Petechial Hemorrhages and Ethanol in Deaths from Intoxication

Petechiae in conjunctivae and in the palpebrae/skin of the eyelids are of particular interest for the forensic pathologist, because of their association with pressure on the neck. They have been described in the eyelids of intoxicated persons both in case reports and in text books of forensic pathology. We studied 590 deaths caused by intoxication, and 75 had petechiae either in the conjunctivae, the eyelids, or in both locations. We examined the influence of drugs and ethanol on the location of the petechial hemorrhages in these deaths. Deaths with ethanol in blood and in urine/vitreous humor more often had petechiae in both locations than those without. This association was statistically significant, independent of body position and livor mortis. No association between the location of petechiae, medicinal drugs, or narcotics was found. These results suggest that ethanol may contribute to the development of petechial hemorrhages in deaths from intoxication.     

Estimating the degree of ethanol intoxication from analysis of cerebro-cranial hematomas

314 cases of combined cerebro-cranial trauma and posttraumatic intracranial hematomas were identified of which ethanol was detected in 114 hematomas. The other investigative group was 103 hospitalized patients who had hematomas evacuated during neurosurgical procedures. In 62 of these cases ethanol was detected. Blood and urine samples were also collected and the alcohol concentration was determined in all specimens by GC and ADH. The ethanol elimination rate for autopsy and operative intracranial hematomas was approximately 0.07–0.08‰/h(±0.034‰/h). The elimination rate of ethanol from blood (β₆₀) was about two or three times greater as that from hematomas. Because of the different water content of intracranial hematomas from blood, it was necessary to adjust the ethanol concentration for water content. On the basis of the corrected ethanol concentrations and the elimination rates for both tissues it was possible to estimate the ethanol concentration at the time of injury. Intracranial hematomas are tissues of possible value in the determination of alcohol intoxication especially in alcoholism. Ethanol can be found in hematomas even after 72 h from head injury.     

The morphological diagnosis of alcoholic embryo- and fetopathy

Principles of morphologic diagnosis of alcoholic embryo- and fetopathy are discussed using data on two cases of this pathology. In the authors' opinion, three conditions are necessary to make diagnosis of alcoholic embryo- and fetopathy (i.e. maternal alcoholism history, morphologic signs of embryo- and fetopathy, ethanol concentration in fetal blood and urine). Alcohol embryo- and fetopathy must be differentiated from acute ethanol intoxication, during which microscopic visceral signs of embryo- and fetopathy are absent and ethanol blood concentration exceeds 2.0%.     

389例不同年份的中毒尸检资料对比分析

本文报告近16年来(1983～1998)本教研室检验的中毒尸检158例,并与本教研室1983年以前26年(1957～1982)的中毒尸检231例进行对比分析.发现中毒毒物的种类在近16年虽然仍以有机磷农药为主,但敌敌畏中毒在90年代后则明显减少,相反新型有机磷农药及其它新型农药则逐渐增加;杀鼠剂、醇类、麻醉品及毒品呈明显增多趋势,而金属盐类毒物则减少较明显.90年代后,杀鼠剂投毒及医源性或非法行医所致药物中毒案例显著增多.     

Positional asphyxiation in adults. A series of 30 cases from the Dade and Broward County Florida Medical Examiner Offices from 1982 to 1990.

Over a 9-year period, 30 cases of positional (or postural) asphyxia were identified in the Dade and Broward County (Florida) Medical Examiner Offices. The victims had an average age of 50.6 years with no significant sex or racial differences as compared with the general medical examiner population. Chronic alcoholism or acute alcohol intoxication was a significant risk factor in 75% of cases and these had an average postmortem ethanol concentration of 0.24 g%. Signs of mechanical asphyxiation (petechiae and/or combined lung weights greater than 900 g) were present in 93% of cases. Victims were commonly (43%) found in a restrictive position producing hyperflexion of the head and neck. Two deaths involved restraint vests ("poseys") in elderly, demented, wheel-chair-confined victims. Scene photographs of the undisturbed decedent are extremely helpful in confirming a suspicion of postional asphyxia.     

Ethanol-oxidizing enzymes of the adrenal glands in acute alcoholic intoxication

Complex morphological-and-histological examinations of the adrenal glands were performed on actual forensic-medical samples in acute alcoholic intoxication (AAI), i.e. 107 death cases of men and women, aged 17 to 60, due to mechanical trauma, lethal ethanol intoxication and somatic complications of chronic alcoholism. A differentiated distribution of ethanol-oxidizing enzymes was defined, i.e. of alcohol-dehydrogenase and acetyl-dehydrogenase in the structural-and-functional zones of the adrenal cortex and medullary substance. A differential activity of enzymes was established that correlated with the level of exogenous alcoholemia. Sets of morphological signs related with examinations of the adrenal glands, which enabled a differential diagnosis of death causes in AAI, were specified.     

Vitreous humor carbohydrate-deficient transferrin concentrations in the postmortem diagnosis of alcoholism

Deaths from the effects of alcohol intoxication are encountered routinely in forensic practice. In an important number of cases difficulty may arise in interpreting the significance of results obtained in the autopsy. In clinical practice biochemical markers, particularly serum gamma-glutamyl-transpeptidase (GGT), alanine aminotransferase (ALT), aspartate transaminase (AST), carbohydrate-deficient transferrin (CDT), and erythrocyte mean corpuscular volume are used to diagnose heavy alcohol consumption. CDT is used as a reliable and specific marker. In postmortem diagnosis, because of the difficulty in interpreting blood alcohol levels and relatively non-specific pathological features, biochemical compounds have been studied for use as possible markers. The aim of this study was to evaluate the usefulness of the postmortem determination of CDT in vitreous humor as a confirmation of antemortem alcoholism. CDT levels were studied in 66 male cadavers with a mean age of 55.9 years (S.D. 17.0, range 22-87 years) with a mean postmortem interval of 17.9 h (S.D. 11.4, range 4-72 h). Cases were assigned to two diagnostic groups according to the antemortem diagnosis of alcoholism. Statistically significant differences were found for CDT and ALT concentrations between the two diagnostic groups. The highest vitreous humor levels of CDT and ALT were obtained in the group of cases with a previous diagnosis of alcoholism. Our results suggest that vitreous humor CDT levels are useful in cases where the postmortem diagnosis of alcoholism is hindered by the non-specificity of data.     

Multiple Symmetric Lipomatosis

A significant number of medicolegal deaths involve ethanol. Deaths may be related to the acute, intoxicating effects of ethanol, either in decedents or within persons responsible for causing the deaths of others. Additionally, deaths may be related to chronic alcoholism. A chronic alcoholic may display characteristic external features which allow an observer, such as a forensic pathologist or other physician, to conclude that he/she is probably an alcoholic. Herein, the authors report two decedents with a rare condition known as “multiple symmetric lipomatosis” (MSL), which has a strong correlation with chronic alcoholism. Identification of the peculiar features associated with MSL should prompt the forensic pathologist to consider chronic alcoholism as a probable diagnosis.     

Forensic medical expert evaluation of lethal poisoning with narcotics

Morphological manifestations of lethal narcotic poisoning are analyzed on the basis of results presented in "Acts of Medical Examination of Corpse" and "Expert Conclusions" on 352 cases with lethal narcotic poisoning, suspected (with good grounds) poisoning, and combined poisoning with narcotics and other agents. Causes of failure to detect narcotics in forensic chemical analysis of biological material from the corpse are enumerated.     

Cases of fatal poisoning in post-mortem examinations at the Institute of Forensic Medicine in Greifswald--analysis of five decades of post-mortems

Apparently, fatal poisoning as cause of death are still rarely found in unnatural deaths investigated in the institutes of forensic medicine. In the Institute of Forensic Medicine at the University of Greifswald, 10-15% of the post-mortem autopsies displayed an intoxication during the last several decades with a possible decreasing tendency. Thirteen thousand eight hundred and nineteen autopsies were carried out in our institute-situated in a low populated rural area-during the last 50 years with the confirmed death cause intoxication in 1,589 times. In this study, especially the intoxication causes and the substance classes of the poisonous agents have been investigated. In addition, we analyzed the frequency of intoxications as well as sex and age of the deceased. Surprisingly, CO-intoxications were found most frequently with an incidence of 49% followed by alcohol intoxications with 21%. The latter was not unexpected taking into account the habits of the local population. Medical drugs and narcotics take only the third place, although the abuse of modern narcotics drugs is already visible even in the far east of Germany. The spectrum of substances which are abused, taken accidentally or deliberately is continuously changing, reflecting scientific progress in the pharmaceutical industry as well as fashion tendencies. Therapeutic use is almost always followed by abuse. Our results confirm prior experience concentrating mostly on other poisons like heavy metals or herbicides, etc. In addition, we could demonstrate the influence of political conditions on use and distribution of illegal drugs in Germany. Our study clearly demonstrates that insufficient equipment or analytical methods are no longer the reason for any problems uncovering lethal intoxications. They are rather due to insufficient investigations of the corpses (without considering the possibility of an intoxication as differential diagnosis) and to frequent mistakes of the prosecutor's office in death without signs of physical violence. These facts may explain the above mentioned decreasing tendency of intoxications, but they also clarify that this tendency probably does not correspond to reality.     

A fatal interaction of methocarbamol and ethanol in an accidental poisoning

A case is presented of a fatal drug interaction caused by ingestion of methocarbamol (Robaxin) and ethanol. Methocarbamol is a carbamate derivative used as a muscle relaxant with sedative effects. Therapeutic concentrations of methocarbamol are reported to be 24 to 41 micrograms/mL. Biological fluids were screened for ethanol using the Abbott TDx system and quantitated by gas-liquid chromatography (GLC). Determination of methocarbamol concentrations in biological tissue homogenates and fluids were obtained by colorimetric analysis of diazotized methocarbamol. Blood ethanol concentration was 135 mg/dL (0.135% w/v) and urine ethanol was 249 mg/dL (0.249% w/v). Methocarbamol concentrations were: blood, 257 micrograms/mL; bile, 927 micrograms/L; urine, 255 micrograms/L; gastric, 3.7 g; liver, 459 micrograms/g; and kidney, 83 micrograms/g. The combination of ethanol and carbamates is contraindicated since acute alcohol intoxication combined with carbamate usage can lead to combined central nervous system depression as a result of the interactive sedative-hypnotic properties of the compounds.     

Morphological changes in the lungs in chronic drug addiction

Morphological studies of the lungs and immune system organs were made in drug addicts with narcotic intoxication. Depletion of the central and peripheral lymphoid organs was found in most cases. It is shown that morphological changes in the lungs in acute and (or) chronic narcotic drug intoxication, the rate of acute and chronic inflammatory lung diseases reflect development of lung inflammation in the presence of aquired immunological deficiency in terminal chronic drug abuse. The documented features of different pathological processes in the lungs can improve diagnosis of acute and chronic drug intoxication by results of section and histological examinations.     

Alcoholic hepatosis in pathogenesis of hepatic encephalopathy

The problem of chronic alcoholism has a great social importance. In the literature there are not methodological grounds for verification of causes and mechanisms of unexpected death caused by chronic alcoholic intoxication. Given literature data show the reasonability of study of hepatic encephalopathy in combination with pathomorphological, histochemical and biochemical analyses in comparison with forensic chemical analysis of alcohol concentration in human organism. That will make possible to determine the mechanisms of tanatogenesis of alcoholic intoxication.     

The interpretation of cocaine and benzoylecgonine concentrations in postmortem cases.

This study examined cocaine and benzoylecgonine concentrations in 100 consecutive deaths where either compound was identified in blood or urine specimens to determine whether any relationship between these concentrations and cause of death can be found. Forty-seven of the 100 cases were deaths attributed to cocaine, narcotic or combined cocaine and narcotic intoxication. There were 13 cases of cocaine intoxication where no psychoactive substance other than ethanol was detected. The mean cocaine concentration in these deaths was 908 ng/ml; three cases had cocaine concentrations greater than 2000 ng/ml, while the other ten cases had cocaine concentrations less than or equal to 700 ng/ml. The mean cocaine concentration in non-cocaine deaths where no psychoactive substance other than ethanol was detected was 146 ng/ml. This difference was not statistically significant. However, the average blood benzoylecgonine concentration in the 13 cocaine deaths was significantly higher than in the 19 non-cocaine deaths. A review of combined cocaine and narcotic deaths suggest that the narcotic is the main causative agent in these deaths.     

Urine/blood ratios of ethanol in deaths attributed to acute alcohol poisoning and chronic alcoholism

The concentrations of ethanol were determined in femoral venous blood (BAC) and urine (UAC) and the UAC/BAC ratios were evaluated for a large case series of forensic autopsies in which the primary cause of death was either acute alcohol poisoning (N=628) or chronic alcoholism (N=647). In alcohol poisoning deaths both UAC and BAC were higher by about 2g/l compared with chronic alcoholism deaths. In acute alcohol poisoning deaths the minimum BAC was 0.74 g/l and the distribution of UAC/BAC ratios agreed well with the shape of a Gaussian curve with mean+/-standard deviation (S.D.) and median (2.5th and 97.5th centiles) of 1.18+/-0.182 and 1.18 (0.87 and 1.53), respectively. In alcoholism deaths, when the BAC was above 0.74 g/l (N=457) the mean+/-S.D. and median (2.5th and 97.5th centiles) UAC/BAC ratios were 1.30+/-0.29 and 1.26 (0.87 and 2.1), respectively. When the BAC was below 0.74 g/l (N=190), the mean and median UAC/BAC ratios were considerably higher, being 2.24 and 1.58, respectively. BAC and UAC were highly correlated in acute alcohol poisoning deaths (r=0.84, residual S.D.=0.47 g/l) and in chronic alcoholism deaths (r=0.95, residual S.D.=0.41 g/l). For both causes of death (N=1275), the correlation between BAC and UAC was r=0.95 and the residual S.D. was 0.46 g/l. The lower UAC/BAC ratio observed in acute alcohol poisoning deaths (mean and median 1.18:1) suggests that these individuals died before absorption and distribution of ethanol in all body fluids were complete. The higher UAC/BAC ratio in chronic alcoholism (median 1.30:1) is closer to the value expected for complete absorption and distribution of ethanol in all body fluids.     

Forensic medical significance of enzymatic products of ethanol oxidation in cadaveric brain

The concentrations of ethanol, acetaldehyde, and the oxidizing enzymes alcohol dehydrogenase (ADH) and aldehyde dehydrogenase (AIDH) were measured in neuronal cytoplasm, limbic cortical capillaries, and cardiovascular center of the medulla oblongata. The measurements were carried out by histochemical methods, gas-liquid chromatography, etc. The results were processed with consideration for the degree and stage of ethanol intoxication in case of death from ethanol poisoning and asphyxia in hanging. Increase of ethanol concentration in the blood was associated with a decrease and then increase in the brain concentrations of ADH and with an increase of AIDH concentration. Enzymatic changes predominated in capillary walls; the minimum shifts were observed in the neuronal cytoplasm of the cerebral limbic cortex, which confirms the neurohumoral nature of detoxication regulation. Lethal ethanol poisoning could occur during any stage of ethanol intoxication. The detected changes in ethanol, acetaldehyde, and metabolizing oxidoreductases in brain tissue can be used for forensic medical diagnosis of ethanol poisoning.     

Forensic medical diagnostics of acute and chronic alcohol intoxication

The principal characteristics and results of experimental studies on the problem of acute and chronic alcohol intoxication are presented. The mechanisms of toxic action of ethanol and acetaldehyde are considered with special reference to the comprehensive qualitative estimation of these toxicants and their pathomorphological effects in the target organs. The influence of ethanol-oxidizing enzyme systems in the brain on the development of alcohol tolerance is illustrated. The mechanisms of hormonal regulation via the hypothalamic-pituitary-adrenal axis in the case of exogenous alcoholemia are considered. The dependence of pathological morphological changes in the brain, hypophysis, and adrenal glands on the stage and severity of alcoholic intoxication has been elucidated. Criteria for the morphological and histochemical evaluation of the degree of alcohol-induced lesions and the severity of abstinence syndrome have been developed. The role of alcohol effects in tanatogenesis associated with alcohol-induced diseases is discussed.     

Cerebral alcohol dehydrogenase-- a marker of individual ethanol tolerance in ethanol intoxication

Brain compartments differing by topical chemical location of alcohol dehydrogenases (ADH) were studied on forensic medical material. ADH were found in magnocytes of giant-cell reticular formation, neuronal nuclei in the blue spot, and capillaries, but not in neurons of the ganglionary layer of the cerebral limbic cortex. ADH activity in the studied brain compartments depended on the level of exogenous ethanolemia. Increased ADH activity in the reticular formation magnocytes characterized the individual tolerance in severe ethanol intoxication. Cerebral ADHs are markers of ethanol intoxication.     

The forensic medical significance of morphometry of the spleen in drug addiction and chronic alcoholic intoxication

Data on histomorphologic damage to the spleen in chronic narcotic and alcoholic intoxication are described. The below features are recommended for the diagnosis of chronic exogenous intoxication: thickening and sclerosis of the spleen connective structures and a lower count of lymphocytes in the white pulp. The diagnosis criteria of chronic intoxication by intravenously administered opiates are: hyperplasia of the spleen follicles as well as a higher quantity of plasmocytes and of eosinophiles in the white pulp. Hypotrophy of the spleen lymphoid follicles and higher counts of monocytes and macrophages in the lymphoid follicles should be also regarded as a sign of chronic alcoholic intoxication. The obtained data can be used by forensic medical experts in the diagnosis of chronic narcotic intoxication and in its differential diagnosis versus alcoholic intoxication.     

Histomorphometric characteristic of human brain in acute alcoholic intoxication

Different brain sections were studied in 20 subjects, who died of ethanol intoxication and in 14 subjects who died of injuries of the heart and main vessels, in order to detect histological changes in the brain and for the purpose of defining spatial and quantitative ratios between cerebral tissue structures in alcoholic intoxication. Different histological, stereometric and morphometric tools were made use of. It was demonstrated that, in alcoholic intoxication, there occur severe disorders of the circulation with affection of vessels in the brain; there are also dystrophic and necrotic changes in neurocytes, glial cells and white substance. The square of neurons shrinks due to death of some of them in the cortex of hemispheres, thalamus and cerebellum. As for the medulla, they are more resistant, there, to ethanol. The diameter of capillaries in the studied brain sections diminishes due to a reduced tonus of cerebral arteries; the quantity of such vessels increases within a standard area, which is conditioned by the compensatory opening of reserve capillaries. All this can be important in dealing with issues of thanatogenesis and of forensic medical diagnosis in death of alcoholic intoxication.