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. 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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. 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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 ,

Forensic Toxicology THE FOLLOWING ARTICLE APPEARED IN THE APRIL 2000 ISSUE THE POISON SLEUTHS DEATH BY HYDROGEN PEROXIDE -Dr. Anil Aggrawal "Good morning doctor. Oh, my God, what are you doing today? You have the dead body of a young boy today. What happened to him? Please tell me.” “Good morning Tarun. The name of this young boy is Ramu and he is five years old. Yesterday he was playing alone in front of his house at around 5 pm. At about 6 pm, he suddenly started vomiting. His mother noted some blood in his vomit. She got scared and immediately phoned her doctor. His abdomen was bloated, and he complained of severe pain in his abdomen. By the time the family doctor arrived, he was having great difficulty in respiration. His face turned blue and he started having seizures. His doctor immediately advised to take him to the hospital, but by the time he could be taken to the hospital, he was dead.” “Oh, that is most unfortunate. But how did he die? Was he having some disease?” “Nobody knows how he died. In fact, that is why Ramu’s body has been brought to me. The doctor, who examined him at the house is not in a position to say anything. The police has however done some preliminary enquiries. Ramu was the son of Mangelal, who was having some tiff with his tenant Bansi for the last five years. Mangelal wanted to have his house vacated, but Bansi wouldn’t do so. On this issue there was lot of enmity between the two. In fact, they were fighting a court case also.” “So is it possible that Bansi had some hand in killing Ramu?” “That is what the police is alleging. But we need some proof. We have enquired into the antecedents of Bansi, and have come up with some interesting findings. One of the most interesting findings is that Bansi works in a textile factory.” “That doesn’t sound like a very exciting finding to me.” “Yeah, but to me it is. You see, the symptoms which Ramu showed pointed only towards one poison, and that poison is very commonly available in a textile factory. So it does appear that Bansi had access to that poison with which Ramu died.” “With which poison did Ramu die? Please tell me.” “Tarun, I took an X-ray of the chest and abdomen of this dead boy Ramu, and I found lot of gas in his heart and in the veins of his abdomen. I took an X-ray before doing a post-mortem, because this was the only way in which I could demonstrate gas in his body. Once I had opened the body, the gas would escape, and I would have no proof to show to the court that there was any gas in his body.” “But how did you suspect gas in his body? And from where did the gas come in the first place?” “Tarun, I suspected gas in his body from his symptoms. Remember his abdomen was bloated and he complained of severe pain in his abdomen. These were sufficient to tell me that there was gas in his abdomen, and probably in some of his veins. I say that because he turned blue very soon, which means that his veins were probably blocked by something, say air. Now there is only one poison which I can think of, and that is Hydrogen Peroxide. When we came to know that Bansi worked in a Textile factory, my suspicion grew stronger, because hydrogen peroxide is very commonly used in textile industry, and it was quite easily accessible to him.” “Does this mean that Bansi gave Hydrogen Peroxide to Ramu? But how can Hydrogen Peroxide be used as a poison? I use it daily for my mouth gargles.” “Yes, most of use hydrogen Peroxide for mouth gargles. It is in fact also used to remove wax from the ear. But in all these preparations, the hydrogen peroxide that is available is in very dilute concentration, say, around 1.5%. In industry, hydrogen peroxide is available in much stronger concentrations, which could be fatal to life.” “Doctor, the story is getting somewhat intriguing. Please tell me in detail about hydrogen peroxide, so that I can understand about it clearly.’ “Tarun, hydrogen peroxide (H2O2), was first recognized as a chemical compound in 1818. It is the simplest member of the class of peroxides. It is a colourless liquid usually produced as aqueous solutions of various strengths. It is used commercially for several purposes, but principally for bleaching cotton and other textiles and wood pulp, in the manufacture of other chemicals, as a rocket propellant, and for cosmetic and medicinal purposes. Hydrogen peroxide is an oxidising agent with antiseptic properties and has also been used for many years as an antiseptic and a disinfectant. However it has not proved much beneficial because of several reasons. First it loses its potency rapidly when kept on the shelf for some time. Secondly a tissue enzyme called catalase destroys it before it can act on microorganisms. This agent is generally available in two strengths: dilute hydrogen peroxide, with a concentration of 3-9% (usually 3%), sold for home use, and concentrated hydrogen peroxide, with a concentration greater than 10%, used primarily for industrial purposes. Commercial-strength hydrogen peroxide is most commonly found as a 27.5-70% solution. Home uses for dilute hydrogen peroxide include ear cerumen removal, mouth gargle, vaginal douche, enema and hair bleaching. It is used as a mouth rinse in the concentration of 1.5%, but the fact is that the contact time is too short for the preparation to be effective. At a concentration of 3-6%, it has been used as a disinfectant and sterilant. For ear wax removal, it is used in a concentration of 1.5% in a solution of salt. In some countries, 35% hydrogen peroxide has become available now to the general public in health food stores, where it is sold as “hyper-oxygenation therapy”. Solutions containing more than about 8 percent hydrogen peroxide are corrosive to the skin. Hydrogen peroxide decomposes into water and oxygen upon heating or in the presence of numerous substances, particularly salts of such metals as iron, copper, manganese, nickel, or chromium. Pure hydrogen peroxide freezes at -0.430 C (+31.30 F) and boils at 150.20 C (3020 F); it is denser than water and is soluble in it in all proportions. Nowadays stabilized hydrogen peroxide has also become available, which doesn’t lose its oxygen very soon. Stabilized Hydrogen Peroxide is made by adding certain negative catalysts to the solution, most commonly, certain tin salts and phosphates.” “How much hydrogen peroxide is needed to kill a human being doctor?” “About 120-180 mL of 35% Hydrogen Peroxide can cause death in a child, and I would say about 250-300 mL of the same concentration could kill an adult human being. This is roughly the same amount as is present in a soft drink bottle, and if a person is thirsty, he can drink this amount in a few quick gulps. So if a killer presents it to an unsuspecting thirsty man, he can kill him easily.” “How does hydrogen peroxide kill doctor?” “Hydrogen peroxide has no taste. The color is also something like that of water, so it can easily be given to an unsuspecting individual. Hydrogen peroxide has two main mechanisms of toxicity: local tissue injury and gas formation. The extent of local tissue injury is determined by the strength of the Hydrogen Peroxide. Dilute hydrogen peroxide is an irritant and concentrated hydrogen peroxide is a caustic. Local toxicity is mediated by hydroxyl radical (OH-), and not by superoxide (O2-), or peroxide (O2-2) radical, as you might imagine. Hydrogen peroxide is also an oxidising agent. Gas formation occurs when hydrogen peroxide interacts with tissue catalase, liberating molecular oxygen and water. One milliliter of 3% hydrogen peroxide can liberate 10 mL of oxygen at standard temperature and pressure. Gas formation can result in life-threatening embolization. This means that gas can form within the veins. This gas travels with the blood up to the heart, and there it can cause blockage of the heart, which is technically known as embolization. The use of hydrogen peroxide in closed spaces such as operative wounds or its use under pressure during wound irrigation increases the likelihood of embolization. When dilute hydrogen peroxide is ingested one gets vomiting and abdominal bloating. The mouth cavity may be discolored white. There may be irritation of the stomach wall, and gas may form in the veins leaving the intestines - mostly portal vein. Ramu ingested concentrated form, and that is why his symptoms were so pronounced.” “How do you know so surely doctor?” “I had the house of Bansi searched, and sure enough we found a large bottle in his house containing 70% Hydrogen Peroxide, which he has stolen from his factory. When we asked him, what that bottle was doing in his house, he could not give any satisfactory reason. The police enquired him, more sternly and he came out with these facts. He and Mangelal were not on friendly terms because of the issue of vacating the house. Bansi did not want to vacate the house, while Mangelal was pressing him to do that. Finally Bansi decided to teach Mangelal a lesson. He wanted to kill his son, and for this purpose, he chose a most unusual poison - Hydrogen Peroxide. This poison was easily available to him in his factory. Furthermore, he was quite sure, that if he used such an unusual poison, nobody would be able to catch him. At about 5.30 pm on that fateful day, Bansi saw Ramu playing. He somehow was successful in coaxing him to drink a glass of water, which actually was nothing but concentrated hydrogen peroxide which he had flicked from his factory. Rest all is known to you. He was sure, he wouldn’t be caught, as the poison disintegrates in the body to just water and oxygen, both of which are ordinary constituents of the body. But he did not realize that I would take the X-ray of the body, and demonstrate that gas - the oxygen- in the veins by X-ray. I have also seen some damage to the stomach wall of Ramu, which is another proof that Hydrogen peroxide was given to him. Coupled with all these findings, the fact that a bottle of concentrated hydrogen peroxide was found in his home would go far in proving his guilt in court.” “Can you demonstrate hydrogen peroxide in Ramu’s body chemically also?” “No Tarun. Unfortunately that is not possible, as Hydrogen Peroxide disintegrates in the body so quickly. This is one of those rare poisons, which can kill, but is impossible to be demonstrated chemically. But I have the X-ray report of Ramu to show to the court, and all the rest as I told you, and I am sure, the court would easily find him guilty.” “That is very clever of you doctor. Without your clever deduction, no one would have thought Ramu was poisoned. Everybody would have thought that he died just of some natural disease. What are you going to tell me next time?” “Tarun, next time, I would tell you about a very interesting poison - Hydrofluoric Acid."

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

Main Page > Vol-26 No- 1 > Editorial by Puneet Setia (you are here) LinkedIn X (Twitter) Facebook Copy link Share Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology Volume 26 Number 1 (January - June 2025) Ref: Setia P. Apology Laws – Are they the right answer for Medical Practitioners? (Editorial). Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology, 2025 ; Vol. 26, No. 1 (January - June 2025): https://www.anilaggrawal.com/ij/vol-026-no-001/others/editorial ; Published January 1, 2025, : [about 5 p]. DOI: 10.5281/zenodo.14599219 . Available from : (Accessed: July 01, 2025) Apology Laws – Are they the right answer for Medical Practitioners? Puneet Setia Mahatma Gandhi, famously said this a number of times, “Confession of errors is like a broom which sweeps away the dirt and leaves the surface brighter and clearer. I feel stronger for confession. ” This year, I want to begin surmising, whether this broom can be applied to medical practitioners too? Can medical practitioners make their – and the entire world’s inhabitants’ – life easier by confessing to their errors, the moment they discover it? Can this be done? Has it ever been done in the form of any legislation? Of course it has been, in several US and Canadian states and several countries in Europe. In Japan there are no explicit “apology laws”, but she does have a strong cultural practice of medical professionals apologizing and explaining errors to patients and families when they occur. After a medical error, usually there are informal meetings between medical staff and affected parties, written explanations of what went wrong, expression of regret and even an offer of compensation. But what happens in other countries? But why in the first place should be worry about some countries, when in general it is clear that these laws do exist at some places and thus the possibility of implementing them everywhere is very much there? These “apology laws” are also called "I'm Sorry" Laws. ¹ They refer to legal provisions in a country/state, where, after a medical error has occurred, the doctor is treated less harshly, if -and only if- he discloses the error and apologizes to a patient or his survivors. On the contrary, if he decides to keep quiet, and the error is discovered later, he would be treated more harshly. ² . . .These kinds of laws have been implemented in some form or the other, virtually in every continent – although not necessarily in relation to medical errors. . These kinds of laws have been implemented in some form or the other, virtually in every continent – although not necessarily in relation to medical errors. Take India for example. India does not have “apology laws” for medical practitioners as such. But apology laws make their appearance in hidden form in several laws. Take for example the recently enacted Bharatiya Nyaya Sanhita, 2023 or BNS, 2023 [roughly translates as the Indian Justice Code, 2023; it replaced the older Indian Penal Code (IPC)]. Several provisions in this new Code include apology laws – albeit hidden. But let me take the example which a forensic pathologist encounters almost on a daily basis – Death by rash and negligent driving. The former law addressed this crime through s304A IPC. Briefly it stated that if someone caused the death of a person by doing a rash or negligent act [such a rash driving] shall be punished with imprisonment of 2 years or fine or both. . . .What was the punishment if someone caused the death of more than one person by rash and negligent act? What about killing 100 people or more, say by driving a vehicle through a crowd. . . Glaring deficiencies in this law were: *What was the punishment if someone caused the death of more than one person by rash and negligent act? What about killing 100 people or more, say by driving a vehicle through a crowd – of course unintentionally; merely because the driver was drunk? Will he still get away with 2 years? No clear cut answer was available. Of course the judge could pronounce 2 years for each of those 100 deaths, and pronounce that the punishments would run consequently – not concurrently [as is the norm]. However I never saw that kind of judgment. Glaring examples are Bhopal gas tragedy of 1984 , and Uphaar Cinema fire of 1997 . None of the perpetrators was given any sentence commensurate with the gravity of crime. *Secondly, was this law applicable to medical practitioners? Nothing was mentioned in the law, although it was usually invoked for this purpose. . . .My prediction is there would be apology laws for medical practitioners everywhere in the world sooner than later.. . . The newly enacted Bharatiya Nyaya Sanhita, 2023 or BNS deals with it through s106. There is a radical change in wordings now. The actual text is far longer and extensive, but I will not get into its details. There are several improvements in it, most importantly inclusion of an apology law, although it is not so apparent at first. Essentially it says that if a rash and negligent driver hits – say a pedestrian – and runs away, and the victim dies, the driver would get 10 years. But if he reports it to a police officer or a magistrate soon after the incident, he will get only 2 years. This is actually an “apology law” loud and clear. Apology laws are here to stay. My prediction is there would be apology laws for medical practitioners everywhere in the world sooner than later. I know currently these laws have not succeeded in US and elsewhere, ³ but there are good reasons for this. And let this be a topic for another day. References Bender FF. "I'm Sorry" Laws and Medical Liability. Virtual Mentor. 2007 Apr 1;9(4):300-4. [ PubMed ] Fields AC, Mello MM, Kachalia A. Apology laws and malpractice liability: what have we learned? BMJ Qual Saf. 2021 Jan;30(1):64-7. [ PubMed ] McMichael BJ, Van Horn RL, Viscusi WK. "Sorry” Is Never Enough: How State Apology Laws Fail to Reduce Medical Malpractice Liability Risk. Stanford Law Rev. 2019 Feb; 71(2): 341-409. [ PubMed ] - Puneet Setia Professor of Forensic Medicine and Toxicology Department of Forensic Medicine, AIIMS, Jodhpur, India Email: forensicaiimsjdh.ps@gmail.com

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

Forensic Toxicology THE FOLLOWING ARTICLE APPEARED IN THE APRIL 1999 ISSUE THE POISON SLEUTHS DEATH BY ARSINE GAS -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 has happened to him? Please tell me." "Good morning Tarun. The name of this middle aged man is Radhey. He used to work in a factory, where they used to make soldering flux. He was working in his factory five days ago, when at about 2 pm, suddenly he started having nausea, headache, vomiting and diarrhea. He had taken lunch only a few minutes before so naturally everybody started thinking that he had had food poisoning. His illness soon became worse. He started complaining of intense headache and pain in the loins. He passed urine after sometime, and everybody was alarmed to see that it was very dark. He was taken to the hospital, where the doctors were unable to diagnose his illness. However the history of having taken his meals only a few minutes before, and the non-specific symptoms prompted some doctor to write "undiagnosed poisoning" on the hospital case sheet." "So it was a case of poisoning? Was somebody else was poisoned too?" "No, nobody else was poisoned - of course presuming that Radhey died of poisoning. Only Radhey showed these peculiar symptoms. The tentative diagnosis of "undiagnosed poisoning" flared up everybody's tempers, especially those of Radhey's relatives. They thought that somebody had surreptitiously mixed poison in his food. And all suspicion fell on another man Suleiman." "Why on Suleiman doctor?" "Because and Radhey apparently did not have good relations. They did not even talk to each other. Nobody knows how their fight started, but it is for sure, that they were sworn enemies. After Radhey was taken to the hospital, the doctors tried their level best to save him, but they could not, and he died today morning after an illness of about four and half days. The doctors refused to give a death certificate, as they did not know the illness Radhey was suffering from. Meanwhile the relatives of Radhey actually lodged an FIR in the police station, in which they alleged that Suleiman had poisoned Radhey, and he should immediately be taken in custody. Apparently the relatives of Radhey had some political clout too, so the police had to act fast. Now they have sent this body to me. My job obviously is to find out how Radhey actually died." "Very interesting indeed. That explains the big mob outside your mortuary. When I came to meet you, I was surprised to see several people sorrounding this mortuary several of whom were toting cellulars." "Yeah, they are very influential people, and apparently they would leave the mortuary only after they have come to know of the cause of Radhey's death. The pressure on police was so much that they had to arrest Suleiman." "What does Suleiman say doctor?" "I have talked to Suleiman myself. The police has also talked to him. He says he has absolutley no hand in this killing. He has hired a lawyer for his defense and he is pressurizing the police by saying that they can not arrest his client without any solid evidence. So the police are finding themselves in a Catch-22 situation. As you can understand, I have been showered upon with a very heavy responsibility." "Yes indeed. I can understand that. Now where do you start from?" "Tarun, I have already started actually. Whenever a death occurs in a factory, I make it a point to visit the factory first and see what kind of activities were going there. I found that Radhey was involved in making soldering flux by putting zinc scrap in hydrochloric acid." "Please explain this to me in some great detail doctor." "Tarun, in several industries there is a "rough and ready" practice of producing zinc chloride to provide a soldering flux by putting zinc scrap in hydrochloric acid. This is actually not recommended as sometimes a very poisonous gas arsine may form in this process. The zinc scrap may contain arsenic as an impurity, and when arsenic acts with hydrochloric acid, it forms arsine (AsH3) a very dangerous gas." "So you think Radhey died of arsine gas?" "I can't say for sure at present, but after you know more about this interesting gas, you can make a guess yourself." "Looks like we are on the trail of yet another interesting poison. Doctor please tell me more about arsine gas." "Tarun, arsine is a very toxic gas, a molecule of which contains just four atoms - three of hydrogen and one of arsenic. It is a colorless inflammable gas. It is supposed to have an odour of garlic, but it is not always apparent, especially when a person is suffering from common cold. It is an unstable compound which when exposed to light or moisture, decomposes to deposit arsenic. It is heavier than air, its vapour density being 2.68 times that of air. You might be surprised to know that the German chemist Gehlen died of accidental arsine poisoning in 1815." "Oh, I didn't know that." "Tarun, arsine is one of the most poisonous gases known. It can kill outright. Even brief exposure to moderate concentrations can cause serious illness. I will give you some figures which will tell you something about the killing power of this gas. The four most poisonous gases are carbon monoxide, phosgene, chlorine and arsine. Inhalation of carbon monoxide in concentrations of 1000 parts per million (ppm) for a few minutes can cause death. The equivalent figures for Chlorine and Phosgene are 400 ppm and 50 ppm respectively, meaning thereby that they are more poisonous. Obviously the lesser concentration required for killing, more poisonous the gas. You would be surprised to know that in the case of arsine, only a concentration of 10 ppm inhaled for about half an hour could be dangerous. And at such low concentrations, the pecualiar garlic odor of the gas may not be apparent at all. The safe maximum concentration of carbon monoxide - generally considered by all to be very toxic - is 100 ppm, while that of arsine is just 0.05 ppm. This can give you some idea of the lethality of this gas" "Oh, sure. From the figures it appears to be about 2000 times more poisonous, which is remarkable. Especially considering the fact that everybody considers carbon monoxide to be a very deadly gas." "Exactly. Like carbon monoxide, arsine is a cumulative poison too. This means that it is excreted much more slowly from the body than it is absorbed. This results in gradual accumulation of the poison in the body which can be very dangerous. A good simily is of a tank, in which poisonous water is entering much faster than it is being let out. This would ultimately result in overloading of the tank with the poisonous water." "Yes, I understand. But what is the significance of a cumulative poison doctor?" "Tarun, it means that repeated or prolonged exposure to even a very low concentration can be dangerous. Thus a cumulative poison - that whose excretion rate is slower than that of its absorption- is a much more dangerous poison, than a non-cumulative poison. The hazard of arsine gas exists in a number of industries including the refining of metal, the manufacture of corrosive acids, galvanizing and electroplating. It is also a risk in laboratories. There was a time when the use of wall papers colored with pigment which contained Scheele's Green, yielded arsine in the home, when acted upon by a mould. This could create severe poisoning in the inmates, especially considering that arsine is a cumulative poison." "Just a minute doctor. What is Scheele's Green?" "Tarun, Scheele's Green is a popular name for cupric arsenite. Its formula is Cu3(AsO3)2.2H2O. It is named thus in the memory of the famous Swedish Chemist Kark Wilhelm Scheele (1742-1786). It is a brilliant green pigment which was once used for paints, but since it is a potentially poisonous compound, it is no more used now. When mould acts on this compound, arsenic may get combined with hydrogen molecules and may form arsine, which may be very poisonous. Arsine may be produced in quite a few other remarkable ways." "What are those doctor? Please tell me." "Tarun, I know of a unique case of industrial poisoning by arsine in which three men were poisoned - one of them fatally. They were engaged in unloading fish scrap from the hold of a wooden schooner. The close, warm atmosphere promoted bacterial activity and, in turn, the production of arsine." "Oh that is indeed quite unusual." "Yes. Another likely source of arsine is the interior of tanks used in the preparation of sulphuric acid from iron pyrites (sulphide). Some of the deposits in these tanks was hard and had to be scraped from the walls. It contained upto 45% of arsenious oxide. The production of arsine from this material was unsuspected for quite some time. In yet another case, a person had cleaned a water jacket by pouring freshly diluted hydrochloric acid into its pipes. Fumes were liberated and he was in close contact with them in an unventilated room for about half an hour. The acid contained an "inhibitor", which proved to be a mixture of sodium arsenate and aniline hydrochloride. Arsine was produced from the inhibitor n the presence of nascent hydrogen and the man was severely poisoned." "Oh, I see. Arsine can be produced in most unusual circumstances. It does appear to me that Radhey too got involved in arsine poisoing." "Yes, it became apparent to me, when I came to know that he was involved in making the soldering flux by that precarious method, which I have described you just now. My suspicion was confirmed to a great extent when I heard that he had passed dark urine. This was because of the presence of hemoglobin in the urine." "Why should hemoglobin appear in the urine in a case of arsine poisoning?" "Arsine is a deadly poison tarun. It hemolyses (breaks) all the Red Blood Cells of the body. This liberates hemoglobin which ultimately finds its way in the urine which become dark. I have made some slides of the blood of this patient, and you can see under the microscope that all the R.B.C.s are broken. This is a very strong indication that he had died of arsine poisoning. Moreover his kidney tubules are blocked by these broken R.B.C.s which is another finding in favour of arsine poisoing. Coupled with his peculiar history, I am sure Radhey died of arsine poisoning, which is an accidental poisoning. Suleiman had nothing to do with it. Come, let us tell the police about it." "Very clever indeed. This was a most interesting discussion doctor. Without your masterly deduction, police could have unnecessarily went on harassing Suleiman. Radhey's relatives and other people might have thought, it was a case of killing by Suleiman. Tell me what are you going to tell me the next time?" "Tarun, next time, I would tell you about death by aflatoxins. "