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Forensic Toxicology THE FOLLOWING ARTICLE APPEARED IN THE NOVEMBER 1999 ISSUE THE POISON SLEUTHS DEATH BY CICUTOXIN -Dr. Anil Aggrawal "Good morning doctor. Oh, my God, what are you doing today? You have the dead body of a middle aged man today. What happened to him? Please tell me.” “Good morning Tarun. The name of this man is Radhey and he is about 54 years old. He was a carpenter by profession and had been in good health till yesterday. Yesterday morning he went to catch some fish in a nearby lake, along with his friend Shyam. Both of them were very friendly. While they were fishing, a person by the name of Lal came there and offered some sweet potatoes to them. Sweet potatoes as you perhaps know are known as ShakkarKandi in Hindustani. Both of them ate some of it. Shyam however spat out after one bite, because he thought it was not tasting how it should be. Radhey took some lusty bites from it, because he was hungry, and he liked its taste too. Half an hour after eating the plant, Radhey felt nauseated and dizzy and had stomach pains. Following this, he suddenly stiffened, fell on the ground unconscious, and made gross, irregular movements of his arms and legs. Shyam was alright by this time.” “Oh, from the story it appears to me, that Lal had given Radhey some poison mixed in sweet potatoes.” “Yeah, it sure does. The police has investigated into the background of Lal, and they have found that Lal held some grudge against Radhey. He wanted to settle an old score with him. So it does appear that Lal had a motive to give him some poison. The question is whether we can prove he gave him some poison or not. According to the only eye witness available - Shyam - the only thing Lal gave to Radhey was sweet potatoes. And sweet potatoes are not poisonous. So the police is going to have a tough time in the court proving anything against Lal. Sure enough they are banking heavily on my investigation.” “So what have you found doctor?” “Let me complete my story first. About one and a half hour after eating the sweet potatoes, Radhey was admitted to a hospital emergency room. On the way to the hospital, he was reported to have had four convulsions. I have asked the doctors who treated Radhey, about his condition when they first saw him. They tell me that when he was brought to them - at about 10 am yesterday - he was comatosed, and was bluish all over. This bluishness is known as cyanosis in medical terminology.” “Oh, that is terrible!” “Yes. He was not responding to any painful stimuli, which means he was really in a deep coma. His blood pressure was normal, but his pulse was more than twice the normal- about 150 per minute. The normal rate as you know is about 72 per minute. His breathing was stertorous. He was perspiring extensively, drooling saliva from his mouth, and his parotid glands were markedly swollen. He alternately clenched and ground his teeth and made chewing movements. His tongue was bleeding from a left sided laceration. His arms and legs showed intermittent, coarse, uncoordinated, and restless movements. He had extreme but intermittent muscle spasms, in particular of the muscles of shoulder and neck, causing throwing back of the neck. The pupils of his eyes were markedly constricted. In fact so constricted were they, that the doctors told me they were like pin points. You know that normally the pupils have a diameter of about 4mm. In this case, they were smaller than half a mm. His eyes were red. The eyeballs protruded somewhat.” “Oh, Radhey must surely have died dreadfully. What did the doctors diagnose?” “They couldn’t know what had befallen Radhey. They gave some conservative treatment, but Radhey’s condition worsened and he expired yesterday night at about 10 pm, about 14 hours after having ingested those mysterious ‘sweet potatoes’.” “Doctor, how do you think Radhey must have died? I think Lal injected some poison in those sweet potatoes.” “He probably could have done that. But by listening to the history of this case, and after talking to the doctors, I can only think of one poison.” “What is that poison doctor. Please tell me. I am getting curious.” “Tarun, the symptoms are so peculiar that there could only have been one poison- Water hemlock.” “What? Water hemlock? Never heard of it as a poison. Could you tell me more about it please?” “Tarun, Water Hemlock is a member of the genus Cicuta, of the Umbelliferae family of plants. There are nine subspecies of Cicuta, and all are very poisonous. Cicuta virosa is the common European water hemlock, and Cicuta maculata and Cicuta douglasii are the varieties found in North America. These varieties are found in India also. Common eponyms for Cicuta are cowbane, five-finger root, snake weed, wild carrot, dead man’s fingers, poison parsnip, wild parsnip, beaver poison, muskrat weed, spotted hemlock, spotted cowbane, musquash root, false parsley, fever root, mockeel root, wild dill, spotted parsley and carotte à moreau. They are found in marshy sloughs and meadows and on the banks of streams. Cicuta plants are difficult plants to identify, which may explain why Radhey mistook them for sweet potatoes. In fact, they have been mistaken for many diverse edible plants such as artichokes, celery, sweet potatoes, sweet anise, and wild parsnip. Cicuta plants are difficult to identify in the early spring, when only the fleshy swollen roots, particularly toxic at this time, are present. Later in the year, the roots are less poisonous, but the leaves and stem then contain sufficient poison to prove fatal if ingested.” “Oh, I see. What is the poisonous substance present in these plants doctor?” “Cicutoxin. Chemically, it is a highly unsaturated higher alcohol. Its formula -if you care- is: HOCH₂ (CH₂)₂ (C≡C)₂ (CH=CH)₃ CH(OH)CH₂CH₂CH₃ There is another poison in these plants, and that is Oenanthotoxin. This is found in Cicuta virosa, and is actually an isomer of cicutoxin. It was first isolated by a scientist Boehm in 1876 and was crystallized by Clarke in 1949.” “Doctor, how do these poisons actually kill the person?” “Tarun, Cicutoxin belongs to a category of poisons known as cholinergic poisons. This name comes from a natural substance found in the nerve endings, acetylcholine. You may be surprised to know that although acetylcholine is normally found in nerve endings - in fact it is essential for muscle contraction - an excess of this substance can prove dangerous to human body. Many insecticides such as organophosphorus compounds also show cholinergic effects and prove poisonous because of that.” “Oh, I see. Please tell me more about these poisons doctor.” “Cholinergic poisons exhibit two main groups of symptoms. One are called muscarinic effects, because they resemble the symptoms caused by eating a poisonous mushroom Amanita muscaria. These symptoms include salivation, perspiration and constriction of pupils. In fact, the moment I heard these symptoms from the doctor, coupled with the information that Radhey had been given “sweet potatoes” by a potential foe, I came to the conclusion that he had been given the root of some plant of the Cicuta species. The second group of symptoms is called the nicotinic effects, because they include symptoms caused by nicotine, a very poisonous alkaloid found in tobacco. Main among these symptoms are muscle twitchings and convulsions.” “Doctor, we have all the circumstantial evidence that Lal gave some poisonous roots to Radhey, but how are you conclusively going to prove in the court that Lal indeed gave him this substance?” “Tarun, I have taken the stomach contents of Radhey and have done a chemical test on that. They have proved positive for Cicutoxin and Oenanthotoxin. This surely means he has been given Cicuta roots by Lal. I did not stop at that. I specifically asked the police to raid Lal’s house. They raided and found many more such roots. Here they are, and any botanist can tell to the court that they are roots of Cicuta plants. Do we need any more proof than that?” "Surely not doctor. That was very clever of you doctor. Without your clever deduction - especially your noticing the peculiar symptoms of Radhey at the time of his death, and your sound knowledge of botany- everybody would have thought he died of some mysterious natural disease. This was a most interesting discussion doctor. Tell me what are you going to tell me the next time?" "Tarun, next time, I would tell you about a very interesting poison- Brodifacoum."

| Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology Call For Reviewers Become a reviewer for Interacting with Anil Aggrawal’s Internet Journal of Forensic Medicine and Toxicology . * This journal receives a large number of manuscripts and other material for publication as original papers/review papers/high resolution pictures for poster presentation/UG material/PG material and contributions for a number of other sections. * To be able to deal with large amount of unprocessed material, we are currently diversifying our reviewer pool. Younger scientists are encouraged specially, so they can be involved in paper publication process. * Interested in reviewing or have questions? Email the editorial office by clicking here . What is peer review ? Peer review is not only the foundation, but a very strong pillar of scientific publishing. It is an honest assessment of a piece of writing by a “peer”, a person who understands and practices the same science. When you are asked to review a manuscript that has been submitted for publication, you are helping the journal to “weed out” unsuitable material, and select what should be included in a well-respected journal. Not only this, simultaneously, your expertise is being acknowledged and your opinion is being valued. Our reviewers – by accepting only high quality original papers – help us to publish only the highest quality research and reviews. Who can become a reviewer? If you are active in the field of forensics/criminology/law and related sciences and can objectively evaluate the quality and rigor of research, we want you! Send us your latest CV attached with your high resolution photograph. We are looking for peer reviewers with following qualities: • Should have sound academic credentials • Should be active in the field of forensics; new research paradigm: interaction process and methodology • Should provide constructive criticism to authors. Benefits of reviewing for this journal Becoming involved in the peer review process for this journal can be a highly rewarding experience for the following reasons: • Reviewers are recognized on an annual basis in the journal; Please Click here to see how reviewers are acknowledged. • If you are interested in joining the editorial board , you would be able to do so, after you have completed 100 peer reviews. • You can get academic credit for your peer review by signing in your Web of Science/Clarivate/ORCID Academic profile. Please click here to sign in or register • You get complimentary access to academic material [papers/books etc needed to consult for reviewing etc.]. You need to send us PMID of the paper required. • You get a reviewers’ certificate after completing 25 reviews. Click here for an example. The peer review process Remember that authors are our friends. Our aim is to improve their manuscripts. If grammar/spellings etc. are wrong, they may be advised to get it corrected through someone who is a native English speaker, or better still with a teacher of English language. The manuscripts are checked especially for originality. We have a zero tolerance for plagiarism. Thus all manuscripts must be checked through an authentic antiplagiarism software [e.g., iThenticate ]. References must always be checked, ensuring specially that they are all in uniform style [Vancouver style]. Manuscripts are always sent to two [in rare cases more also] independent reviewers. Based on the feedback from these reviewers and the editors' judgment, a decision is given on the manuscript.

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SCIENCE IN CRIME DETECTION-2 WHO HANDLED THE GUN ? Often a difficulty arises in cases of firing, about who fired the shot. The police wants to know from the scientist if a particular criminal has fired a gun or not. Consider a case where a man has been shot dead. Two witnesses have identified the assailant in an identification parade, within minutes of the incident. The suspected assailant keeps asserting that he hasn't fired the gun. Now how can one prove scientifically that the suspect did indeed fire the gun? Scientists make use of a curious fact involved in firing to test it. Each cartridge used in firing contains a propellant charge or powder which burns during he firing action. The commonly used powders are either black powder or smokeless powder. Black powder, also known as gun powder, consists of charcoal (15%), sulphur (10%) and potassium nitrate (75%). When ignited, it produces a lot of smoke. Smokeless powder contains either nitrocellulose alone (in which case it is known as a single base powder) or nitrocellulose mixed with nitroglycerine (in which case it is known as double base powder). Besides the propellant mixture, the cartridge also contains some special chemicals called the primer. These chemicals have the special property of getting ignited when subjected to great pressure. Several types of primers may be used, but the most commonly used are lead azide, lead styphnate, mercury fulminate, barium nitrate, potassium chlorate and antimony sulphide. In fact, when the trigger of a gun is pressed, the firing pin strikes the cartridge at a point where the primer is kept. This cause the primer to ignite. The flames thus produced ignited the propellant charge. The burning of the propellant charge produces large amounts of gases, which finally propel the bullet. So much so about the primer and black powder. Now how does the scientist make use of these facts? Actually when a gun is fired, the products of combustion (of propellant and primer) come out of the barrel of the gun. Some may leak through the back of the gun and may get deposited on the hands of the person who has fired. Depending of whether the gun was handled by the right or the left hand, the products of combustion get deposited on certain specific areas of the hand which are exposed (fig 1). Now if somehow, one can detect the products of combustion from the hands, one can be in a fairly good position to say whether the accused did handle the gun. The first such idea occurred to Teodoro Gonzalez of the Criminal Identification Laboratory, Mexico City police headquarters, as far back as in 1933. He employed, what later became famous as the "paraffin test", also known as the "Dermal nitrate" or "diphenylamine test". In this test, the hands of the suspect are coated with a layer of paraffin. After cooling, the casts are removed and treated with an acid solution of diphenylamine. This reagent detects nitrites and nitrates that originate from gun powder and are deposited on the hands of the criminal. A positive test is indicated by the presence of blue flecks in the paraffin. In 1959, two scientists Harrison and Gilroy introduced another test. This test was designed to detect chemicals such as barium, antimony and lead. Those chemicals are produced by the burning of the primer and may get deposited on the hands of the criminal. This test, too, is used frequently to determine whether a criminal indeed fired a shot. In this test, a square of white cotton cloth is moistened with hydrochloric acid. This is a common chemical used in most laboratories. Most people know it by the name tezaab , which is sometimes used to clean toilets. However, the acid that is used in the test is quite diluted; so it does not burn the hands of the suspect. The cotton cloth, moistened with this diluted hydrochloric acid, is used to swab the hands of the suspect. If the suspect has fired the gun, the particles of the chemicals mentioned above will get transferred to the cotton. The cotton swab is then treated with a special chemical triphenyl methyl arsonium iodide also known as "antimony detector" (because it detects antimony). To be more accurate, the cotton swab is split into two. One half is treated with the above chemical, which detects antimony and the other half with another chemical called sodium rhodizonate. This chemical detects the presence of barium and lead, by changing the color of the cotton, treated with either chemical changes, then it is confirmed decisively that the person is the culprit. Several times, I have been asked by the police to opine if a particular criminal fired the fun or not and I have used these two tests to my benefit with great accuracy. Most of the time, criminals have been prosecuted on this evidence. SO next time when you read in newspapers that the scientists determined the actual gun man by conducting certain tests, don't be in awe. You know exactly what chemicals and tests have been used. Who knows, you might even give a hint or two to the police!

SCIENCE IN CRIME DETECTION-15 SPEECH SPECTOGRAMS CATCH CRIMINALS This time I tell you about an exciting new technique, by which we can recognize a person from his speech. This technique is useful in cases like abduction, when kidnapper asks for ransom over the telephone. Can a person be positively recognized from his voice? You must have noticed that you can readily recognize a person from his voice. Even when you are sitting engrossed in your work and someone calls you from the back, you can readily recognize his voice. This is because, the voice‑generating system in each individual is different. In fig(1) you can see the various structures of the mouth which are involved in speech production such as palate, tongue, teeth, lips, cheeks, nasal aperture etc. These structures are different in different individuals and this is the basis of speech recognition. For a long time scientists were thinking of having a kind of "photographs" of human speech. It is always easier and simpler to compare two photographs, than to compare two sounds. Moreover, if a person has not heard the voice of a culprit for a long time, and he was asked to recognize that culprit again by his voice after a period of, say ten years, he might be at a loss to recognize him. If there was no way of converting the sound to a photograph, a police officer would face this problem very often. To overcome this handicap, in 1963, as scientist Lawrence G.Kersta, developed a unique machine in his laboratory in Somerville, New Jersey. This machine is known as the speech spectrograph and is shown Fig(2). The speech spectrograph converts a human speech into various graphs which can be easily compared. Fig 3, shows the spectrograms (the voice graphs) of male and female voice. Once can easily spot the difference between the two. Fig 4, shows the spectrograms or voice prints of 5 people saying a single word"you". there are 6 spectrograms which show clearly that one person has said" you" two times. Try to visualize the photograph carefully and try to find out which two voice prints look similar. These are the words uttered by the same person. With this background in mind, it is now easier to explain, how the machine helps in police investigation. Suppose a kidnapper has kidnapped a child, and then asks for ransom over the phone. The police scientist can record his voce and make speech spectrograms from that recorded voice, by the help of the spectrograph. The voice prints are then stored in the police prints are then stored in the police records for future reference. In future whenever a suspect is arrested, his voice prints can be made again and matched with that of the telephone caller. If the voice prints match perfectly, then the suspect is indeed the real kidnapper, otherwise not. The same technique can he used in several other situations. Sometimes people phone young females just for fun sake and speak obscene languages over the phone. These are basically harmless people, but their repeated malicious calls may be a nuisance. Till now the only way to tackle with such malicious callers was to keep the phone off the hook or to keep the receiver off the cradle. But now the affected party can call the police and ask them to make voice prints of such callers. These voice prints are permanent records in the files of the police and can be used anytime later when a suspect is arrested. Several countries are using this new technique now regularly to investigate crime.. Michigan State Police for example have been using this method with success since 1968. Some very famous crimes have been solved by this technique. This account should give you an idea of how deeply modern science has affected crime investigation. This is a new field of crime investigation. This is a new field of crime investigation and more research is needed before we can say the final word on it.

SCIENCE IN CRIME DETECTION-6 THE VITAL EVIDENCE ? During my long professional career, I have been involved in a number of interesting cases, where a sound medical knowledge helped me to unravel crime. I will discuss one such case here. Ram Avtar was a God fearing man living on the outskirts of Delhi. He had a small family; a religious wife, a fifteen year old son Raju and a twenty-one year old daughter Neetu. Ram Avtar was worried about Neetu as she was growing older rapidly, and he wanted to get her married. She was beautiful and moderately educated, but as Ram Avtar did not have enough money to pay as dowry, he was having difficulty in finding a suitable groom. A beautiful, poor, young girl is often the target of bad elements in the neighborhood. Shamsher and Kishore, two bad characters of the locality, often teased her. Whenever Neetu would pass through the streets, they would pass filthy remarks on her. In several such remarks, they proposed marriage with her even. But Neetu knew them well and quite rightly ignored and avoided them. But one day they transcended all limits of decency. It was about 10.00 pm on August 22, 1983. Neetu was returning home after visiting her aunt. Normally she wouldn't have been so late but the DTC bus in which she was traveling, went out of order. She could not get an alternative transport for quite some time. Finally she decided to walk home as she could not afford an auto rickshaw. Shamsher and Kishore were drinking at the local pub, round the corner. By the time they saw Neetu arrive, they were quite tipsy. They staggered towards her as she advanced towards her house. One of them caught hold of her dupatta (Dupatta is a small band of cloth used in India by the girls to cover breasts) and pulled it while the other tried to touch her breasts. He managed to lay his hand on her left breast and even succeeded in stealing a kiss on her cheeks. Naturally this enraged her and she started calling for help. Ramavtar came out of the house and as soon as he saw the two youths and his disheveled daughter, he understood the whole story and instinctively started beating them. He also raised an alarm, on hearing which many residents came out of their houses. They also gave them a sound thrashing and later dragged both of them to the police station. The police swung into action and registered a case under Section 354 on the Indian penal Code (which deals with “indecent assault on women”). The case did not drag on for long. Eight residents of the colony, besides Ramavtar and Neetu, gave evidence against Shamsher and Kishore. Against such an overwhelming evidence, the court found no difficulty in prosecuting both of them. They were sentenced to six months of rigorous imprisonment. When the two criminals were being dragged to jail, they openly swore to get even with Ramavtar and Neetu. Many people heard their threats, but none took them seriously as they were petty criminals and could not do much harm to them. On January 14, 1986, the unexpected happened. Ramavtar's wife and son were away on a marriage. Only Ramavtar and Neetu were at home. At 6.00 am when the milkman knocked at Ramavtar's door, there was no response. Normally the milkman would have gone away but he had to collect the payment, which was already delayed by a week. When there was no response even after 5 minutes, the milkman got suspicious and informed the neighbors. Soon many people collected outside. Someone informed the police. When the police broke open the door, they found a horrible scene. Ramavtar was found dead on his bed, his head badly mangled. Neetu was lying stark naked, spread-eagled on the floor. There was a gag in her mouth and foam at her nostrils. Her genitals were bleeding. Anyone with a rudimentary knowledge of crime could see that she had been sexually assaulted a number of times. The window of the room was ajar. It appeared that the criminals had escaped from the window. A detailed enquiry could not reveal much. A faint lead came from one neighbor, Satbir. He said that on the night of January 13-14, he had got up to urinate twice, sometime in the night. For urination, he had to go to his backyard, from where he could clearly see Ramavtar's house. He usually got up in the night to urinate and he couldn't help but see Ramavtar's house, as it lay exactly at the back of his house. Normally the lights in Ramavtar's house used to be off, but last night, when he went to urinate for the second time, he found that the lights were on. He was quite drowsy initially, but he noticed that the lights were flickering. It appeared that someone was moving about with a torch. It was a strange sight, but he did not give it much importance, as no sound was coming from there. He thought that their electricity may have failed and they were looking for something, probably a candle. The police asked him for more information, but he could not reveal more. Finally they came to me for help. I saw the scene of the crime and listened to Satbir's versions. The police inspector was standing besides me when I was interrogating him. The police inspector again asked him if he could remember the time when he saw those flickering lights. Clearly if he could remember the time, the police would know the exact time of murder, down to the last minute. But Satbir had not looked at the clock and try hard as he would, he could not remember the time. It could have been 1 am, 2 am or even 5.15 am. He just did not know the time. The already faint clue was becoming fainter. I looked at my watch. It was 8.15 am now. Tired of interrogation, Satbir asked to be permitted to go to the urinals. I asked him if he had gone to the urinals again after seeing those lights. He answered in the negative. I produced a flask from my bag and asked him to urinate in that. The police officer was surprised at this strange request, but I told him that everything could become clear soon. When Shamsher and Kishore were rounded up for investigation, they came up with an iron-strong alibi. They were in Chandigarh the previous night and had landed in Delhi only at 3.00 am, on January 14. They had bus tickets to prove this. When the driver and conductor of the bus were contacted, they affirmed that Shamsher and Kishore had indeed traveled on that bus that night. With the time of murder not yet fully solved, it seemed difficult to implicate them for murder, although the police had a strong hunch that Shamsher and Kishore were the ones who had murdered them out of revenge. The police inspector came to me and asked if I could say anything about the time of murder. On hearing the latest developments, I realized that in the light of fresh revelations, the calculation of the time of murder had become vital now. I brought out the flask of urine, measured the volume of urine and told him that Ramavtar and Neetu had been murdered at 4.35 am on January 14. This took the police officer by surprise. Indeed if my calculation was correct, he could implicate Shamsher and Kishore in the murder, because by that time they were already in Delhi. In fact, if the time of murder was found to be earlier than 3.00 am (the time when Shamsher and Kishore landed in Delhi), his task would have become a lot more difficult. He asked me how I had calculated the time of death of Ramavtar and Neetu, from Satbir's urine. In fact, initially he thought that I was joking. But like a good old medical detective, I wanted to keep my secrets. I told him that I would reveal my calculations in the court only. The court duly acknowledged my scientific evidence and both Shamsher and Kishore were sent to jail for life. Now, let me share this secret with the readers. All medical people know that our kidneys produce 1 ml of urine in 1 minute. Thus, in a day we produce about 1440 ml of urine. When the bladder accumulates about 300-400 ml of urine, we feel an urge to go to the urinals. When Satbir got up in the night to urinate, he emptied his bladder completely. We can be sure of that. Now what is important is that his kidneys started pouring exactly 1 ml of urine per minute into his urinary bladder. When at 8.15 am, I took his urine in my flask, its volume was 220 ml. It meant that Satbir had emptied his bladder 220 minutes earlier, i.e. 3 hours and 40 minutes earlier. When this time was subtracted from the time the urine sample was taken (which was 8.15 am), I got the required time, which was 4.35 am. This meant that Satbir must have got up at 4.35 am (for the second time) to urinate and it was at that time when he saw strange lights in Ramavtar's house. Here Satbir's kidneys worked as effective clocks for me. The human body works in a rhythmic fashion and if we know how to make use of this rhythm, we can unravel seemingly unsolvable mysteries.

Book Review Journal Aims & Objectives This journal has been started by Dr Anil Aggrawal, Professor of Forensic Medicine at the Maulana Azad Medical College, New Delhi - 110002. Dr. Aggrawal is quite keen to interact with people who are interested in books. Dr. Aggrawal adores books and literally thrives on them. Though being a medical doctor specializing in forensic medicine, he loves books on all subjects encompassing such diverse ranges from astronomy and zoology to paleontology, history, occult science, philosophy, mathematics, and classical literature, et al. His penchant for books was conceived quite early in life. Even as a three year old he always pined for books instead of toys-as his siblings did. There is a legend about the Greek mathematician and engineer Archimedes (ca. 287 B.C. - ca. 212 B.C.). When Roman armies sacked Syracuse in 212 B.C. he was busy studying a geometrical figure made in sand. When a Roman soldier commanded him to come along, he motioned to him imperiously, "Don't disturb my circles". The soldier felt so insulted that he killed Archimedes on the spot! In a similar situation Dr. Aggrawal would probably say, "Don't disturb my books!" Writers and thinkers have always been his idols. Some of the people who have inspired him are (i)Lord Buddha (he remains first on his list) (ii)Albert Einstein (iii)Robert James Fischer (The only American who has been an official World Chess Champion) and (iv)Isaac Asimov (he wrote close to 500 books, and is reputed to be the only author to have published books in all ten categories of the Dewey Decimal System! Oh, well, we all know it's not true, but he has really written so widely, it seems cruel to challenge this statement.) Aggrawal is no Asimov, but like him, he loves writing books. He has written nine books so far (till 2006 end). Four of them are quiz books, which reflect his morbid passion for quizzes. The books, in order they were published are (i) 1000 Crime Quiz (published 30 March 1992) (ii)1000 Love & Sex Quiz (published 13 August 1992) (iii) Some Common Ailments (Published 27 January 1993)(iv)The Book of Medicine (Published 5 February 1994) (v)Narcotic Drugs (Published on 2 May 1995) (vi) 1000 Biology Quiz (Published on 29 August 1995) (vii)Modern Diagnostics (Published on 8 March 2001) (viii) Health Quiz Book (Published on 5 August 2002) (ix) Self Assessment and review of Forensic Medicine and Toxicology (the first book related to his profession). And since we all love statistics, here is a detailed statistics of these books. Here they are: S. no. Book Started on Completed on Published Publisher Publisher Cost 1. 1000 Crime Quiz 1.2.91 31.5.91 31.5.91 March 1992 Rupa 30 2. 1000 Love & Sex Quiz 1.6.91 7.1.92 7.1.92 August 1992 Rupa 30 3. Some Common Ailments 1.6.91 28.11.91 28.11.91 January 1993 NBT 25 4. The Book of Medicine Nov 92 15.1.93 15.1.93 February 1994 Rupa 30 5. Narcotic Drugs 1.1.93 9.5.94 9.5.94 May 1995 NBT 46 6. 1000 Biology Quiz 6.1.92 17.3.93 19.3.93 August 1995 Rupa 80 7. Modern Diagnostics 1995 1996 1996 March 2001 NBT 80 8. Health Quiz book Feb 2002 July 2002 July 2002 August 2002 Ocean Books 200 9. Self Assessment and review of Forensic Medicine and Toxicology 2005 April 2006 April 2006 May 2006 PeePee 295 (Books published till 2007 end) N.B. 1. NBT stands for National Book Trust, India. 2. Dates mentioned are in this format: day/month/year. 3. The cost is in Indian Rupees. 4. Some Common Ailments has been translated in Assamiya, Bangla, Hindi, Kannada, Konkani, Marathi, Nepalese, Oriya, Punjabi, Telugu and Urdu (Total 12 languages). 5. Narcotic Drugs has been translated in Assamiya, Bangla, Hindi, Punjabi and Urdu (Total 6 languages). 6. Health Quiz Book has been translated in Hindi (Total 2 languages). Why is Dr. Aggrawal interested in writing book reviews? Whenever he reads a book he tries to discover its strong points. There is a subconscious effort on his part perhaps, to incorporate those points in his own writings. He then wants to share his findings with everyone. In the year 2000, he started an Internet Journal of Forensic Medicine and Toxicology , and out of his sheer interest in books, he included a book review section to it. The unprecedented popularity of the review section took him by complete surprise. He received books from authors and publishers in thousands. And they belonged to all subjects-not only forensic medicine and toxicology, which he had intended at the inception of the above journal. With time he and his group realized that they must conjure another journal devoted solely to Book Reviews for books of all genre. In this all-new journal they would accommodate all kinds of books, and hence the present Anil Aggrawal's Internet Journal of Book Reviews . Dr. Aggrawal fondly cites the examples of many regular journals (not devoted to book reviews), which have come out with issues especially devoted to book reviews. One pertinent example is Archives of Sexual Behavior , which came out with an issue (Volume 28, Number 5 / October, 1999, pages 377-467) especially devoted to book reviews in 1999. Readers can access this issue by clicking here .

Anil Aggrawal's Internet Journal of Book Reviews Aims and Objectives This journal has been started by Dr Anil Aggrawal, Professor of Forensic Medicine at the Maulana Azad Medical College, New Delhi - 110002. Dr. Aggrawal is quite keen to interact with people who are interested in books. Dr. Aggrawal adores books and literally thrives on them. Though being a medical doctor specializing in forensic medicine, he loves books on all subjects encompassing such diverse ranges from astronomy and zoology to paleontology, history, occult science, philosophy, mathematics, and classical literature, et al. His penchant for books was conceived quite early in life. Even as a three year old he always pined for books instead of toys-as his siblings did. There is a legend about the Greek mathematician and engineer Archimedes (ca. 287 B.C. - ca. 212 B.C.). When Roman armies sacked Syracuse in 212 B.C. he was busy studying a geometrical figure made in sand. When a Roman soldier commanded him to come along, he motioned to him imperiously, "Don't disturb my circles". The soldier felt so insulted that he killed Archimedes on the spot! In a similar situation Dr. Aggrawal would probably say, "Don't disturb my books!" Writers and thinkers have always been his idols. Some of the people who have inspired him are (i)Lord Buddha (he remains first on his list) (ii)Albert Einstein (iii)Robert James Fischer (The only American who has been an official World Chess Champion) and (iv)Isaac Asimov (he wrote close to 500 books, and is reputed to be the only author to have published books in all ten categories of the Dewey Decimal System! Oh, well, we all know it's not true, but he has really written so widely, it seems cruel to challenge this statement.) Aggrawal is no Asimov, but like him, he loves writing books. He has written nine books so far (till 2006 end). Four of them are quiz books, which reflect his morbid passion for quizzes. The books, in order they were published are (i) 1000 Crime Quiz (published 30 March 1992) (ii)1000 Love & Sex Quiz (published 13 August 1992) (iii) Some Common Ailments (Published 27 January 1993)(iv)The Book of Medicine (Published 5 February 1994) (v)Narcotic Drugs (Published on 2 May 1995) (vi) 1000 Biology Quiz (Published on 29 August 1995) (vii)Modern Diagnostics (Published on 8 March 2001) (viii) Health Quiz Book (Published on 5 August 2002) (ix) Self Assessment and review of Forensic Medicine and Toxicology (the first book related to his profession). And since we all love statistics, here is a detailed statistics of these books. Here they are: Book Statistics Book 1000 Crime Quiz 1000 Love & Sex Quiz Some common Ailments The Book Of Medicine Narcotic Drugs 1000 Biology Quiz Modern diagnostics Health Quiz Book Self assessment and review of Forensic Medicine & Toxicology Started On 1.2.91 1.6.91 1.6.91 Nov 92 1.1.93 6.1.92 1995 Feb 2002 2005 Completed On 31.5.91 5.1.92 28.11.91 Jan 93 9.5.94 17..3.93 1995 July 2002 2006 Submitted On 31.5.91 7.1.92 28.11.91 15.1.93 9.5.94 19.3.93 1996 July 2002 April 2006 Published March 1992 Aug 1992 Jan 1993 Frb 1994 May 1995 Aug 1995 March 2001 Aug 2002 May 2006 Publisher Rupa Rupa NBT Rupa NBT Rupa NBT Ocean Books PeePee Cost 30 30 25 30 46 80 80 200 295 (Books published till 2007 end) N.B. 1. NBT stands for National Book Trust, India. 2. Dates mentioned are in this format: day/month/year. 3. The cost is in Indian Rupees. 4. Some Common Ailments has been translated in Assamiya, Bangla, Hindi, Kannada, Konkani, Marathi, Nepalese, Oriya, Punjabi, Telugu and Urdu (Total 12 languages). 5. Narcotic Drugs has been translated in Assamiya, Bangla, Hindi, Punjabi and Urdu (Total 6 languages). 6. Health Quiz Book has been translated in Hindi (Total 2 languages). Why is Dr. Aggrawal interested in writing book reviews? Whenever he reads a book he tries to discover its strong points. There is a subconscious effort on his part perhaps, to incorporate those points in his own writings. He then wants to share his findings with everyone. In the year 2000, he started an Internet Journal of Forensic Medicine and Toxicology, and out of his sheer interest in books, he included a book review section to it. The unprecedented popularity of the review section took him by complete surprise. He received books from authors and publishers in thousands. And they belonged to all subjects-not only forensic medicine and toxicology, which he had intended at the inception of the above journal. With time he and his group realized that they must conjure another journal devoted solely to Book Reviews for books of all genre. In this all-new journal they would accommodate all kinds of books, and hence the present Anil Aggrawal's Internet Journal of Book Reviews. Dr. Aggrawal fondly cites the examples of many regular journals (not devoted to book reviews), which have come out with issues especially devoted to book reviews. One pertinent example is Archives of Sexual Behavior, which came out with an issue (Volume 28, Number 5 / October, 1999, pages 377-467) especially devoted to book reviews in 1999. -Puneet Setia Journal Associate

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 ( 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. Spare Parts: Organ Replacement in American Society. (Routledge, New York, 2017). doi:10.4324/9781315130125. Fox, R. & Swazey, J. The Courage to Fail: A Social View of Organ Transplants and Dialysis. Routledge & CRC Press Link . Sharp, L. Strange Harvest: Organ Transplants, Denatured Bodies, and the Transformed Self 9780520939615. dokumen.pub Link (2006). Sque, M. R. G. A dissonant loss: the bereavement of organ donor families. in (eds. Sque, M. R. G. & Payne, S.) 59–81 (Open University, 2007). Antipov, A. V. & Владимирович, А. А. The Bioethics of Dying: Dignity, Commercialisation and the Organ as a Gift. Čelovek 36, 32–51 (2025). Ben-David, O. B. Organ Donation and Transplantation : Body Organs as an Exchangeable Socio-Cultural Resource. (Westport, Conn. : Praeger Publishers, 2005). Crowley-Matoka, M. Domesticating organ transplant: Familial sacrifice and national aspiration in Mexico. Medicine Anthropology Theory | An open-access journal in the anthropology of health illness and medicine 4, 216 (2017). Scheper-Hughes, N. The tyranny of the gift: sacrificial violence in living donor transplants. Am J Transplant 7, 507–511 (2007). Siminoff, L. A. & Chillag, K. The fallacy of the ‘gift of life’. Hastings Cent Rep 29, 34–41 (1999). Hogle, L. F. Recovering the Nation’s Body. Bucknell University Press Link (1999). MoHFW-GoI. NOTTO: National Organ & Tissue Transplant Organisation. Under Aegis NOTP, Dir Gen Heal Serv MoHFW, Govt India. (2011). DGHS. National Organ Transplant Programme. Link Chakradhar, K. et al. Knowledge, Attitude and Practice Regarding Organ Donation among Indian Dental Students. Int J Organ Transplant Med 7, 28–35 (2016). Burra, P. et al. Changing attitude to organ donation and transplantation in university students during the years of medical school in Italy. Transplant Proc 37, 547–550 (2005). Shroff, S. Legal and ethical aspects of organ donation and transplantation. Indian J Urol 25, 348–355 (2009). Muraleedharan, V. R., Jan, S. & Ram Prasad, S. The trade in human organs in Tamil Nadu: the anatomy of regulatory failure. Health Econ Policy Law 1, 41–57 (2006). Parakh, H. Illegal Organ and Human Trafficking during Covid 19 | International Journal of Law Management & Humanities. Link (2021). Manojan, K., Raja, R., Nelson, V., Beevi, N. & Jose, R. Knowledge and Attitude towards Organ Donation in Rural Kerala. (2018) doi:10.4103/0973-. Kennedy, K. Organ Donation and Transplantation in India: An Inquiry in Kerala. Journal of Social Distress and the Homeless 11, 41–67 (2002). Khan, N., Masood, Z. & Zahra, S. KNOWLEDGE AND ATTITUDE OF PEOPLE TOWARDS ORGAN DONATION. Journal of University Medical & Dental College 2, 15–21 (2011). Vijayalakshmi, P., Sunitha, T. S., Gandhi, S., Thimmaiah, R. & Math, S. B. Knowledge, attitude and behaviour of the general population towards organ donation: An Indian perspective. Natl Med J India 29, 257–261 (2016). Abraham, G. et al. Evolution of deceased-donor transplantation in India with decline of commercial transplantation: a lesson for developing countries. Kidney International Supplements 3, 190–194 (2013). Pfaller, L., Hansen, S. L., Adloff, F. & Schicktanz, S. ‘Saying no to organ donation’: an empirical typology of reluctance and rejection. Sociol Health Illn 40, 1327–1346 (2018). Saxena, D. et al. Challenges and Motivators to Organ Donation: A Qualitative Exploratory Study in Gujarat, India. Int J Gen Med 16, 151–159 (2023). Lampe, N. M. SATISFICING DEATH: Ageing and end-of-life preparation among transgender older Americans. Sociol Health Illn 46, 887–906 (2024). Haddow, G. The phenomenology of death, embodiment and organ transplantation. Sociology of Health & Illness 27, 92–113 (2005). Jamieson, L. 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-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 [Epub Ahead] ( 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. Revalidating the prognostic relevance of the Abbreviated Burn Severity Index (ABSI): A twenty-year experience examining the performance of the ABSI score in consideration of progression and advantages of burn treatments from a single center in Vienna. Journal of Plastic, Reconstructive & Aesthetic Surgery [Internet]. 2024;94:160–8. Available from: https://www.sciencedirect.com/science/article/pii/S1748681524002274 Pemerintah Pusat RI (Central Government of Indonesia). Undang-undang (UU) Nomor 1 Tahun 2023 tentang Kitab Undang-Undang Hukum Pidana (Penal Code). Jakarta: DPR RI; 2023. Pemerintah Pusat RI (Central Government of Indonesia). Undang-undang (UU) Nomor 23 Tahun 2004 tentang Penghapusan Kekerasan dalam Rumah Tangga (Elimination of Domestic Violence). Jakarta: DPR RI; 2004. Pemerintah Pusat RI (Central Government of Indonesia). Undang-Undang Republik Indonesia Nomor 23 Tahun 2002 Tentang Perlindungan Anak (Child Protection). Jakarta: DPR RI; 2002. 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

Main Page > Vol-26 No- 2 > Book 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) Book Review (Technical Section) Basic Sciences as applied to Forensic Medicine and Toxicology By Anil Aggrawal Basic Sciences as applied to Forensic Medicine and Toxicology, 1st Edition, Publication date: 2025, by Anil Aggrawal , Paperback, Publisher: Arya Publishing Company, ISBN 9789360590864, Language: English, Pages: XVIII + 301. Price: ₹ 1310. A forensic masterclass in basic sciences for postgraduates. The current book by the Author is an attempt- novel and unique, in the sense that the effort is inspired by the Indian post-graduate curriculum designed by the erstwhile Medical Council of India (known as National Medical Commission now) for M.D. course in the discipline of Forensic Medicine, more specifically the Paper-I of the Theory examination. The import of the title “Basic Sciences as Applied to Forensic Medicine and Toxicology” is very wide in scope and pertains to all the relevant anatomy, biochemical and physiologic principles, etc which is the basis of understanding the morbid anatomy and application of those to better understand the core Forensic Pathology. The book is an attempt to provide a one stop solution to the postgraduates in the discipline who earlier had to scroll through voluminous texts of Anatomy, Physiology, Biochemistry, etc to derive examination oriented content for better presentation in the examinations. Although the relevant basic sciences applicable to particular topics of interest in Forensic Medicine have already been provided by the Author in his earlier books viz. Textbook of Forensic Medicine & Toxicology, Injuries- Forensic and Medico Legal Aspects and Clinical and Forensic Toxicology, the present book goes several leaps ahead to explain most commonly asked topics from the entire ream of basic sciences which are some of the emerging domains e.g. stem cells, immunohistochemistry and molecular pathology- to name a few. Yet, the book remains connected to the very soul of Forensic Medicine, Traumatology and Toxicology by referring back to prior cited texts and thus avoiding repetition and maintaining chronology stimulating the reader and allowing for both horizontal and vertical integration, which is also the essence of Competency Based Medical Education Curriculum. The text is amply studded with memory aids and some of the handmade diagrams by the Author- one of particular note is memory aid designed for remembering cranial nerves on Page No 18, which makes the anatomical orientation of the various cranial nerves with respect to each other as well as vastly simplifies the topographic anatomy. Not to suffice, the text contains numerous demonstration videos which are a rarity in the existing literature and help the reader in grasping the basic concept e.g. experimental demonstration of the law of Laplace given on page no 51, which helps in conceptual understanding of the abstract terminologies. General Pathology given in Chapter 4 is a welcome inclusion as it helps in understanding the basic pathologic principles which are the basis for understanding and interpreting Forensic Pathology. A clear differentiation between Septicemia, sepsis and septic shock, based on updated scientific criteria is heartening to see on Page no’s 96 and 97. Another exciting feature of the book is the innumerable case studies which make the topics both entertaining to read and further act as reminders how one particular development has a legal bearing or implication. Chapter 6 discusses general pharmacological principles which have importance in the field of clinical and forensic toxicology. Questionnaire towards the end of each topic are though provoking e.g. anti-neoplastic drug for homicide brings one to an old case of murder by means of Lomustine, which is a drug employed for brain tumor treatment but the aplastic anemia and multi-organ failure which are the consequence of it’s overdose resemble natural death. This is significant for even clinicians/ emergency physicians who treat a significant number of accidental drug over-dosages to be mindful of the drug history- both prescriptions as well as Over-the-counter (OTC). The chapter on “Radiology as Applied to Forensic Medicine and Toxicology” is very thoughtfully designed considering the advent of Virtual Autopsy at AIIMS in 2021 by the Government of India after the Virtopsy project under Prof Richard Dirnhofer of the Institute of Forensic Medicine, University of Bern, Switzerland. The radiographs important from the point of view of a forensic practitioner have been given along with comparative diagrammatic representation for simplification purposes. Readers shall be in a better position to interpret the basic postmortem radiographic findings if and when needed. National Board of Examinations (NBE) has been asking one question every year in Paper I of Forensic Medicine DNB Theory Examination based upon biostatistics accounting for 10 marks. The inclusion of statistics as applied to Forensic Medicine and Toxicology in Chapter 8 of the book is a welcome step to strengthen the students with the most essential and desired topics e.g. Null Hypothesis, P-value, Z score, etc. which could be asked. The next chapter on Research Methodology is educative for the thesis going and any researcher to understand the various study designs and how to calculate the sample size for a proposed research study. Types of citations and referencing systems have also been elaborated upon and the various indexing systems have been deliberated upon. This is very much needed for a novice researcher as imprecise understanding of these may create impediments in the growth and advancement of the latter. The last few chapters focus on infrastructural requirements related to setting up of a Museum and Analytical Toxicological Laboratory in the Department of Forensic Medicine and Toxicology. Basic chemistry has been given at the end to simplify the understanding of subtlety and nuances of Forensic Toxicology. Few sample questions have been provided in the appendix which could further be enhanced through the addition of previous year questions from various universities. Tentative thesis/ research topics given in the appendix give important food for thought to the examinees and the research oriented ones. Overall the book is a novel and fresh initiative in an unexplored genre/ theme which will bode well to the lot to whom it is intended to cover- postgraduates in Forensic Medicine & Toxicology and the faculty. - Dr. Varun Modgil He is currently working as Assistant Professor at Dayanand Medical College & Hospital, Ludhiana, Punjab. He was Senior Resident at Postgraduate Medical Education & Research (PGIMER), Chandigarh. He deposed as an expert witness at various courts in Punjab, Haryana and Chandigarh. He has completed his D.N.B. in Forensic Medicine and also published articles in various National & International journals and also delivered guest lectures in National Conferences on Forensic Medicine. He can be contacted at dr_varun_modgil@dmch.edu ,