological fluctuations based on the circadian rhythm. Need for ‘this’ study Despite most studies describing lip prints as being stable, there is only a study measuring lip print stability quantitatively using similarity percentage. [9] This study presented new insights to lip print stability by classifying the similarity rate of lip print patterns into three categories based on their similarity percentage. Based on the results, the lip print similarity percentage was classified as medium (73.8%), meaning there may be potential changes in lip print patterns. The authors would like to provide new insights to these lip print pattern changes. On the other hand, digital analysis needs to be utilised in lip print analysis to accurately measure potential changes in lip prints. The application of digital analysis methods in forensic science allows better visualization, easier identification, and complete recording of images. [10] Our research findings would be able to provide new insights in measuring lip print similarity percentage. This study also presents a new perspective to measuring lip print stability. While time is usually the parameter used, the authors believe potential changes of lip print patterns based on the circadian clock system. The circadian clock plays an important role in oral and maxillofacial physiological and pathological processes. [11] In this present work, we studied the similarity of lip prints collected in a university campus population during the day and night phenomenon. Methodology This descriptive cross-sectional comparative study of 200 individuals was conducted periodically from November 2024 to March 2025. Every subject underwent a sample collection period of 2 weeks where the prints were collected on Day 1, Day 7 and Day 14. Collection sessions were divided into morning and evening. The suitable sample size, 200 was calculated based on these factor considerations as suggested by the Cohen’s D convention. [12] The factors are as below: i) Effect size Set at a value of 0.2, a small effect size magnitude is used to observe the potential small variations in lip print patterns. ii) Significance level, α Set at 5% as the majority of studies in this field which has a similar motive of observing lip print changes. [13, 14, 15] iii) Power Set at 80% as the majority of studies in this field with similar motives mentioned as above. [13, 14, 15] The G*Power statistical software is used to calculate an appropriate sample size. The supporting figure from the software is as below where the suggested sample size is 199, and rounded up to 200 subjects [Figure. 1] . Figure 1. Sample size calculation on G*Power software The Ethical Committee from Universiti Kebangsaan Malaysia approved this study. It was made sure all subjects were above 18 years old. Written consent from the subjects were taken before collecting their lip print as samples. The subjects consisted of both students and staff. 57 of the subjects were staff while 143 were students. From the 143 students, 50 were 2nd year undergraduate students, 83 were final year undergraduate students while 40 were postgraduate students as mentioned in [Figure 2] . Figure 2. Phase wise Distribution of Study Population From the consent form, several sociodemographic parameters related to the study such as sex, race, university campus and age are included in a table [Table 1]. Table 1. Sociodemographic profile of subjects Smeared lip prints, with unclear structure visualisation, or lip prints which were too dark due to excess lipstick smear were not included in analysis. Excluded lip prints were lips and/or nearby surrounding structures with inflammation/trauma, lips with malformation or deformity, lips with surgical scars, lips with ulcers, lips with wounds, lips with abnormalities, dry and chapped lips, and history of smoking cigarettes/vaping. Materials Lipstick (crimson poppy shade, non-glossy; IN2IT brand), white A4 sized papers (Double A brand, 80 gms), facial tissues (Premier brand, 2 Ply), facial wipes (Guardian brand), disposable lip brush (Cleo brand), digital printer (Brother DCP- J100 brand, 600 dpi). Software Google Colaboratory, Contrastive Language-Image Pre-training (CLIP) image processing model Sample collection 1. Sample preparation The lip prints were compared from the same subject at Day 1, Day 7, and Day 14. The collection sessions were held at the morning and evening of these days. The subjects cleaned their lips with facial wipes. A thin lipstick layer was applied using a clean disposable lip brush to the lips in a singular motion. [16] The subject then rubbed their lips to spread the lipstick more uniformly. [17] A plain white paper was used to take a print while minimal pressure was applied with the index finger (by the researcher). The slightest movement of the lips while recording print can smear the samples hence, the subject was advised to remain still and maintain the position of their lips so they could be adequately traced. Facial wipes were used to clean the lips after the procedure. Three lip prints were collected at each collection period where the best print in terms of clarity was chosen for analysis. 2. Image Digitization Three replicated lip print samples were taken from each subject at every collection period, where the clearest print would be digitised with a high-resolution printer (600 dpi). All selected lip prints were scanned in grayscale (8-bit) format. The digital images were standardized to a uniform dimension (550 x 232 pixels, 72-point resolution) and saved in Tag Image File Format (TIFF). These images were inputted in the Google Drive folder. Digital Analysis A modified Python code is used train the CLIP model for image recognition. The code is run on Google Colaboratory (Colab) platform. This study just uses the CLIP model alone for all image analysis tasks, making it quite different compared to traditional image recognition studies that needs different models for different tasks. [18,19] In this study, the image encoder feature and the zero-shot feature from the CLIP model are widely used for feature extraction and classification of these lip print images. The zero-shot feature is useful for model training to match up the lip prints between two subjects. The comparison between the lip print collected in the morning and evening of the same day was quantified as a percentage based on the cosine similarity of their respective feature vectors [Figure. 3] . A value closer to 100% indicates a higher probability of a match between both prints. Figure 3. Detection of lip print’s unique features with the CLIP image analysis model Prior to analysis, control samples were processed as a validation and testing step to ensure accuracy. A negative control (clean blank paper) was used to establish a baseline. A positive control (lip print from an existing database) was used to verify script functionality. The workflow is as below [Figure. 4]. Figure. 4 Methodology Workflow Statistical Analysis The software used for statistical purposes was the Statistical Package for Social Sciences (SPSS) software, IBM manufacturer, Chicago, USA, version 29.0. The similarity index of lip prints collected day and night on Day 1, Day 7 and Day 14 was analysed with repeated measures ANOVA. The reliability of the CLIP model was determined using Interclass Correlation Coefficient (ICC). A threshold of 0.75 was used to define good reliability. [20] Results Based on the CLIP analysis model, the mean of lip print similarity percentage obtained after comparing the lip prints collected on the day and night of Day 1, Day 7 and Day 14 were plotted in a graph as below [Figure 5] . Figure 5. Similarity Scores graph across Day 1, Day 7 and Day 14 The mean ± SD values of day and night similarity percentage values at Day 1 (87.97±7.08), Day 7 (86.46±6.76) and Day 14 (85.15±7.94) shows a slight decrease in similarity as the week progresses. Repeated Measures ANOVA test evaluated the effect of the day and night phenomenon on lip print similarity. Based on the Mauchly test with rejected sphericity, χ²(2) = 6.795, p < 0.05, the degrees of freedom were corrected using Greenhouse-Geisser, (ε = .967). ANOVA results portrayed a significant difference of the day and night phenomenon towards lip print similarity, F(2,398 ) = 9.163, p < .05, partial η² = .044. Reliability test type used is the test-retest reliability, to assess the reliability of the CLIP image analysis model in analyzing lip prints. The ICC test is conducted using a two-way mixed-way model with a single rating mode. The generated value was 0.649, which is in between the fair and good range (0.556-0.726). Discussion The authors aim to challenge the assumption of lip prints temporal stability which has always been considered consistent and does not change over time. [6, 7, 9] We aim to challenge this using digital analysis as a more robust method and by measuring lip print stability, using a different physiological factor such as the circadian rhythm which strongly influences the morning and evening phenomenon. Our results challenge this assumption of lip prints stability, especially in high- resolution digital contexts. Lip prints were analysed with a customised Python script to train the CLIP image analysis model to measure the similarity percentage of lip prints taken on different collection times over several days. The Python script was run on Google Colab for free of charge. Using this platform, we are not required to install specific modules to run codes and the platform is user friendly to non-technical individuals who do not possess programming knowledge. [21] The computing power is also not dependant on your machine but on Google servers, which ensures performance of your local machine or computer. [22] The data were also obtained in a week. The whole analysis method ensured optimization to lip print analysis as results were obtained in a short period of time with no costs. As a whole, the study also demonstrates the feasibility of using artificial intelligence (AI) tools like CLIP for forensic image analysis. Our findings suggest that lip print morphology may exhibit changes from day to night in a same day. The reduced similarity observed between the day and night prints supports the hypothesis that circadian or physiological factors may influence lip features. Cortisol, a steroid hormone crucial in the body’s metabolic reaction to stress are interconnected to the circadian rhythm and can influence human facial appearance. [23] Cortisol levels normally exhibit a circadian pattern throughout the day, peaking in the early morning and dropping in the late afternoon and night. [24] Therefore, the facial features may appear slightly plumper and more defined in the morning to increase alertness. As for the evening, the skin is more relaxed because of the low level of cortisol. [25, 26] This factor will indirectly influence the perception of the lips, producing different lip print changes throughout the day. The moderate ICC values suggest that lip prints are not as temporally robust as previously assumed. This has important implications for forensic identification, where the assumption of immutability underpins evidentiary reliability. As there is no standardised procedure in the collection method, the procedure should be explored. In this study, the lip prints were replicated three times after an one-time lipstick application. The application of lipstick for every lip print transfer on paper should be explored to see if it increases the accuracy of lip print similarity . Limitations of the study include the usage of small sample size, potential artifacts from lipstick application and scanning inconsistencies. Further research with larger, more diverse populations and controlled imaging protocols is warranted. Changes of lip prints during the day and night phenomenon should also be explored with other sociodemographic factors such as sex which are also affected by the circadian rhythm to in future research. Conclusion Lip prints may not be entirely stable over short time intervals, particularly between day and night. This finding raises important considerations on the forensic use of lip prints for personal identification. Future studies should investigate biological and environmental factors that may affect lip morphology and explore standardized protocols to enhance reliability. Ethical committee clearance Obtained [JEP-2024-947, dated: 21-11-2024] Conflict of Interest None Source of funding Faculty of Health Sciences, Universiti Kebangsaan Malaysia Acknowledgements The authors express their gratitude to the student committee from all Residental Colleges, postgraduate students from the Faculty of Medicine and the staff from Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia (UKM) for their support. What’s new in our Paper 1. What is already known on this topic? Lip prints stability are quite known in cheiloscopic research, as being unchanged over long time intervals, usually across several months. Time intervals are usually the condition used to measure temporal stability of lip prints. Most studies conduct lip print stability research using manual observations. 2. What question did this study address? As specific lip print collection times in previous research are unknown, authors decided to measure lip print stability across day and night. Till date, there are no studies investigating lip print stability over one-day intervals within the morning and evening of the same day. Digital analysis is also used by utilizing the CLIP, a deep learning image analysis model to generate similarity scores of lip prints changes from the morning to the evening of the same collection day. 3. What does this study add to our knowledge? Authors discovered that lip prints pattern do changes across day and night and believe this is due to the natural biological fluctuations based on the circadian rhythm. We also discovered a novel digital analysis method, using a custom Python code on Google Colaboratory as a language to train the CLIP model to conduct various image analysis tasks such as lip print recognition, lip print feature extraction and lip print similarity match. This whole procedure was conducted at no cost and used a very short period of time for analysis. 4. Suggestions for further development We suggest future research into identifying a potential correlation among sex and day and night lip print pattern changes as there is much evidence about the different hormonal fluctuations among male and female. More quantitative and robust studies like these would determine the feasibility of lip prints as a potential identification tool that may be accepted by the judicial system. References Tsuchihashi Y. Studies on personal identification by means of lip prints. Forensic Science. 1974; 3:233-248. Neo XX, Hamzah NH, Osman K, Hamzah SPAA. Lip Prints in Sex and Race Determination. Jurnal Sains Kesihatan Malaysia. 2012; 10(1): 29-33. Udin NHMD, Rahman NSSABD, Gabriel GF, Hamzah NH. Digital Approach for Lip Prints Analysis in Malaysian Malay Population (Klang Valley): Photograph on Lipstick-Cellophane Tape Technique. Jurnal Sains Kesihatan Malaysia. 2019; 17(2): 43-50.doi:10.17576/JSKM- 2019-1702-05. Jamaludin UK, Gabriel GF, Osman K, Hamzah NH. Digital Approach for Lip Prints Analysis in Malaysian Malay population (Klang Valley): Scanning Technique. Jurnal Sains Kesihatan Malaysia. 2021;19(1): 31-38.doi:10.17576/JSKM-2021-1901-04. Hamzah NH, Gabriel GF, Osman K, Fung MLA, Isa NMMd. Gender Discrimination Based on Lip Prints Analysis in Malaysian Chinese Population (Klang Valley): Photograph on Lipstick-Cellophane Tape Technique. Buletin Sains Kesihatan. 2022;4(2):1-10. Eldomiaty MA, Anwar RI, Algaidi SA. Stability of lip-print patterns: a longitudinal study of Saudi females. J Forensic Leg Med. 2014;22(1):154-158. doi:10.1016/j.jflm.2013.12.011 Kapoor N, Badiye A. A study of distribution, sex differences and stability of lip print patterns in an Indian population. Saudi J Biol Sci. 2017;24(6):1149-1154. doi:10.1016/j.sjbs.2015.01.014 Blinka, Daniel D. The Daubert Standard in Wisconsin: A Primer. Faculty Publications. 2011;197. Moshfeghi M, Iranparvar P, Mortazavi H, Nasrabadi N. Study of Lip Print Patterns Distribution and Their Stability in Time Pass. Journal of Iranian Medical Council. 2023;7(1):147-155.doi:10.18502/jimc.v7i1.14222. Zhou H. Lip Print Recognition Algorithm Based on Convolutional Network. J Appl Math.2023;1:1-8.doi:10.1155/2023/4448861 Feng G, Zhao J, Peng J, Luo B, Zhang J, Chen L, Xu Z. Circadian clock - A promising scientific target in oral science. Front Physiol. 2022;13.doi:10.3389/fphys.2022.1031519 Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed. Lawrence Erlbaum Associates; 1997. Patil DV, George J, Singh A, Ahuja P. Assessment of lip and finger print patterns in patients with type 2 diabetes mellitus and dental caries: A cross-sectional study. J Oral Maxillofac Pathol. 2024;28(3):409–414. doi:10.4103/jomfp.jomfp_78_24 Vanguru R, Pasupuleti S, Manyam R, Supriya AN, Shrishail BS, Yoithapprabhunath TR. Analysis of inheritance patterns, gender dimorphism and their correlation in lip and palm prints – a cross-sectional study. J Oral Maxillofac Pathol.2023;27(1):130–137. doi:10.4103/jomfp.jomfp_535_22 Vanguru R, Pasupuleti S, Alapati NS, Manyam R, BK A, BR P. Sexual dimorphism in the lip size and finger pattern by digital method - A cross-sectional study. Advancements in Life Sciences - International Quarterly Journal of Biological Sciences. 2023;10(2). Gardezi S, Hassan N, Memon S. Analysis of lip print for Gender Identification in Karachi (Pakistan) population. Journal of Advances in Medicine and Medical Research. 2017;24(11):1–6. doi:10.9734/jammr/2017/38406 Rastogi P, Parida A. Lip Prints – an aid in identification. Australian Journal of Forensic Sciences. 2011;44(2):109–116. doi:10.1080/00450618.2011.610819 Hentschel S, Kobs K, Hotho A. CLIP knows image aesthetics. Front Artif Intell. 2022;5.doi:10.3389/frai.2022.976235. Li P. Application of clip on advanced gan of zero-shot learning. In: Proceedings from the 2021 International Conference on Signal Processing and Machine Learning. 2021 14 Nov ;Stanford, CA; 2021. p. 234-238. Koo TK, Li MY. A guideline of selecting and reporting intraclass correlation coefficients for Reliability Research. Journal of Chiropractic Medicine. 2016;15(2):155–163. doi:10.1016/j.jcm.2016.02.012 7 advantages of using google colab for python. python.plainenglish.io. Published June 5, 2020. Accessed May 16, 2025. https://python.plainenglish.io/7-advantages-of-using-google- colab-for-python-82ac5166fd4b Carneiro T, Medeiros Da Nobrega RV, Nepomuceno T, Bian G-B, De Albuquerque VH, Filho pp. Performance analysis of google colaboratory as a tool for accelerating deep learning applications. IEEE Access. 2018;6:61677-61685. doi:10.1109/access.2018.2874767 Jones C, Gwenin C. Cortisol level dysregulation and its prevalence—is it nature’s alarm clock? Physiol Rep. 2020;8(24). doi:10.14814/phy2.14644 Azmi NASM, Juliana N, Azmani S, Effendy NM, Abu IF, Teng NIMF, Das S. Cortisol on Circadian Rhythm and Its Effect on Cardiovascular System. Int J Environ Res Public Health. 2021;18(2):1-15. doi:10.3390/ijerph18020676 Elverson CA, Wilson ME. Cortisol: Circadian Rhythm and Response to a Stressor. Newborn Infant Nurs Rev. 2005;5(4):159-169. doi:10.1053/j.nainr.2005.09.002 Lyons AB, Moy L, Moy R, Tung R. Circadian Rhythm and the Skin: A Review of the Literature. J Clin Aesthet Dermatol. 2019;12(9):42-45. *Corresponding author and requests for clarifications and further details: Dr. Khairul Osman Associate Professor, Forensic Science Program Centre for Diagnostic, Therapeutic and Investigative Studies (CODTIS) Faculty of Health Sciences Universiti Kebangsaan Malaysia, Bangi, Malaysia Email: khairos@ukm.edu.my

Main Page > Vol-27 No- 2 > Paper 1 (you are here) LinkedIn X (Twitter) Facebook Copy link Share Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology Volume 27 Number 2 (July - December 2026) Received: Apr 1, 2025 Revised manuscript received: May 3, 2025 Accepted: June 16, 2025 Ref: Chaldun I, Yudianto A, Permana PBD. Domestic Violence Leading to Pediatric Burns: A Clinical Forensic Case From East Java, Indonesia. Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology [serial online], Vol. 27, No. 2 (July - December 2026): [about 11 p]. Available from: https://www.anilaggrawal.com/ij/vol-027-no-002/papers/paper001 Published as Epub Ahead: June 26, 2025 DOI: 10.5281/zenodo.15743408 Email- ibnu.chaldun-2022@fk.unair.ac.id Click here to access PDF. ( All photos can be enlarged on this webpage by clicking on them ) Domestic Violence Leading to Pediatric Burns: A Clinical Forensic Case From East Java, Indonesia Abstract Background : Burns encompassed all types of injuries to the skin and underlying tissues caused by heat, cold (e.g., frostbite), chemicals, electricity, radiation, or trauma. They often result in significant physical, psychological, and legal implications, especially in determining the extent of injury and potential criminal liability. In East Java, Indonesia—a region with a dense population and varied socio-economic conditions—burn cases require meticulous clinical forensic examinations to support law enforcement and legal processes. Method: This study presents a clinical forensic examination conducted at the request of law enforcement through a visum et repertum letter (No. VER/B/92/IV/YAN.2.14/2023/SPKT Polsek Lakarsantri). The case involved a 17-year-old male patient treated at Dr. Soetomo General Academic Hospital in Surabaya, Indonesia. Result: The patient sustained burns covering 68% of his total body surface area, involving the face, neck, chest, upper limbs, and lower limbs, accompanied by inhalation trauma. The burns occurred during a fire at his stepfather's house while he was asleep. Clinical management included debridement and wound dressing to prevent infection, reduce exudate, and maintain a moist environment for healing. The forensic evaluation concluded that the injuries could be classified as fatal based on Article 90 of the Indonesian Penal Code. Conclusion: Comprehensive clinical forensic examinations are vital in burn cases, as the findings are essential for assessing the severity of injuries and determining legal accountability. This case highlights the critical role of forensic evaluations in supporting justice and ensuring appropriate care for burn victims in East Java. Keywords : forensic sciences; burns; visum et repertum; east java; burn injury severity Introduction Burns are thermal injuries with a wide range of clinical consequences, including minor injuries and death. From a medicolegal standpoint, numerous factors must be taken into account when assessing both fatal and non-fatal burn injuries .¹ Burn injuries are a significant global health concern, accounting for approximately 180,000 deaths annually, with nearly two-thirds occurring in low- and middle-income regions such as Africa and Southeast Asia, according to WHO statistics. ² The Indonesian Ministry of Health’s survey data revealed a 35% increase in burn cases from 2014 to 2018, with 1,701 cases (20.19%) reported in 2018, compared to 1,570 cases (18.64%) in 2017, 1,432 cases (17.03%) in 2016, 1,387 cases (16.46%) in 2015, and 1,209 cases (14.35%) in 2014. 3 East Java, a province in Indonesia, accounted for 1.66% of burn cases out of 964 total samples, highlighting the regional prevalence of burn injuries in this region.³ Traumatic burns requiring legal intervention may result from various circumstances, including household accidents, workplace incidents, negligence, or cases of abuse involving children or parents. The patient’s history collected during the clinical evaluation is vital in identifying potential abuse. Inconsistent or illogical explanations for burns, unexplained injuries, or delayed symptoms should raise suspicions of maltreatment. Additionally, the type, pattern, and location of burns are critical factors to assess during the physical examination to establish a connection with possible abuse .¹ Case Report On April 14, 2023, at approximately 11:30 PM, the patient, a 17-year-old male, was transported by the Indonesian Red Cross Society “ Palang Merah Indonesia ” (PMI) team to the Emergency Room of Dr. Soetomo General Academic Hospital in Surabaya, following a traumatic incident in which he sustained extensive burns. The local law enforcement of Lakarsantri Police Sector, Surabaya formally submitted a request for a clinical forensic examination of the victim through an official visum et repertum request letter (No. VER/B/92/IV/YAN.2.14/2023/SPKT Polsek Lakarsantri). The accompanying documentation specified that the burn injuries sustained by the victim were allegedly inflicted by the stepfather, who set the victim on fire while the latter was asleep. Upon arrival at the hospital, the patient was fully alert and responsive to the situation. General Examination The subject of the clinical forensic evaluation was a 17-year-old male, measuring 165 cm in height, weighing 60 kg, with dark skin, and in a state of good nutritional health. Upon examination, the patient was conscious and oriented despite the evident burn injuries sustained. Vital signs recorded were as follows: blood pressure of 107/77 mmHg, pulse rate of 88 beats per minute, and respiratory rate of 20 breaths per minute. Examination of the chest revealed symmetrical movements without retractions, vesicular breath sounds, and the absence of adventitious sounds such as rhonchi or wheezing. Cardiac auscultation was unremarkable, with no abnormal heart sounds detected. The abdomen was soft, non-tender, with normal bowel sounds. Capillary refill time in the extremities was less than 2 seconds, indicating adequate peripheral perfusion. Wound Examination In this case, wounds of varied degrees and depths were observed on each affected body area. Second-degree burns (2a / mid dermal - deep dermal ) affected 6% of the face and neck (Figure 1). The skin was a reddish-brown color, with the epidermis flaking off in parts. There were also blisters with clear fluid within them. They burned the nose and scorched some of the front hair. They discovered second-degree burns (2a / mid dermal - deep dermal ) covering 15% of the chest and belly, as well as a reddish-brown color, epidermis peeling on some regions of the skin, and clear fluid-filled blisters. They discovered second-degree burns (2a / mid dermal - deep dermal ) covering 11% of the back, along with a reddish-brown tint, epidermis peeling on some portions of the skin, and blisters filled with clear fluid. A second-degree burn (2a / mid dermal - deep dermal ) covering 9% of the area was discovered on the right upper limb, encircling the entire upper side from the upper arm to the fingertips, with a reddish-brown color and epidermis peeling on some parts of the skin, as well as blisters containing clear fluid. A second-degree burn (2a / mid dermal - deep dermal ) covering 9% of the area was also discovered on the left upper limb, encircling the entire upper side from the upper arm to the fingertips, with a reddish-brown color, epidermal peeling, and blisters containing clear fluid. On the right lower limb, from the knee to the tips of the toes, there was a 1st to 2nd degree burn covering 9% of the area and ranging from the epidermal to the mid-dermal . The skin was peeling off in some places, and there were blisters with clear fluid inside them. The left lower limb had a 1st to 2nd degree burn, covering 9% of the area and extending from the skin's surface to the middle layer. The burn was reddish-brown, and blisters were filled with clear fluid. It did not cover the limb from the knee to the toe tips. Figure 1. Patient external wound examination photographs taken from the right side (top image), face upfront (middle left), front torso (bottom left), right upper extremity (middle center), left upper extremity (bottom center), right lower extremity (middle right), and left lower extremity (lower right). Supporting Examination A comprehensive blood test was conducted, revealing a significant increase in white blood cell (leukocyte) count, with a rise of 21,380 g/dL. Blood chemistry tests, including serum albumin, blood urea nitrogen (BUN), serum creatinine, and electrolyte levels, yielded the following results: serum albumin at 3.97 g/dL, serum BUN at 14.2 mg/dL, serum creatinine at 1.1 mg/dL, and electrolytes at 134 Na, 3.8 K, and 103 Cl/L. These clinical chemistry results remain within normal reference ranges. The patient was subsequently referred to a pulmonologist for evaluation of inhalation trauma, which was diagnosed as Ocular Dextra Sinistra (ODS) thermal injury. A chest X-ray was performed, which revealed no abnormalities. Management The patient received treatment from a plastic surgeon for his burn injuries. An internal medicine specialist was also consulted, and an insertion of a nasogastric tube (NGT) was performed. The patient was kept on a fasting regimen for the first 24 hours, after which modified Parkland fluid resuscitation therapy was initiated, accompanied by fluid balancing and the insertion of a urinary catheter. Additionally, the patient was referred to an anesthesiologist for the implantation of an endotracheal tube (ETT) and administration of oxygen therapy. A pulmonologist was consulted for inhalation trauma, resulting in the administration of high-dose antibiotics, a chest/thorax examination, and nebulization therapy. Lastly, the patient was referred to an ophthalmologist, who diagnosed corneal and conjunctival sac burns, and prescribed antibiotic eye drops and eye ointment for treatment. Discussion Trauma and accidents are typical in forensic cases. Wounds, bleeding, and/or scarring, as well as organ function impairment, are the results of trauma or accidents. Mechanical forces, temperature action, chemical agents, electromagnetic agents, hypoxia, and embolic trauma are among the various types of agents that cause trauma.⁴ Trauma patients are classified as minor or major based on a set of medical triage criteria. As a result, in forensics, medical practitioners must describe trauma in a way that is suitable and understandable to the judicial system, as well as indicate its etiology. ⁵ The patient in this case was burned by a thermal agent at a high temperature (hyperthermia). Flames or hot solid or liquid substances can cause hyperthermia, often known as high temperature. Burns are caused by the impact of heat on skin or body parts that come into contact. ⁴ Burns are traumatic injuries that are typically produced by thermal events, although they can also be caused by chemical, electrical, or radiation exposure to the skin, mucous membranes, and deep tissues. The injured area has increased capillary permeability, which allows fluids and big molecules such as albumin to escape out of circulation. This results in considerable fluid loss, particularly if the burns cover a vast surface area, impacting metabolism and body cell function. This patient's burns were caused by thermal damage.⁶⁻⁸ Thermal burns are caused by a heat source raising the skin's temperature, causing tissue cells to die or char. A temperature of at least 44°C is required for the skin to burn. Burns from high temperatures, such as hot metal, boiling liquids, steam, or fire, are the most prevalent cause. Determination of burn wound qualifications in burn cases is based on the assessment of the depth of damaged tissue, the extent of affected tissue, and injuries accompanying the burn. Burn wound classification based on the depth of tissue damage is divided into first degree, second degree, and third degree burns (Table 1).⁹ Table 1. Burn wound classification based on depth/thickness Burn Thickness Description First Degree (superficial thickness) Involves only the epidermis. Painful, dry, red, and blanches with pressure. No blisters. Heals without scarring. Second Degree (partial thickness) Involve the epidermis and part of the dermis. Superficial partial thickness (2a): Involves epidermis and superficial dermis. Painful, red, blisters form within 24 hours, blanches with pressure. Heals in 1–2 weeks. Deep partial thickness (2b): Extends deeper into dermis. Reduced pain, reduced/absent blanching, higher risk of scarring. Healing takes weeks. Third Degree (Full thickness) Involves destruction of epidermis, dermis, and often subcutaneous tissue. Eschar formation, dry and stiff. Sensation absent due to nerve damage. Requires surgical intervention (e.g., grafting). The classification of burn severity is divided into three based on the cause, depth, and surface area of the burn as seen from the percentage of TBSA, namely minor, moderate, and major burns (Table 2). The patient had varying degrees and depths of burns on each affected body part. On the face and neck, there are 2nd-degree burns/2a covering 3% and 2nd-degree burns/2b covering 3%. On the chest and abdomen, there are 2nd-degree burns/2a covering 7.5% and 2nd-degree burns/2b covering 7.5%. On the back, there are 2nd-degree burns/2a covering 5.5% and 2nd-degree burns/2b covering 5.5%. On the right upper limb, there are 2nd-degree burns/2a covering 4.5% and 2nd-degree burns/2b covering 4.5%. On the left upper limb, there are 2nd-degree burns/2a covering 4.5% and 2nd-degree burns/2b covering 4.5%. On the right lower limb, there are 1st-degree burns covering 4.5% and 2nd-degree burns/2a covering 4.5%. On the left lower limb, there are 1st-degree burns covering 4.5% and 2nd-degree burns/2a covering 4.5%. In 1st-degree burns, only the epidermis layer of the skin is affected. In 2nd-degree burns, the epidermis and part of the dermis layer of the skin are affected, which is then classified as superficial dermis. In contrast, a second-degree burn extends into the deep dermis .⁹ Table 2. Burn wound classification based on severity. Criteria Minor burn Moderate burn Major burn TBSA <10% in adults, <5% in children or elderly, <2% for full thickness burn 10-20% in adults, 5-10% in children or elderly, 2-5% for full thickness burn >20% in adults, >10% in children and elderly, >5% for full-thickness burn Other N/A Low-voltage burn, suspected inhalation injury, circumferential burn, concomitant medical problem predisposed to infection (e.g. diabetes, sickle cell disease High-voltage burn, chemical burn , any clinically significant burn to face, eyes, genitalia or major joints, clinically significant associated injuries (e.g. fracture, other major trauma) To assess the area of burn wounds accurately and correctly, the use of calculation methods such as the " Rule of Nines " is required to produce the total burn area percentage (Figure 2). The Wallace’s " Rule of Nines " divides the body's surface area into multiples of 9%, except for the perineum, which is estimated to be 1%. [10,11] However, evidence have shown that this method of estimation is not recommended for use in those younger than 12 years as children exhibit dissimilar body proportions than adults. A more advanced version of burn injury extent estimation is by using the Lund-Browder chart, which was developed by Dr. Charles Lund and Dr. Newton Browder based on their experiences treating burn victims from the 1942 Cocoanut Grove fire. Unlike the Wallace rule of nines, it accounts for age-related variations, adjusting the percentage BSA for the head and legs as children grow, making it particularly effective in managing pediatric burn cases.[12,13] (click to enlarge) Figure 2. Estimation of the total body surface area affected from burn injury based on the Lund and Browder Chart. Based on the examination of the patient using the Total Body Surface Area (%TBSA) method, the total burn area was calculated to be 68%, involving the face, neck, chest, abdomen, back, both upper limbs, and both lower limbs, caused by exposure to high temperatures (Figure 1). According to the classification of burn severity based on cause, depth, and surface area, this case falls under the category of severe burns, as it exceeds 10% in children (Figure 2). Table 3. Abbreviated Burn Severity Index. Parameter Finding Points Parameter Finding Points Sex Female 1 TBSA (%) 1-10 1 Male 0 11-20 2 Age 0-20 1 21-30 3 21-40 2 31-40 4 41-60 3 41-50 5 61-80 4 51-60 6 81-100 5 61-70 7 Inhalation Injury Yes 1 71-80 8 No 0 81-90 9 Full-thickness burn Yes 1 91-100 10 No 0 ABSI Threat to life Probability of survival (%) 2-3 Very low >99% 4-5 Moderate 98% 6-7 Moderately severe 80-90% 8-9 Serious 50-70% 10-11 Severe 20-40% ≥12 Maximum ≤10% In this case, it is essential to consider the prognosis to predict the patient’s mortality. One commonly used method is the Abbreviated Burn Severity Index (ABSI), introduced in 1982 and widely utilized to estimate mortality in burn patients (Table 3).¹⁴⁻¹⁶ The ABSI scoring system involves five variables: gender, age, presence of inhalation trauma, presence of full-thickness burns, and the percentage of TBSA affected. For this patient, the ABSI score was calculated to be 9, indicating a severe prognosis with only a 50–70% probability of survival. The score was determined as follows: gender (male = 0), age (0–20 = 1), inhalation trauma (yes = 1), full-thickness burns (no = 0), and TBSA% (61–70 = 7) (Table 3). Based on the ABSI score, the patient was treated in the intensive care unit to provide the required level of care. Medico-legal aspects In this case, the burn injuries are classified under the Indonesian Penal Code (KUHP) Article 90, which pertains to injuries or wounds that cause a fatal danger, and KUHP Articles 353(1) and 353(2), which address premeditated assault resulting in injuries that do not lead to severe harm or death, as well as premeditated assault that causes severe injuries.¹⁷ The examination of burn wounds in a living person constitutes a form of clinical forensic examination conducted by a forensic doctor, general practitioner, or other medical professionals to assist in the enforcement of law and judicial proceedings, in accordance with the Indonesian Criminal Procedure Code (KUHAP) Articles 120(1) and 133(1) and (2).¹⁷ In this case, the victim is a child, and the perpetrator is the victim's stepfather, making this a case of domestic violence (KDRT), in accordance with the Indonesian Law No. 23 of 2004 on the Elimination of Domestic Violence, specifically Articles 1, 2, 44(1), and 44(2).¹⁸ Additionally, as the victim is a child, this case falls under the scope of Law No. 35 of 2014, which amends Law No. 23 of 2002 on Child Protection, particularly Articles 76C and 80(1), (2), and (3).¹⁹ Conclusion The case involves a young male patient with extensive burn injuries covering 68% of his body surface area, compounded by inhalation trauma. From a medicolegal perspective, this case is categorized as an incident resulting in life-threatening injuries, with indications of premeditated abuse causing severe harm. The incident is subject to legal provisions under the Domestic Violence Act and Child Protection Act, emphasizing the need for comprehensive medical, psychological, and legal interventions to ensure justice and holistic care for the patient. References Aydogdu HI, Kirci GS, Askay M, Bagci G, Peksen TF, Ozer E. Medicolegal evaluation of cases with burn trauma: Accident or physical abuse. Burns. 2021 Jun 1;47(4):888–93. Smolle C, Cambiaso-Daniel J, Forbes AA, Wurzer P, Hundeshagen G, Branski LK, et al. Recent trends in burn epidemiology worldwide: A systematic review. Vol. 43, Burns. Elsevier Ltd; 2017. p. 249–57. Kemenkes RI. Hasil Riset Kesehatan Dasar Tahun 2018. Kementrian Kesehatan RI. 2018;53(9):1689–99. Kara YA. Burn etiology and pathogenesis. Hot Topics in Burn Injuries. 2018;17(1). Yudianto A. Ilmu Kedokteran Forensik. Surabaya: Scopindo Media Pustaka; 2020. Kumar R, Keshamma E, Kumari B, Kumar A, Kumar V, Janjua D, et al. Burn injury management, pathophysiology and its future prospectives. Journal for Research in Applied Sciences and Biotechnology. 2022;1(4):78–89. Kaddoura I, Abu-Sittah G, Ibrahim A, Karamanoukian R, Papazian Njta. Burn injury: review of pathophysiology and therapeutic modalities in major burns. Ann Burns Fire Disasters. 2017;30(2):95. Jeschke MG, Chinkes DL, Finnerty CC, Kulp G, Suman OE, Norbury WB, et al. Pathophysiologic response to severe burn injury. Ann Surg. 2008;248(3):387–401. Warby R, Maani C V. Burn classification. In: StatPearls [Internet]. StatPearls Publishing; 2023. Kemenkes RI (Indonesia Ministry of Health). Pedoman Nasional Pelayanan Kedokteran Tata Laksana Luka Bakar (Indonesian National Treatment Guidelines on Burn Injury). Jakarta: Keputusan Menteri Kesehatan Republik Indonesia; 2019. 1–116 p. ANZBA. Emergency Management of Severe Burns (EMSB): Course Manual. 18th ed. Australian and New Zealand Burn Association; 2016. Carrougher GJ, Pham TN. Burn size estimation: A remarkable history with clinical practice implications. Burns Open [Internet]. 2024;8(2):47–52. Available from: https://www.sciencedirect.com/science/article/pii/S2468912224000014 Hussain S, Ferguson C. BET 1: ASSESSING THE SIZE OF BURNS: WHICH METHOD WORKS BEST? Emergency Medicine Journal. 2009;26(9):664–6. Tobiasen J, Hiebert JM, Edlich RF. The abbreviated burn severity index. Ann Emerg Med [Internet]. 1982;11(5):260–2. Available from: https://www.sciencedirect.com/science/article/pii/S0196064482800966 Doyle DJ. Abbreviated Burn Severity Index (ABSI). In: Doyle DJ, editor. Computer Programs in Clinical and Laboratory Medicine [Internet]. New York, NY: Springer New York; 1989. p. 101–5. Available from: https://doi.org/10.1007/978-1-4612-3576-7_22 Christ A, Staud CJ, Krotka P, Resch A, Neumüller A, Radtke C. 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Acknowledgements The authors acknowledge the use of ChatGPT 4.0, a Generative AI tool developed by OpenAI, during the preparation of this manuscript. Specifically, ChatGPT 4.0 was utilized for translation, grammar checking, and paraphrasing to enhance the clarity and professionalism of the text. This use complies with the Taylor & Francis AI Policy, and the authors confirm that all content generated or revised using ChatGPT 4.0 was reviewed and validated to ensure its accuracy and relevance to the manuscript. Disclosure The authors declare no financial or non-financial conflict of interest. Accompanying Sheet 1. What is already known on this topic? Burn injuries are a global public health problem, especially in low- and middle-income countries, with high morbidity and mortality rates. Pediatric burns resulting from domestic violence are particularly severe and challenging, requiring clinical and forensic evaluation to ensure both medical care and legal justice. 2. What question did this study address? This study examined how clinical forensic assessment can support legal processes in cases of pediatric burns suspected to result from domestic violence, using a real-life case from East Java, Indonesia. It aimed to highlight the role of visum et repertum in identifying life-threatening injuries and guiding judicial outcomes. 3. What does this study add to our knowledge? This case report underscores the importance of comprehensive clinical and forensic documentation in suspected child abuse cases involving burns. It provides detailed insights into the severity classification, prognosis estimation (using ABSI), and legal interpretations under Indonesian law. Furthermore, it demonstrates the practical application of forensic medicine in supporting child protection efforts. 4. Suggestions for further development Future studies should explore a larger series of burn cases resulting from domestic violence to identify patterns, improve forensic protocols, and inform preventive policies. Interdisciplinary collaboration among healthcare, law enforcement, and social services is also essential for more effective interventions and protection of vulnerable populations. *Corresponding author and requests for clarifications and further details: Ibnu Chaldun, Forensic Medicine and Medicolegal Specialist Program, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia Email- ibnu.chaldun-2022@fk.unair.ac.id

SCIENCE IN CRIME DETECTION-22 DEATH BY AIR INJECTION I had a tremendous response for my article "Deaths in Police custody", published in the November, 1994 issue of Crime & Detective. Mr. Shambhu Nath Gupta writes from Ludhiana, Punjab that he loved the article. However he wants to know why physical torture in police custody is known as the third degree method. Well Mr. Gupta, there is no clear cut answer to this. There are many theories as to the origin of the term "third degree". One that I am aware of is this. Generally when one utters the word "third" in connection with anything it is used as equivalent to "poor" or "inferior in quality". We commonly talk of a third division, or a third rate book. We even talk of third class people, when we want to talk about mean people. "Third degree" might refer to a poor and unscientific method of extracting information from a criminal. Torture certainly is an unscientific method of extracting information from a criminal. However Mr. Sudhir Bansal from Karol Bagh has come out with another ingenious explanation. He also liked the article and has himself volunteered information on this. He says that there are three degrees of extracting information from a criminal, the degrees increasing in severity and brutality as we go up by numbers. First degree method is to extract the truth by interrogation. Second degree method is to inflict mental torture. Third degree is the well-known method of inflicting physical torture. Sounds quite a reasonable and plausible explanation to me! Many people have asked if I could tell them something about the history of "third degree" method. Well, the use of physical torture to test a person's innocence was commonly practiced in Europe during medieval times in trial by ordeal. The principle-adapted from pagan rites by the Church-was that a person's innocence in respect of a criminal accusation could be tested by his ability to withstand pain and injury. Two of the most popular tests involved contact with boiling water and red-hot metal. In cases where there was a lack of clear guilt, the accused person was required to plunge his arm into a bowl of scalding water and retrieve a stone! If after 3 days there was evidence of burning on the skin the person was judged to be guilty. Similar tests involved walking on red hot ploughshares or gripping a piece of hot metal in the hands without the flesh being burned. The idea was that if a person was not guilty of the accusation, his innocence would protect him. So much for the third degree. This time I am going to tell you about a very ingenious way of committing murder. This is by injecting air in somebody's veins. If somebody is indeed murdered using this technique, it is extremely difficult to detect it. Yet there are ways to detect it, if the forensic pathologist is careful. The interesting thing about this sinister technique is that it uses none of the traditional gory weapons like firearms or daggers, nor does it use poisons. The murder device is quite simply and surprisingly air, which is so harmless and ubiquitous. It is almost unbelievable that such an innocuous looking thing as air could kill someone. Actually air or for that matter anything in this universe can kill a person, if it is wrongly placed in a human body. This case is also a similar case. In this case air gets ensconced in a place where it normally shouldn't be! Such cases are technically known as cases of "air embolism". The word embolism comes from Greek en, "in," and ballein, "to throw or cast". Since in this technique, air is "thrown in" or "cast in" the blood vessels, it is known as air embolism. Henceforth we will be using the term "air embolism", whenever we would refer to injection of air in the blood vessels to kill someone. Readers may be interested to know that the concept of air embolism for murder has been used time and again in crime novels, one of the best instances being in the famous writer Dorothy L. Sayer's novel where `a hypodermic of air was injected into an artery'. Before telling anything further about death by air embolism, let us first understand a little bit about the way our blood circulates in our body. This is very essential to understand how a person get killed by injection of air. Our heart is comprised of 4 chambers. There are two chambers on the right and two on the left side. The chambers on the right side are known as right atrium and right ventricle, while the chambers on the left side are known as left atrium and left ventricle. The location of these chambers will become clearer by referring to the adjacent figure (Ed: Please reproduce the figure on page 282 here. Please reproduce in colour, as this is very essential for proper understanding) . Here lungs, legs, head and arms are depicted only symbolically. Bad blood from legs, head, arms and in fact from every part of the body returns to the upper right chamber called the right atrium. The bad blood in the figure has been represented by blue colour, while the good blood has been represented by red colour. Keep referring to the figure to follow the route taken by the blood. A proper understanding of the normal route of the blood is very essential. With each contraction of the heart the right atrium sends this bad blood to the right ventricle. The right ventricle, in turn, sends this blood to the lungs via pulmonary arteries. Do not let the complicated names baffle you. Just remember that atrium and ventricles are fancy sounding names of some chambers of the heart. Ventricle is a larger chamber than atrium. Also keep in mind that "artery" is the name of a conduit which takes the blood away from the heart while vein is the name of a conduit which brings blood to the heart. The word pulmonary comes from Latin pulmo, "the lung". Thus "pulmonary artery" refers to a conduit which takes the blood away from the heart towards the lung. In the lung, the bad blood is purified. This is done by the help of the air which we breathe all the time (even at the time of sleeping). The pure blood (now depicted as red) is returned to the heart via pulmonary veins. The blood comes in the third chamber of the heart known as left atrium. Left atrium sends this blood to the left ventricle, which in turn, pumps this pure blood to the whole body via a very big conduit known as aorta. The body organs use this pure blood, and when this blood becomes impure, it is once again returned to the right atrium. And thus the circulation goes on. Now we are ready to understand how air embolism works. First of all we must appreciate that nature has made this whole system of circulation air-proof. This means that there is no way, air could enter this system of conduits and pipes. If somehow air could enter the system (such as by injection of plain air through a syringe), the air will form an "air lock" within the system. This "air lock" is quite familiar to plumbers and owners of diesel engines, where the normal flow of liquid through tubes is wholly or partially blocked by air. Quite in the same manner this air lock blocks the flow of blood through the arteries and veins, thus bringing the circulation to a halt. Let us make this a little more clearer. Air could be made to enter the circulation either through the arteries (red coloured conduits) or through the veins (blue coloured conduits). More commonly injections for murder are given in the veins. When such an injection is given, the air bubbles start travelling towards the right atrium. From right atrium they keep travelling onwards till they come to the lung. Here the capillaries are too narrow to allow the big bubbles to pass. The result is that these bubbles get entangled in the blood vessels of the lung. The whole blood traffic stops and the person dies very quickly. In fact his bad blood can not be purified by the lungs, because traffic of blood towards the lungs has been stopped. The body can not imagine that such a sinister thing has happened. It "thinks" that the blood is not getting purified because of lack of air. So it quickens the respiration. The person starts gasping. But nothing helps because the cause lies somewhere else and the person dies. The beauty of the technique lies not only in its simplicity but also in another thing-the difficulty of detection of this condition at post-mortem examination. When a person dies of air embolism, the only abnormal thing that is there within his body is a bubble of air somewhere in his blood vessels. If the forensic pathologist is not careful, the bubble would vanish the moment the body is opened. Thus in every suspected murder case, first of all I take an X-ray of the dead body. It might surprize the reader as to why one would like to X-ray a dead person. The reason is that the air bubbles are seen very well in an X-ray. When the body is still not open, the air bubbles lie undisturbed in the blood vessels and we can see where the bubbles lie. Look at the adjacent figure closely to know where I expect the air bubbles to lie in a case of air-embolism. In the place of lungs you see a network of conduits, which is partly blue coloured and partly red coloured. The air bubbles lie in this network of conduits, and many times in the pulmonary artery itself. When the X-ray of the dead body indicates that this might indeed be a case of air embolism, we open the body very carefully. Because if we do not open it carefully, the air bubbles might escape the moment the body is opened. In such cases we dissect the blood vessels under water. The detailed technique is very complicated and I do not want to confuse you by giving details of this technique. Just remember that we dissect the blood vessels under water. If air is present within the blood vessels, bubbles of air will be seen to emerge. It is like finding a leak in a bicycle tube by immersing the tube in water! Murder by air embolism is quite rare, despite the strong chances of a murderer escaping scot free in such cases. This is because such a technique requires great skill. Not everyone can handle a syringe, let alone puncture a vein successfully with it. I have a nagging fear that such type of murder might be very common among the drug addicts of our country. They are quite suited for committing such types of murder. They can handle syringes very deftly (almost as deftly as doctors, as they have to inject the drugs through the syringe all the time), and they need to do away with people fairly commonly. In my whole life, I have encountered just one case of murder by air embolism and that too when I was in Edinburgh. The case was of a doctor husband who had got tired of his nagging wife. The husband was carrying on an affair with one of his female patients and his wife had got hint of that. She was having fits of faintness for quite sometime. So one day the doctor filled up a large syringe with air and injected air into her veins under the pretext that he was giving her some drug. About 200 c.c. of air is required to kill a person by air embolism. I do not know how he managed to inject that much amount through a syringe. Even a commonly used large syringe takes in about 20 c.c. of air only. He might have used a bigger syringe or may be he repeatedly pushed the air inside by removing the piston from the syringe again and again. Well, the important thing is that he did use the air for committing the murder. He would have gone scot free, but when I asked one of the witnesses as to what were the symptoms of the lady when she was dying, I was told that she was gasping for air. This immediately alerted me. This is a symptom of air embolism as we have already seen. Coupled with this was the fact that her husband was a doctor. He was ideally suited for committing such a type of act. So before opening the body, I decided to take a radiograph (X-ray) of the body. Sure enough the bubbles of air could be seen in the deceased woman's pulmonary arteries. Then I looked at the dead woman's forearms. They showed marks of injection. Immediately I alerted the Lothian and Borders Police (the police force that mans the city of Edinburgh). A detailed interrogation was done and sure enough the doctor admitted his guilt. This was yet another victory of Forensic Medicine.

SCIENCE IN CRIME DETECTION-8 WHEN THE BODY TURNS INTO WAX ! Saroj, 16, and Mahendra, 12 were brother and sister. On June 8, 1987, they went to play as usual in the garden, but they never returned. Saroj was a beautiful girl and her parents were always quite reserved in allowing her out alone. On that day however, she was able to cajole her parents into allowing her to go out with her brother. A complaint with the police did not result in any benefit either. The police asked various questions, including about the people the parents suspected. But the family had no enemies whatsoever. As time passed, it became clear that Saroj and Mahendra were kidnapped by some gang, presumably with the purpose of having intercourse with Saroj. There was a gang in town which had once kidnapped a young 19 year old girl, kept her in detention for as many as three months, during which she was forced into intercourse day and night. When the gang members were tired of sex, they would all sit together in a circle and ask her to perform naked dances in the center. After meting out this inhuman treatment to her for three months, they finally did away with her. Her body was found three and a half months later, quite putrefied in a forest. Only one member of the gang could be arrested and from him, the whole story was revealed. The body bore several stab marks, which showed that the modus operandi of the gang was to kill by stabbing. Lakhiram and Revati, the parents of Saroj and Mahendra shivered at this thought. They kept searching for their children, but without any success. On January 15, 1988, one highly putrefied body was found in a forest about 50 miles away from the village of Lakhiram and Revati. Most of the body had been eaten away by animals and maggots were crawling on what remained of the corpse. It was impossible to identify the dead person from the remains. I was called by the police inspector at the place. I made some preliminary examination of the bone and told the police that the bones belonged to a male between 11 and 13 years of age. Moreover, the person, whoever he was, had suffered osteomyelitis (an infection of the bone) in his right leg, about two year before. This description fitted Mahendra exactly. Lakhiram and Revati were immediately contacted and they admitted that Mahendra had suffered from a terrible weeping sore about two and a half years back and also that the sore had healed with great difficulty after about six months of treatment. This, of course, is not the main part of the story. This only established that the victim was Mahendra. But I could not say who had killed him or how had he been killed. This was vital for the police to know. One thing however became clear. If Mahendra had been killed, it was quite possible that his sister Saroj had also been killed and was disposed off in a nearby area itself. A police party launched a massive search for the body of Saroj. They were expecting her body, too, to be in the same state of deterioration; so everyone's stomach was turning topsy-turvy. But lo and behold! Two days later a constable of the search party accidentally stumbled upon a quite well-preserved body of a teenaged girl on the shores of a nearby pond. The body was naked and so well preserved that everybody could at once recognize it was Saroj. When the search party touched the body, it felt as it was like soft wax. Everyone was nonplussed. What had happened to Saroj? I was called immediately. When I arrived there and looked at the body, I realized at once that I was dealing with an adipocere. I rubbed some of the body's material between my thumb and index finger. It gave me a cheesy feeling. I smelt the material. The smell was somewhat similar to that of old cheese. Here then was the body of Saroj, turned into adipocere and intuitively I knew that now I could tell a lot of things to the police regarding the crime. Let us introduce a red herring into the story and first see what an adipocere is. The word adipocere comes from two Latin words, adeps meaning fat and sera meaning wax. It is also known by several other names such as Grave Wax, Mortuary Fat , or Saponified Tissue . This is a situation when the body fat turns into wax under certain special conditions. When a person is killed and thrown away in a forest, his body will normally putrefy. But if there is water in the vicinity or the ground on which the body is thrown is wet and the temperature is quite high then the conditions are just right for the body fats to turn into wax. A very complex chemical reaction takes place for this to happen. For the more scientifically-minded readers, the unsaturated body fats are first saturated to firmer fats and this firmer fat is then split into fatty acids and glycerol. Glycerol usually drains away. The remaining fatty acids (mainly saturated fatty acids such as palmatic acid, stearic acid, hydroxystearic acid and oleic acid) may then combine with body calcium to form soaps and waxes. Adipocere is thus essentially composed of saturated fatty acids such as palmatic acid, stearic acid, hydroxystearic acid, oleic acid and their calcium salts. Adipocere forms mainly at those parts of the body where there is a lot of accumulation of body fat. Such areas are cheeks, buttocks, breasts and thighs. Since Saroj's body had been thrown near a pond, the conditions were just right for her body to be turned into adipocere. Once a body turns into adipocere, it does not undergo normal decomposition, and remains as such. It gives the forensic expert a lot of benefits. For one thing, the features of the person remain discernible. Secondly, since the body is more or less preserved, one can say how the person died. Adipocere is a yellowish white, greasy, wax like substance with a rancid smell. It is lighter than water. If we cut out some adipocere from the body of such a person, and put it in water, we find that it will float. It cuts easily and burns with a faint yellow flame giving offensive odor. Fresh adipocere is soft and moist, but old samples are dry and brittle. Adipocere takes about 3 months to form, so we can form a idea when the person was done to death. The body of Saroj was found on January 15, 1988. So, at a rough guess, she must have been killed on or around October 15, 1987. She had been kidnapped on June 8, 1987. So it appeared that she had been kept in captivity for about 4 months. This pointed to her having been used for sexual purposes. Since her body was well preserved, I could examine her genitals, which too had been converted into adipocere. Her hymen, the soft membrane which cover the vagina, was completely mutilated indicating that she had indeed been used for sexual intercourse. Her left breast and both buttocks showed very clear stab wounds. These stab wounds would normally have been obliterated if normal putrefaction had set in. But since her body had been converted into the wax-like adipocere, the stab marks were clearly visible. Her kidnapping and confinement, her use as an object of sexual intercourse and the method of her killing, all pointed to the dreaded Devi gang which had earlier done the same deed. Devi gang had big political connections and until and unless the police had solid clues to back them, they could not dare to touch the gang. But now since I had provided them with all vital clues, they went fully armed to nab the Devi Gang and made tough inquires. Sure enough, very soon, the gang cracked up and confessed to the abduction, sexual molestation and killing of Saroj. They had to finally kill Saroj because she had become pregnant. When the case went to court, the court admitted my medical evidence and had no difficulty in convicting the members of Devi gang. In this particular case, my knowledge of science helped me to unravel crime. A non-specialist would have been quite nonplussed to see the waxy body of Saroj, but I knew it was adipocere. To summarize, this adipocere formation helped me to (i) establish her identity (ii) establish the cause of her death and (iii) indicate the time of her death. These facts together enabled me to weave a coherent story which ultimately helped in catching the culprits.

Science in Crime Detection Author- Dr. Anil Aggrawal Click on the topic to access. More articles will be added daily ! When did the murder take place ? Who handled the gun ? Did the communists kill the czar ? Was she actually raped ? What do the bite marks tell us ? The Vital evidence ? When the body turns Blue ! When the body turns into Wax ! Testing for Homosexuality What do the Fingerprints tell us ? What do the Bones tell us ? Examining the Scene of Crime How do we recognize a person from his skull ? Contusions - The vital evidence Speech spectograms catch criminals Murder by electricity Deaths due to accidents Use of infrared photography in forensic science Deaths in police custody Defence Wounds What do the abrasions tell us ? Death by Air injection Knowing about car headlights Clues from Putrefaction Death by Strangulation Forgery of Cheques Deaths from hanging Drowning Deaths An unusual case of skull fracture An unusual case of death IMPORTANT NOTE: THIS MATERIAL IS COPYRIGHTED BY THE AUTHOR AND MAY NOT BE REPOSTED, REPRINTED OR OTHERWISE USED IN ANY MANNER WITHOUT THE WRITTEN PERMISSION OF THE AUTHOR.