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A case of suicide disguised as natural death
Case Report
A case of suicide disguised as natural death
C Brandt-Casadevall, T Krompecher, C Giroud and P Mangin lnstitut universitaire de Medecine legale, Bugnon 21, 1005 Lausanne, Switzerland Science & Justice 2003 43 41
A case report describing the suicide of a physician classified initially as a natural death. Faced with the vehement protest of the family of the deceased the magistrate decided to request a 'preventive' forensic autopsy. Forensic investigations revealed the cause of death as being a pentobarbital intoxication and the circumstances favoured the hypothesis of a genuine suicide. This case illustrates that the tendency of magistrates to request or not an autopsy is related to their experience or intuition. Cet article dCcrit un cas de suicide d'un mCdecin initialement class6 comme mort de cause naturelle. Confront6 ii des dCnCgations vChCmentes de la famille de la personne dCcCdCe, le magistrat instructeur a dCcidC de procCder ii une autopsie forensique ccprkventiver. Les investigations forensiques ont montrC que la mort provenait d'une intoxication au pentobarbital et que les circonstances favorisaient l'hypoth2se d'un vCritable suicide. Ce cas illustre que la tendance des magistrats ii requCrir ou non une autopsie est like B leur expCrience ou B leur instinct.
- 43 Received 18 February 2002 accepted 20 September 2002
Es wird iiber den Selbstmord eines Arztes berichtet, welcher zunachst als natiirlicher Tod eingestuft worden war. Angesichts vehementer Proteste seitens der Familie des Verstorbenen ordnete der Untersuchungsrichter vorbeugend eine Autopsie an. Die forensischen Untersuchungen wiesen Pentobarbitalvergiftung als Todesursache nach und die Begleitumstande stiitzten die Annahme, dass in Wirklichkeit ein Selbstmord vorlag. Dieser Fall veranschaulicht, dass die Bereitschaft von Untersuchungsrichtern, eine Autopsie anzuordnen, mit ihrer Erfahrung bzw. ihrem Instinkt in Zusammenhang steht. Se describe un caso de suicidio de un medico clasificado inicialmente como una muerte natural. Enfrentado a la violenta protesta de la familia del difunto el magistrado decidi6 solicitar una autopsia forense preventiva. Las investigaciones forenses revelaron como causa de muerte una intoxicaci6n por pentobarbital y la circunstancias favorecian la hip6tesis de un verdadero suicidio. Este caso ilustra que la tendencia de 10s magistrados para pedir o no una autopsia depende de su experiencia o instinto.
O The Forensic Science Society 2003 Key words Forensic science, forensic medicine, autopsy, disguised suicide, pentobarbital intoxication.
sciencetkjustice Volume 43 ~ o . (2003) 1 41 - 43
Page 41
C Brandt-Casadevall, T Krompecher, C Giroud and P Mangin A case of suicide disguised as natural death
Introduction Sudden deaths represent a large proportion of investigations conducted by forensic pathologists. In the majority of cases (up to 9&95%), the cause of death is established using forensic investigations relying on autopsy, histological and toxicological analyses, as well as other means. A small proportion of cases (5 to 10%) are not solved and the cause of death remains obscure 11,21. In the south-west region of Switzerland assigned to this Institute, investigations are conducted in close collaboration with the examining magistrates who are the only authority that can formally request a forensic autopsy. In a sense, the forensic expert plays the role of a consultant whose involvement may or may not be solicited. Our experience has shown that the magistrates' tendency to request autopsies is related to their experience or intuition. The case presented here illustrates this finding. Case report A 64 year-old man, a cardiologist with a solid local reputation, was found lifeless by his wife at around 23:00, the body collapsed on the first steps of the stairs leading from the ground level to the first floor of the family residence. The woman called the paramedics but they were unable to revive him. In the vicinity of the corpse, still on the stairs, there laid a bottle of whisky and two cups: an almost empty one and one filled with 10 ml of a yellowish and viscous liquid smelling of honey. According to the wife, the deceased usually drank a glass of whisky with some honey before going to sleep. The attitude of the family of the deceased was perceived as very demonstrative and protesting by all the intervening parties: the paramedics, the emergency physician and the police. Hence, to avoid any later complaints about the medical intervention, the magistrate requested a "preventive" autopsy of the victim. Autopsy findings Prior to the autopsy, the following information was made available: in the last few years, the victim, who was a very successful practitioner, had been suffering from Parkinson syndrome that represented a serious handicap in his professional and social lives. Sometimes, he could not even sign his prescriptions because of the tremor in his hands. He did not have an attending physician. The autopsy revealed only non-specific lesions such as acute stasis of the viscera, moderate pulmonary and cerebral oedema and moderate generalised atheromatosis. Histological examinations did not yield any unusual findings. Given the context of the death, the magistrate ordered toxicological analyses. We learned later on that his mother suffered from the same condition and he was a direct witness of her decline. Toxicological analyses The liquids contained in the bottle of whisky and the two cups were analysed by gas chromatography-mass spectrometry (GC-MS).
Page 42
Various body fluids and organ tissues were assayed for volatile, therapeutic, abused drugs (acidic, basic and neutral drugs) and organic poisons using routine methods 131. Volatile testing in blood was performed by head space gas chromatography with FID detection. The urine was screened by immunoassays, colorimetric tests and GC-MS. Before being submitted to GCMS analysis, polar and conjugated molecules were hydrolysed in the presence of hydrochloric acid, extracted into a mixture of chloroform/isopropano1 (9: 1, vlv) at pH 9.5 and acetylated with acetic anhydridelpyridine (3:2, vlv) at 60°C for 30min. Xenobiotics were also screened in blood and gastric content by GC-MS following acidic or basic extraction. The basic blood extract was acetylated before GC-MS analysis. Pentobarbital quantification was carried out in body fluids (urine, peripheral blood, gastric content, bile, vitreous humour, cerebrospinal fluid (CSF)) and tissue homogenates (liver) by GC-MS following acidic extraction and methylation with trimethylaniline hydroxyde (TMAH, Supelco, Switzerland) [4]. Results No drugs were detected both in the whisky bottle and the cup filled with 10 ml of a 'honey-like' substance. Pentobarbital was found in the 200 yl yellowish syrup residue of the second cup. This could be the residue of the liquid ingested by the victim. The presence of barbiturates in urine was suggested by radioimmunoassay, no other drug classes were detected with preliminary tests. Besides pentobarbital which was found during GC-MS screening procedures in gastric content, peripheral blood and urine samples, the analysis of peripheral blood revealed the presence of a metabolite of pentobarbital, ethanol and traces of phenobarbital. In addition, urine analysis showed the presence of venlafaxine (an antidepressant, EfexoP), its metabolite norvenlafaxine, as well as the benzophenone of lorazepam (a tranquillising and sedating benzodiazepine) and metoclopramide (an antiemetic, Primperano). An ethanol concentration of 0.2 g %O was determined in peripheral blood. Phenobarbital levels (1 mgA) were below its therapeutic domain. The results of pentobarbital quantification in body fluids and tissue homogenates are shown in Table 1. Pentobarbital is a hypnotic belonging to the class of rapidly acting barbiturates 15, 61. It is mainly used in a clinical situation and is not available in Swiss pharmacies as commercial preparations. However, it could be ordered with a medical prescription from local drug distributors. Pentobarbital is often used to commit suicide [4, 7, 81.
Table 1
Pentobarbital distribution in body fluids (mg/l), gastric contents (mg) and liver (mg/kg).
Specimens Blood 21.4
Gastric Bile 91
71.3
Liver
CSF
90
11
Vitreous Urine 11
2.4
science&justice Volume 43 No.1 (2003) 41 - 43
C Brandt-Casadevall, T Krornpecher, C Giroud and P Mangin A case of suicide disguised as natural death
The detected levels were clearly compatible with a scenario of a pentobarbital overdose with a lethal outcome 161. They were also much higher than the concentrations determined when the circumstances of death excludes the possibility of incapacitation by drugs 191. Therapeutic levels in plasma from living people following oral administration of 100 mg of pentobarbital were in the range of 4-6 mgA 16, 101 and were significantly lower than the concentration determined in the blood of the victim. The finding that the gastric contents included 91 mg of this substance indicates that resorption was not complete at time of death. The low levels measured in urine suggest that death occurred soon after ingestion of the pentobarbital mixture. Discussion In the case presented here, the laboratory analyses clearly revealed the actual cause of death. Indeed, the toxicological results and the absence of any detectable pathology after thorough macroscopic and microscopic examinations led to the conclusion that death was caused by pentobarbital intoxication in the presence of other substances known to act on the central nervous system (phenobarbital and ethyl alcohol).
Conclusion In Switzerland, the examining magistrate is the only authority that decides whether a forensic autopsy is indicated. The forensic expert merely plays the role of a consultant. In some cases, the reasons for a magistrate's decision to request an autopsy are linked to his or her experience and feelings. Because violent death caused intentionally by a third party is rare in our region, the magistrate decides, according to the case and after discussion with the forensic pathologist, which services are required of the forensic expert - an autopsy or an external examination. Different cases are thus dealt with on an individual basis. Particular circumstances (great wealth of the deceased, foreign nationality, political eminence, links to homosexuality or prostitution, etc.) may influence the magistrate in favour of an autopsy. Such is the case here: the protests and the aggressive attitude of the family influenced the magistrate who then requested the intervention that made it possible to determine the cause of death and its surrounding circumstances. References 1 2
Several circumstances favour the hypothesis of a genuine suicide. The toxic substance that was ingested is difficult to obtain, unless one is a healthcare or veterinary professional 17, 111. Pentobarbital was detected in the syrup residue of the cup found near the victim; this substance is usually recommended by the EXIT association (a voluntary organisation aimed at assisting individuals to commit suicide 14, 12, 131) and is often used by medical staff to commit suicide 181. There was also presence of another hypnotic and an antiemetic (the EXIT association usually recommends the ingestion of an antiemetic when barbiturates are used 112, 131). The deceased had previous knowledge of the Parkinson syndrome which represented an important handicap in his professional and social lives. The mother of the victim suffered from the same condition and the deceased was a direct witness of her decline and anticipated the outcome of his disease.
Knight B. The obscure autopsy. Forensic Sclence lnternatlonal 1980; 16: 237-240. El-Zentani 0. Obscure death. The medico-legal dllemma in cases of undetermined cause and mode of death. These de doctorat: Faculte de Medecine de Lausanne 1998.
3
Romain N, Giroud C, Michaud K. Augsburger M, Mangin P. Fatal flecainlde intoxication. Forensic Science International 1999, 106: 115-123.
4
Giroud C, Augsburger M, Horisberger 6, Lucchini P, Rivier L, Mangin P. Exit association-medlated suicide. The American Journal of Forensic Medicine and Pathology 1999; 20: 4 M 4 .
5
Smith RB, Dittert LW, Griffen WO, Doluisio JT. Pharmacokinetlcs of pentobarbltal after Intravenous and oral administration. Journal of Pharmacokinetlcs and Biopharmaceutics1973; 1: 1-1 6.
6
Baselt RC. Dispositionof toxic drugs and chemicals in man. 4th ed. Foster City, CA: Chemical Toxicology Institute 2000: 66E670.
7
Poklis A and Hameli AZ. Two unusual barbiturate deaths. Archives of Toxicology
8
Clark MA, Jones JW. Suicide by Intravenous injection of a veterinary euthanasia
1975; 34: 77-80.
agent: report of a case and toxicological studies. Journal of Forensic Sciences 1979; 23: 762-767.
At the same time, it is obvious that the victim attempted to hide his suicide from his family circle. Thus, we obtained no evidence indicating that he might have spoken at any point of putting an end to his life. There was no written note. The victim did not wait to be alone at home. Instead, he committed his act in a routine situation: his wife was watching television late at night and he was upstairs, presumably going to sleep. Thus, he had one to two hours at his disposal and he ingested a very fast-acting drug which would make any attempt at reanimation impossible, even after a brief period of time. This may have induced the physician in charge to believe that the cause of death was cardiac origin, a likely hypothesis given the age of the victim. Had the family not behaved in an assertive manner, the magistrate may have not been informed of the event or would have requested a simple external examination.
science&justice Volume 43 ~ o . 1(2003) 41 - 43
9
Druid H, Holmgren P. A compilation of fatal and control concentrations of drugs In postmortem femoral blood. Journal of Forensic Sciences 1997; 42: 79-87.
10
Nair SG, Dundee JW, Clarke RSJ, Howard J. Plasma pentobarbitone levels, influence of the preparation, route and method of administration.Anaesthesia 1976; 31: 1037-1042.
11
Cordell WH, Cuny SC, Furbee RE, Mitchell-Flynn DL. Veterinary euthanasia
12
Guillon C, LeBonniec Y. Suicide mode d'ernploi, histoire, technique, actualite. Ed.
drugs as suicide agents. Annals of Emergency Medlcine 1986; 15: 939-943.
Alain Moreau. Paris, 1982. 13
Humphry D. Exit final, pour une mort dans la dignite. Ed. EJ Le Jour, Sogides, Quebec. 1991.
Page 43
A case of suicide disguised as natural death
C Brandt-Casadevall, T Krompecher, C Giroud and P Mangin lnstitut universitaire de Medecine legale, Bugnon 21, 1005 Lausanne, Switzerland Science & Justice 2003 43 41
A case report describing the suicide of a physician classified initially as a natural death. Faced with the vehement protest of the family of the deceased the magistrate decided to request a 'preventive' forensic autopsy. Forensic investigations revealed the cause of death as being a pentobarbital intoxication and the circumstances favoured the hypothesis of a genuine suicide. This case illustrates that the tendency of magistrates to request or not an autopsy is related to their experience or intuition. Cet article dCcrit un cas de suicide d'un mCdecin initialement class6 comme mort de cause naturelle. Confront6 ii des dCnCgations vChCmentes de la famille de la personne dCcCdCe, le magistrat instructeur a dCcidC de procCder ii une autopsie forensique ccprkventiver. Les investigations forensiques ont montrC que la mort provenait d'une intoxication au pentobarbital et que les circonstances favorisaient l'hypoth2se d'un vCritable suicide. Ce cas illustre que la tendance des magistrats ii requCrir ou non une autopsie est like B leur expCrience ou B leur instinct.
- 43 Received 18 February 2002 accepted 20 September 2002
Es wird iiber den Selbstmord eines Arztes berichtet, welcher zunachst als natiirlicher Tod eingestuft worden war. Angesichts vehementer Proteste seitens der Familie des Verstorbenen ordnete der Untersuchungsrichter vorbeugend eine Autopsie an. Die forensischen Untersuchungen wiesen Pentobarbitalvergiftung als Todesursache nach und die Begleitumstande stiitzten die Annahme, dass in Wirklichkeit ein Selbstmord vorlag. Dieser Fall veranschaulicht, dass die Bereitschaft von Untersuchungsrichtern, eine Autopsie anzuordnen, mit ihrer Erfahrung bzw. ihrem Instinkt in Zusammenhang steht. Se describe un caso de suicidio de un medico clasificado inicialmente como una muerte natural. Enfrentado a la violenta protesta de la familia del difunto el magistrado decidi6 solicitar una autopsia forense preventiva. Las investigaciones forenses revelaron como causa de muerte una intoxicaci6n por pentobarbital y la circunstancias favorecian la hip6tesis de un verdadero suicidio. Este caso ilustra que la tendencia de 10s magistrados para pedir o no una autopsia depende de su experiencia o instinto.
O The Forensic Science Society 2003 Key words Forensic science, forensic medicine, autopsy, disguised suicide, pentobarbital intoxication.
sciencetkjustice Volume 43 ~ o . (2003) 1 41 - 43
Page 41
C Brandt-Casadevall, T Krompecher, C Giroud and P Mangin A case of suicide disguised as natural death
Introduction Sudden deaths represent a large proportion of investigations conducted by forensic pathologists. In the majority of cases (up to 9&95%), the cause of death is established using forensic investigations relying on autopsy, histological and toxicological analyses, as well as other means. A small proportion of cases (5 to 10%) are not solved and the cause of death remains obscure 11,21. In the south-west region of Switzerland assigned to this Institute, investigations are conducted in close collaboration with the examining magistrates who are the only authority that can formally request a forensic autopsy. In a sense, the forensic expert plays the role of a consultant whose involvement may or may not be solicited. Our experience has shown that the magistrates' tendency to request autopsies is related to their experience or intuition. The case presented here illustrates this finding. Case report A 64 year-old man, a cardiologist with a solid local reputation, was found lifeless by his wife at around 23:00, the body collapsed on the first steps of the stairs leading from the ground level to the first floor of the family residence. The woman called the paramedics but they were unable to revive him. In the vicinity of the corpse, still on the stairs, there laid a bottle of whisky and two cups: an almost empty one and one filled with 10 ml of a yellowish and viscous liquid smelling of honey. According to the wife, the deceased usually drank a glass of whisky with some honey before going to sleep. The attitude of the family of the deceased was perceived as very demonstrative and protesting by all the intervening parties: the paramedics, the emergency physician and the police. Hence, to avoid any later complaints about the medical intervention, the magistrate requested a "preventive" autopsy of the victim. Autopsy findings Prior to the autopsy, the following information was made available: in the last few years, the victim, who was a very successful practitioner, had been suffering from Parkinson syndrome that represented a serious handicap in his professional and social lives. Sometimes, he could not even sign his prescriptions because of the tremor in his hands. He did not have an attending physician. The autopsy revealed only non-specific lesions such as acute stasis of the viscera, moderate pulmonary and cerebral oedema and moderate generalised atheromatosis. Histological examinations did not yield any unusual findings. Given the context of the death, the magistrate ordered toxicological analyses. We learned later on that his mother suffered from the same condition and he was a direct witness of her decline. Toxicological analyses The liquids contained in the bottle of whisky and the two cups were analysed by gas chromatography-mass spectrometry (GC-MS).
Page 42
Various body fluids and organ tissues were assayed for volatile, therapeutic, abused drugs (acidic, basic and neutral drugs) and organic poisons using routine methods 131. Volatile testing in blood was performed by head space gas chromatography with FID detection. The urine was screened by immunoassays, colorimetric tests and GC-MS. Before being submitted to GCMS analysis, polar and conjugated molecules were hydrolysed in the presence of hydrochloric acid, extracted into a mixture of chloroform/isopropano1 (9: 1, vlv) at pH 9.5 and acetylated with acetic anhydridelpyridine (3:2, vlv) at 60°C for 30min. Xenobiotics were also screened in blood and gastric content by GC-MS following acidic or basic extraction. The basic blood extract was acetylated before GC-MS analysis. Pentobarbital quantification was carried out in body fluids (urine, peripheral blood, gastric content, bile, vitreous humour, cerebrospinal fluid (CSF)) and tissue homogenates (liver) by GC-MS following acidic extraction and methylation with trimethylaniline hydroxyde (TMAH, Supelco, Switzerland) [4]. Results No drugs were detected both in the whisky bottle and the cup filled with 10 ml of a 'honey-like' substance. Pentobarbital was found in the 200 yl yellowish syrup residue of the second cup. This could be the residue of the liquid ingested by the victim. The presence of barbiturates in urine was suggested by radioimmunoassay, no other drug classes were detected with preliminary tests. Besides pentobarbital which was found during GC-MS screening procedures in gastric content, peripheral blood and urine samples, the analysis of peripheral blood revealed the presence of a metabolite of pentobarbital, ethanol and traces of phenobarbital. In addition, urine analysis showed the presence of venlafaxine (an antidepressant, EfexoP), its metabolite norvenlafaxine, as well as the benzophenone of lorazepam (a tranquillising and sedating benzodiazepine) and metoclopramide (an antiemetic, Primperano). An ethanol concentration of 0.2 g %O was determined in peripheral blood. Phenobarbital levels (1 mgA) were below its therapeutic domain. The results of pentobarbital quantification in body fluids and tissue homogenates are shown in Table 1. Pentobarbital is a hypnotic belonging to the class of rapidly acting barbiturates 15, 61. It is mainly used in a clinical situation and is not available in Swiss pharmacies as commercial preparations. However, it could be ordered with a medical prescription from local drug distributors. Pentobarbital is often used to commit suicide [4, 7, 81.
Table 1
Pentobarbital distribution in body fluids (mg/l), gastric contents (mg) and liver (mg/kg).
Specimens Blood 21.4
Gastric Bile 91
71.3
Liver
CSF
90
11
Vitreous Urine 11
2.4
science&justice Volume 43 No.1 (2003) 41 - 43
C Brandt-Casadevall, T Krornpecher, C Giroud and P Mangin A case of suicide disguised as natural death
The detected levels were clearly compatible with a scenario of a pentobarbital overdose with a lethal outcome 161. They were also much higher than the concentrations determined when the circumstances of death excludes the possibility of incapacitation by drugs 191. Therapeutic levels in plasma from living people following oral administration of 100 mg of pentobarbital were in the range of 4-6 mgA 16, 101 and were significantly lower than the concentration determined in the blood of the victim. The finding that the gastric contents included 91 mg of this substance indicates that resorption was not complete at time of death. The low levels measured in urine suggest that death occurred soon after ingestion of the pentobarbital mixture. Discussion In the case presented here, the laboratory analyses clearly revealed the actual cause of death. Indeed, the toxicological results and the absence of any detectable pathology after thorough macroscopic and microscopic examinations led to the conclusion that death was caused by pentobarbital intoxication in the presence of other substances known to act on the central nervous system (phenobarbital and ethyl alcohol).
Conclusion In Switzerland, the examining magistrate is the only authority that decides whether a forensic autopsy is indicated. The forensic expert merely plays the role of a consultant. In some cases, the reasons for a magistrate's decision to request an autopsy are linked to his or her experience and feelings. Because violent death caused intentionally by a third party is rare in our region, the magistrate decides, according to the case and after discussion with the forensic pathologist, which services are required of the forensic expert - an autopsy or an external examination. Different cases are thus dealt with on an individual basis. Particular circumstances (great wealth of the deceased, foreign nationality, political eminence, links to homosexuality or prostitution, etc.) may influence the magistrate in favour of an autopsy. Such is the case here: the protests and the aggressive attitude of the family influenced the magistrate who then requested the intervention that made it possible to determine the cause of death and its surrounding circumstances. References 1 2
Several circumstances favour the hypothesis of a genuine suicide. The toxic substance that was ingested is difficult to obtain, unless one is a healthcare or veterinary professional 17, 111. Pentobarbital was detected in the syrup residue of the cup found near the victim; this substance is usually recommended by the EXIT association (a voluntary organisation aimed at assisting individuals to commit suicide 14, 12, 131) and is often used by medical staff to commit suicide 181. There was also presence of another hypnotic and an antiemetic (the EXIT association usually recommends the ingestion of an antiemetic when barbiturates are used 112, 131). The deceased had previous knowledge of the Parkinson syndrome which represented an important handicap in his professional and social lives. The mother of the victim suffered from the same condition and the deceased was a direct witness of her decline and anticipated the outcome of his disease.
Knight B. The obscure autopsy. Forensic Sclence lnternatlonal 1980; 16: 237-240. El-Zentani 0. Obscure death. The medico-legal dllemma in cases of undetermined cause and mode of death. These de doctorat: Faculte de Medecine de Lausanne 1998.
3
Romain N, Giroud C, Michaud K. Augsburger M, Mangin P. Fatal flecainlde intoxication. Forensic Science International 1999, 106: 115-123.
4
Giroud C, Augsburger M, Horisberger 6, Lucchini P, Rivier L, Mangin P. Exit association-medlated suicide. The American Journal of Forensic Medicine and Pathology 1999; 20: 4 M 4 .
5
Smith RB, Dittert LW, Griffen WO, Doluisio JT. Pharmacokinetlcs of pentobarbltal after Intravenous and oral administration. Journal of Pharmacokinetlcs and Biopharmaceutics1973; 1: 1-1 6.
6
Baselt RC. Dispositionof toxic drugs and chemicals in man. 4th ed. Foster City, CA: Chemical Toxicology Institute 2000: 66E670.
7
Poklis A and Hameli AZ. Two unusual barbiturate deaths. Archives of Toxicology
8
Clark MA, Jones JW. Suicide by Intravenous injection of a veterinary euthanasia
1975; 34: 77-80.
agent: report of a case and toxicological studies. Journal of Forensic Sciences 1979; 23: 762-767.
At the same time, it is obvious that the victim attempted to hide his suicide from his family circle. Thus, we obtained no evidence indicating that he might have spoken at any point of putting an end to his life. There was no written note. The victim did not wait to be alone at home. Instead, he committed his act in a routine situation: his wife was watching television late at night and he was upstairs, presumably going to sleep. Thus, he had one to two hours at his disposal and he ingested a very fast-acting drug which would make any attempt at reanimation impossible, even after a brief period of time. This may have induced the physician in charge to believe that the cause of death was cardiac origin, a likely hypothesis given the age of the victim. Had the family not behaved in an assertive manner, the magistrate may have not been informed of the event or would have requested a simple external examination.
science&justice Volume 43 ~ o . 1(2003) 41 - 43
9
Druid H, Holmgren P. A compilation of fatal and control concentrations of drugs In postmortem femoral blood. Journal of Forensic Sciences 1997; 42: 79-87.
10
Nair SG, Dundee JW, Clarke RSJ, Howard J. Plasma pentobarbitone levels, influence of the preparation, route and method of administration.Anaesthesia 1976; 31: 1037-1042.
11
Cordell WH, Cuny SC, Furbee RE, Mitchell-Flynn DL. Veterinary euthanasia
12
Guillon C, LeBonniec Y. Suicide mode d'ernploi, histoire, technique, actualite. Ed.
drugs as suicide agents. Annals of Emergency Medlcine 1986; 15: 939-943.
Alain Moreau. Paris, 1982. 13
Humphry D. Exit final, pour une mort dans la dignite. Ed. EJ Le Jour, Sogides, Quebec. 1991.
Page 43