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The manner and cause of death in a forensic series of chronic alcoholics
171
Fortic Science International, 49 (1991) 171-178 Elsevier Scientific Publishers Ireland Ltd.
THE MANNER AND CAUSE OF DEATH IN A FORENSIC SERIES OF CHRONIC ALCOHOLICS
ANDERS U. HANSEN and JBRN SIMONSEN Institute of Forensic Medicine, Odmse University, DK-5000 Oo!en.seC. (Denmark) (Received October 30th, 1990) (Revision received January llth, (Accepted January 12th, 1991)
1991)
Summary Chronic alcoholics account for an increasing number of the cases which are examined in forensic pathology. The manner and cause of death in 122 chronic alcoholics is described and compared with a previous investigation and to a group of non-alcoholics. The percentage of cases in which the manner of death is undetermined is twice as high as in the control group, whilst the percentage of suicide, surprisingly enough is only half that of the control group. The patho-anatomic findings in the liver and the causes of death are discussed in detail. Key words: Chronic alcoholic; Manner of death; Cause of death
Introduction No other single factor is responsible for so many medico-legal examinations as is alcohol, at least in the western world. This includes acute intoxication as well as chronic alcoholism. It is difficult to judge with certainty if an acute intoxication has been of decisive importance in a specific event e.g. a traffic accident. Statistics can only prove that alcohol intoxication is demonstrated with a certain high incidence under those circumstances and therefore might be of importance. In Danish society, the alcohol intake has been stable for many years. From 1916 to 1956, the yearly intake was approximately 3 1of alcohol per person above the age of 14 years [l]. During the last 30 years, this intake has increased markedly and at the present time reached a level about 12 1 per year, the highest intake among the Nordic countries. It is well known among forensic scientists that such an increase is reflected in the composition of the material which passes through the Institutes of Forensic Medicine. To clarify the role of acute intoxication, the authors have decided to Correspondence to: J$rn Simonsen, DK-2100 Copenhagen 0, Denmark. 0379-0738/91/$03.50 0 1991 Elsevier Scientific Publishers Printed and Published in Ireland
Institute
of Forensic
Ireland Ltd.
Pathology,
Frederik
den Femtesvej
11,
172
examine chronic alcoholics in a series of postmortem examinations. As a similar series was presented by one of the authors (J.S.) 7 years ago, it is also possible to compare the results and point out the differences and changes that have developed since that time. Materials The definition of chronic alcoholism in a postmortem material is not very strict since the anamnestic information often is insufficient and the term is not simply related to the amount of alcohol consumed. The cases in this material were chosen after examination of the anamnestic information from the relatives, friends and the general practitioner as well as hospital staff, who are always contacted in medico-legal cases in Denmark. In many cases, alcohol-related organ changes supported the diagnosis and only in very few cases was the diagnosis “chronic alcoholism” derived from the pathoanatomic findings alone. There is no doubt that the number of cases represents minimum figures, because some information is purposely hidden due to the negative view of the society upon chronic alcoholics. It should also be emphasized that many alcoholics die in hospital from diseases some time after admission. Those cases are not reported for medico-legal examination. It is not possible to judge the magnitude of this hidden figure but it is not negligible. The manner of death and the cause of death is finally decided by the physician on basis of the results of the investigation, e.g. scene investigation, postmortem, histology, toxicology etc. It should be emphasized that acute alcohol intoxication alone does not fulfill the criteria for inclusion in the present material. “Acute intoxication” indicates that the intoxication alone is responsible for the cause of death. This event does not necessarily mean that the person in question is a chronic alcoholic. For that classification, anamnestic information and/or alcohol-related patho-anatomic organ lesions are further needed. Results Based on the above mentioned, 122 cases fulfilled the criteria of being a chronic alcoholic out of a total of 724 consecutive postmortems in the period 1986-1988 inclusive (Table 1). This leaves 561 non-alcoholics as controls since 41 cases of sudden infant death syndrome (SIDS) are excluded from the controls. These cases were all registered as undetermined. There is close correspondence in manner of death, except for suicides where the frequency was half that of the controls. Of the 122 chronic alcoholics, 86 (70.5%) were males while 36 (29.5%) were females. The ages ranged from 24 to 78 years, the average being 48. There was no significant age difference between the sexes. Table 2 demonstrates that there is no difference in the frequency of liver
173 TABLE
1
THE MANNER
OF DEATH
IN A FORENSIC
MATERIAL
1986-1988
Manner of death
Non-alcoholics
Alcoholics
Natural Accidental
181 (32.2%) 259 (46.2%)
38 (31.1%) 57 (46.7%)
79 (14.1%) 14 (2.5%) 28 (5.0%)
8 (6.6%) 3 (2.5%) 16 (13.1%)
Suicidal Homicidal Undetermined* Total
561
INCLUSIVE
(N = 724)
122
*Forty-one cases of SIDS were excluded.
changes between male and female. Two-thirds had fatty degeneration of the liver and almost one-fifth demonstrated cirrhosis of the liver. There were very few cases with organic changes in the pancreas - only two with acute pancreatitis. Not surprising, more than one-half of the chronic alcoholics were acutely intoxicated at the time of death (Table 3). In approximately lo%, no alcohol analysis was performed due to decomposition of the body or hospitalization prior to death. In the group of natural causes of death, heart diseases were far the commonest, accounting for approximately 40%. In seven cases, ischaemic changes were responsible for the death and in eight cases, unspecific heart changes were demonstrated (hypertrophy, myocarditis, amyloidosis etc.) (Table 4). The inflammatory changes of the lungs were dominated by lobar pneumonia. In the various group were two cases of diabetic coma, two acute haemorrhagic pancreatitis and one anaplastic lung carcinoma. The causes of death in the suicide group is shown in Table 5. There are three poisonings, three shootings and two suffocations and in six of the cases the deceased was acutely alcohol-intoxicated at the time of death. Table 6 reveals that alcohol poisoning alone or in association with medicine is responsible for approximately 50% of the accidental deaths in alcoholics. Only two cases were traffic accidents. TABLE
2
PATHO-ANATOMIC
CHANGES
IN THE LIVER
IN CHRONIC ALCOHOLICS
sex
Fatty liver
Cirrhosis
Males (N = 86) Females (N = 36)
56 (65.1%) 23 (63.9%)
15 (17.4%) 7 (19.4%)
Total (N = 122)
79 (64.8%)
22 (18.0%)
174 TABLE
3
BLOOD ALCOHOL
ANALYSIS
IN CHRONIC ALCOHOLICS
Positive Negative
70 (57.4%) 39 (32.9%)
Not performed
13 (10.6%)
(N = 122)
Tables 7 and 8 give a survey of the pure alcohol intoxications and the combined alcohol medicine poisoning, respectively. In the three cases with blood alcohol concentration (BAC) below 0.3%, two occurred in connection with hypothermia, while an ischaemic heart disease was found co-responsible in the third case. Note the preponderance of females among the pure lethal alcohol intoxications. It is interesting to note that barbiturate was involved in two of the combined poisonings despite the fact that barbiturates were removed from the dispensaries except for phenobarbital with a very restricted indication after January 1, 1986. In the latter group, it should be noted that the BAC in two instances was above 0.3%. Left are 16 cases in which the manner of death could not be established with reasonable certainty. This group does not differ from the entire group of alcoholics concerning age and sex, but it is interesting to note that of 14 cases in which it was possible to do alcohol analysis, 10 (71.4%) were negative, and only 4 (28.6%) positive. In two cases, the cause of death was established with certainty; in three cases inhalation of vomit might have been totally or partly responsible for the death, and in another two cases the examination was insufficient since no toxicology was performed. This leaves nine really obscure cases. In three cases, there was information or evidence of epileptic seizures; three demonstrated a fatty liver (two as the only findings and one in connection with 0.1% BAC), one was suffering from diabetes mellitus and two were mentally disturbed.
TABLE
4
THE CAUSE
OF DEATH
Lung inflammation Heart disease
IN NATURAL
Exsanguination Cerebral haemorrhage various
7 15 3 2 11
Total
38
DEATHS
AMONG ALCOHOLICS
(N = 38)
175
TABLE 5 SUICIDES
Age
AMONG CHRONIC ALCOHOLICS (A’ = 8)
Sex
Diseases etc.
BAC
(years)
43 60 33 58 44 41 34 60
Cause of death
(W
Male Female Male Female Male Male Male Female
Drug addict Several suicidal attempts, diabetes Several suicidal attempts Psychiatric treatment, suicidal threats Several suicidal threats Several suicidal threats Several suicidal threats Several suicidal attempts, suicide note
0
0
0.11 0.24 0.28 0.13 0.21 0.22
Bullet wound (head) Propoxyphene poisoning Barbiturate poisoning Suffocation (plastic bag) Shotgun wound (neck) Bullet wound (head) Suffocation (hanging) Propoxyphene poisoning
Discussion In the material, chronic alcoholics accounted for 16.9% of the total. Even with the reservation that those are selected medico-legal postmortems, it is a remarkably high incidence. The incidence seems even higher than that described by Clark, 1988 [3], where he found alcohol-related deaths accounting for 16% of all postmortems performed. The present series does not comprise deaths related only to acute alcohol intoxication, the person has to fulfill the criteria of being a chronic alcoholic. The incidence compared to the former investigation [2] is increased by 3.6%. When it comes to the manner of death, there is a marked difference in the incidence of suicides and undetermined cases. The frequency of suicides among chronic alcoholics is surprisingly only half that of the group of non-alcoholics,
TABLE 6 ACCIDENTAL
DEATH AMONG CHRONIC ALCOHOLICS (N = 57)
Cause of death
Number
Acute alcohol intoxication Combined alcohol and medicine posioning Medicine poisoning Carbon monoxide poisoning Fall lesions (crania-cerebral lesions) Traffic accident Drowning Various
16 12 5 2 7 2 7 6
Total
57
176 TABLE I ACUTE ALCOHOL INTOXICATION
Age
Sf?X
BAC (%)
Female Female Female Female Female Female Male Male Female Female Male Male Male Male Male Female
0.35 0.41 0.22 0.52 0.34 0.28 0.43 0.31 0.43 0.40 0.35 0.32 0.45 0.20 0.33 0.41
(Years) 49
71 62 28 40 53 55 66 61 53 42 39 42 63 37 44
IN CHRONIC ALCOHOLICS (N = 16) comments
Toxicology negative, hypothermia
Toxicology negative, hypothermia
Toxicology negative, ischaemic heart disease
TABLE 8 COMBINED ALCOHOL AND MEDICINE
POISONING IN CHRONIC ALCOHOLICS (iV = 12)
Sex
Drug
BAC (%)
Male Male Male Female Male Male Male Male Male Female Male Male
Phenobarbital Dextromoramide Propoxyphene Propoxyphene Phenobarbital Propoxyphene Morphine Methadone Chlordiazepoxide Karbemazepine Ketogane ChlorpromazinelBromazepam
0.19 0.19 0.29 0.24 0.15 0.34 0.27 0.17 0.28 0.40 0.04 0.28
51 25 42 50 39 56 24 36 48 58 31 43
while the frequency of undetermined manner of death is approximately twice as high among chronic alcoholics compared to that of the controls, when the SIDS cases are excluded. Two-thirds of the chronic alcoholics were male and one-third female which is in concordance with others [3]. Regarding females, there was an increase of approximately 10% compared to the former investigation [2]. There is a high incidence of liver diseases and the figures demonstrate a doubling in 7 years [2]. Compared to the former investigation, there is equality between the sexes when it comes to patho-anatomic findings in the liver. It is not surprising that 57% were acutely intoxicated at the time of death. This is in concordance with the former investigation [2]. Compared to the earlier investigation, ischaemic heart disease dominates among the natural causes of death, while it is in concordance with the Scottish material [3]. Also in concordance with others, is the inflammatory disease of the lungs frequency. It should be emphasized that only two deaths were due to acute haemorrhagic pancreatitis and that liver diseases also only accounted for two cases, one of hepatic failure and one of exsanguination from ruptured varices. These low figures are probably due to the fact that many alcoholics die in hospital after prolonged illness and were therefore not subjects for medico-legal investigation. This could also explain that cirrhosis was quite infrequent in the present material (18%). In the suicide group, 75% were acutely intoxicated, which is not surprising [2,3]. The most common methods employed were violent procedures (shooting, suffocation) while overdose only was used in one-third. This is not in concordance with others [2,3] but the figures are small. In the accident group, death from simple intoxication accounted for 16 cases (28%) and alcohol combined with drugs for another 12 cases (21%) which lead to the conclusion that alcohol intoxication played an important role in almost half of the accident cases (49%). This is not in accordance with the Scottish experience [3], where simple intoxication accounted for 77% and only very few poisonings were due to alcohol and drugs combined. This difference might be explained by differences in drinking habits in the two areas [l]. In concordance with the experience in other investigations, only two accidents occurred in traffic and both were pedestrians [2,3]. These persons are so far down in the socioeconomic scale that they have no access to motor vehicles. In the group of simple intoxication, the BAC was below 0.3% in three cases (Table 7) which all showed significant co-existing conditions such as hypothermia (2) and ischaemic heart disease (1). It is surprising to note a preponderance of females (56%) especially compared with the male dominance in the group of combined poisonings (Table 8). An interesting group comprises of the 16 cases in which the manner of death was not determined. Age and sex distribution is in concordance with the entire group while the percentage of intoxication was much lower than that of the entire material - 29% compared to 57%. In two cases, the cause of death was demonstrated but it was not possible to conclude if the death was suicidal or
178
accidental. In another three cases, inhalation of vomit could explain the death completely or partly. Finally, there were two insufficiently investigated cases where no toxicology was performed because the police refused to finance the examination. This demonstrates an unsatisfactory side effect of the “privatization” of the medico-legal service which took place from January 1, 1986 in Denmark. Those cases could easily be poisoning cases but that is just an assumption, which cannot be proved. There remain nine cases (7.4%) in which it is impossible, despite extensive examinations, to establish a cause of death and therefore also a manner of death. Three of those cases demonstrated fatty liver and the BAC was very low or zero. The well-known hypothesis of hypoglycaemia should be kept in mind. In another three cases, there was evidence of epileptic seizures, so the explanation of the death might be epilepsy. One of the remaining three cases was suffering from diabetes and diabetic coma could not be ruled out as well as simple intoxication. Due to decomposition, chemistry was not possible. The remaining two cases occurred in mentally unstable persons, one of which showed totally negative investigation and the other a sublethal concentration of paracetamol in the blood. Even in well examined series of cases, there is always a minority of obscure cases in chronic alcoholics [2,3], and more research is needed to elucidate those cases. References 1 T. Thorsen, One Hundred Years of Alcohol Abuse, Alkohol- & Narkotikartiet, Copenhagen, 1990 (in Danish). 2 J. Simonsen, Chronic alcoholics in a forensic material. Manedsskr. Prakt. Laegegem., 61(1983) 353-360 (in Danish). 3 J.C. Clark, Sudden death in the chronic alcoholic. Forensic Sci. Znt., 36 (1988) 105-111.
Fortic Science International, 49 (1991) 171-178 Elsevier Scientific Publishers Ireland Ltd.
THE MANNER AND CAUSE OF DEATH IN A FORENSIC SERIES OF CHRONIC ALCOHOLICS
ANDERS U. HANSEN and JBRN SIMONSEN Institute of Forensic Medicine, Odmse University, DK-5000 Oo!en.seC. (Denmark) (Received October 30th, 1990) (Revision received January llth, (Accepted January 12th, 1991)
1991)
Summary Chronic alcoholics account for an increasing number of the cases which are examined in forensic pathology. The manner and cause of death in 122 chronic alcoholics is described and compared with a previous investigation and to a group of non-alcoholics. The percentage of cases in which the manner of death is undetermined is twice as high as in the control group, whilst the percentage of suicide, surprisingly enough is only half that of the control group. The patho-anatomic findings in the liver and the causes of death are discussed in detail. Key words: Chronic alcoholic; Manner of death; Cause of death
Introduction No other single factor is responsible for so many medico-legal examinations as is alcohol, at least in the western world. This includes acute intoxication as well as chronic alcoholism. It is difficult to judge with certainty if an acute intoxication has been of decisive importance in a specific event e.g. a traffic accident. Statistics can only prove that alcohol intoxication is demonstrated with a certain high incidence under those circumstances and therefore might be of importance. In Danish society, the alcohol intake has been stable for many years. From 1916 to 1956, the yearly intake was approximately 3 1of alcohol per person above the age of 14 years [l]. During the last 30 years, this intake has increased markedly and at the present time reached a level about 12 1 per year, the highest intake among the Nordic countries. It is well known among forensic scientists that such an increase is reflected in the composition of the material which passes through the Institutes of Forensic Medicine. To clarify the role of acute intoxication, the authors have decided to Correspondence to: J$rn Simonsen, DK-2100 Copenhagen 0, Denmark. 0379-0738/91/$03.50 0 1991 Elsevier Scientific Publishers Printed and Published in Ireland
Institute
of Forensic
Ireland Ltd.
Pathology,
Frederik
den Femtesvej
11,
172
examine chronic alcoholics in a series of postmortem examinations. As a similar series was presented by one of the authors (J.S.) 7 years ago, it is also possible to compare the results and point out the differences and changes that have developed since that time. Materials The definition of chronic alcoholism in a postmortem material is not very strict since the anamnestic information often is insufficient and the term is not simply related to the amount of alcohol consumed. The cases in this material were chosen after examination of the anamnestic information from the relatives, friends and the general practitioner as well as hospital staff, who are always contacted in medico-legal cases in Denmark. In many cases, alcohol-related organ changes supported the diagnosis and only in very few cases was the diagnosis “chronic alcoholism” derived from the pathoanatomic findings alone. There is no doubt that the number of cases represents minimum figures, because some information is purposely hidden due to the negative view of the society upon chronic alcoholics. It should also be emphasized that many alcoholics die in hospital from diseases some time after admission. Those cases are not reported for medico-legal examination. It is not possible to judge the magnitude of this hidden figure but it is not negligible. The manner of death and the cause of death is finally decided by the physician on basis of the results of the investigation, e.g. scene investigation, postmortem, histology, toxicology etc. It should be emphasized that acute alcohol intoxication alone does not fulfill the criteria for inclusion in the present material. “Acute intoxication” indicates that the intoxication alone is responsible for the cause of death. This event does not necessarily mean that the person in question is a chronic alcoholic. For that classification, anamnestic information and/or alcohol-related patho-anatomic organ lesions are further needed. Results Based on the above mentioned, 122 cases fulfilled the criteria of being a chronic alcoholic out of a total of 724 consecutive postmortems in the period 1986-1988 inclusive (Table 1). This leaves 561 non-alcoholics as controls since 41 cases of sudden infant death syndrome (SIDS) are excluded from the controls. These cases were all registered as undetermined. There is close correspondence in manner of death, except for suicides where the frequency was half that of the controls. Of the 122 chronic alcoholics, 86 (70.5%) were males while 36 (29.5%) were females. The ages ranged from 24 to 78 years, the average being 48. There was no significant age difference between the sexes. Table 2 demonstrates that there is no difference in the frequency of liver
173 TABLE
1
THE MANNER
OF DEATH
IN A FORENSIC
MATERIAL
1986-1988
Manner of death
Non-alcoholics
Alcoholics
Natural Accidental
181 (32.2%) 259 (46.2%)
38 (31.1%) 57 (46.7%)
79 (14.1%) 14 (2.5%) 28 (5.0%)
8 (6.6%) 3 (2.5%) 16 (13.1%)
Suicidal Homicidal Undetermined* Total
561
INCLUSIVE
(N = 724)
122
*Forty-one cases of SIDS were excluded.
changes between male and female. Two-thirds had fatty degeneration of the liver and almost one-fifth demonstrated cirrhosis of the liver. There were very few cases with organic changes in the pancreas - only two with acute pancreatitis. Not surprising, more than one-half of the chronic alcoholics were acutely intoxicated at the time of death (Table 3). In approximately lo%, no alcohol analysis was performed due to decomposition of the body or hospitalization prior to death. In the group of natural causes of death, heart diseases were far the commonest, accounting for approximately 40%. In seven cases, ischaemic changes were responsible for the death and in eight cases, unspecific heart changes were demonstrated (hypertrophy, myocarditis, amyloidosis etc.) (Table 4). The inflammatory changes of the lungs were dominated by lobar pneumonia. In the various group were two cases of diabetic coma, two acute haemorrhagic pancreatitis and one anaplastic lung carcinoma. The causes of death in the suicide group is shown in Table 5. There are three poisonings, three shootings and two suffocations and in six of the cases the deceased was acutely alcohol-intoxicated at the time of death. Table 6 reveals that alcohol poisoning alone or in association with medicine is responsible for approximately 50% of the accidental deaths in alcoholics. Only two cases were traffic accidents. TABLE
2
PATHO-ANATOMIC
CHANGES
IN THE LIVER
IN CHRONIC ALCOHOLICS
sex
Fatty liver
Cirrhosis
Males (N = 86) Females (N = 36)
56 (65.1%) 23 (63.9%)
15 (17.4%) 7 (19.4%)
Total (N = 122)
79 (64.8%)
22 (18.0%)
174 TABLE
3
BLOOD ALCOHOL
ANALYSIS
IN CHRONIC ALCOHOLICS
Positive Negative
70 (57.4%) 39 (32.9%)
Not performed
13 (10.6%)
(N = 122)
Tables 7 and 8 give a survey of the pure alcohol intoxications and the combined alcohol medicine poisoning, respectively. In the three cases with blood alcohol concentration (BAC) below 0.3%, two occurred in connection with hypothermia, while an ischaemic heart disease was found co-responsible in the third case. Note the preponderance of females among the pure lethal alcohol intoxications. It is interesting to note that barbiturate was involved in two of the combined poisonings despite the fact that barbiturates were removed from the dispensaries except for phenobarbital with a very restricted indication after January 1, 1986. In the latter group, it should be noted that the BAC in two instances was above 0.3%. Left are 16 cases in which the manner of death could not be established with reasonable certainty. This group does not differ from the entire group of alcoholics concerning age and sex, but it is interesting to note that of 14 cases in which it was possible to do alcohol analysis, 10 (71.4%) were negative, and only 4 (28.6%) positive. In two cases, the cause of death was established with certainty; in three cases inhalation of vomit might have been totally or partly responsible for the death, and in another two cases the examination was insufficient since no toxicology was performed. This leaves nine really obscure cases. In three cases, there was information or evidence of epileptic seizures; three demonstrated a fatty liver (two as the only findings and one in connection with 0.1% BAC), one was suffering from diabetes mellitus and two were mentally disturbed.
TABLE
4
THE CAUSE
OF DEATH
Lung inflammation Heart disease
IN NATURAL
Exsanguination Cerebral haemorrhage various
7 15 3 2 11
Total
38
DEATHS
AMONG ALCOHOLICS
(N = 38)
175
TABLE 5 SUICIDES
Age
AMONG CHRONIC ALCOHOLICS (A’ = 8)
Sex
Diseases etc.
BAC
(years)
43 60 33 58 44 41 34 60
Cause of death
(W
Male Female Male Female Male Male Male Female
Drug addict Several suicidal attempts, diabetes Several suicidal attempts Psychiatric treatment, suicidal threats Several suicidal threats Several suicidal threats Several suicidal threats Several suicidal attempts, suicide note
0
0
0.11 0.24 0.28 0.13 0.21 0.22
Bullet wound (head) Propoxyphene poisoning Barbiturate poisoning Suffocation (plastic bag) Shotgun wound (neck) Bullet wound (head) Suffocation (hanging) Propoxyphene poisoning
Discussion In the material, chronic alcoholics accounted for 16.9% of the total. Even with the reservation that those are selected medico-legal postmortems, it is a remarkably high incidence. The incidence seems even higher than that described by Clark, 1988 [3], where he found alcohol-related deaths accounting for 16% of all postmortems performed. The present series does not comprise deaths related only to acute alcohol intoxication, the person has to fulfill the criteria of being a chronic alcoholic. The incidence compared to the former investigation [2] is increased by 3.6%. When it comes to the manner of death, there is a marked difference in the incidence of suicides and undetermined cases. The frequency of suicides among chronic alcoholics is surprisingly only half that of the group of non-alcoholics,
TABLE 6 ACCIDENTAL
DEATH AMONG CHRONIC ALCOHOLICS (N = 57)
Cause of death
Number
Acute alcohol intoxication Combined alcohol and medicine posioning Medicine poisoning Carbon monoxide poisoning Fall lesions (crania-cerebral lesions) Traffic accident Drowning Various
16 12 5 2 7 2 7 6
Total
57
176 TABLE I ACUTE ALCOHOL INTOXICATION
Age
Sf?X
BAC (%)
Female Female Female Female Female Female Male Male Female Female Male Male Male Male Male Female
0.35 0.41 0.22 0.52 0.34 0.28 0.43 0.31 0.43 0.40 0.35 0.32 0.45 0.20 0.33 0.41
(Years) 49
71 62 28 40 53 55 66 61 53 42 39 42 63 37 44
IN CHRONIC ALCOHOLICS (N = 16) comments
Toxicology negative, hypothermia
Toxicology negative, hypothermia
Toxicology negative, ischaemic heart disease
TABLE 8 COMBINED ALCOHOL AND MEDICINE
POISONING IN CHRONIC ALCOHOLICS (iV = 12)
Sex
Drug
BAC (%)
Male Male Male Female Male Male Male Male Male Female Male Male
Phenobarbital Dextromoramide Propoxyphene Propoxyphene Phenobarbital Propoxyphene Morphine Methadone Chlordiazepoxide Karbemazepine Ketogane ChlorpromazinelBromazepam
0.19 0.19 0.29 0.24 0.15 0.34 0.27 0.17 0.28 0.40 0.04 0.28
51 25 42 50 39 56 24 36 48 58 31 43
while the frequency of undetermined manner of death is approximately twice as high among chronic alcoholics compared to that of the controls, when the SIDS cases are excluded. Two-thirds of the chronic alcoholics were male and one-third female which is in concordance with others [3]. Regarding females, there was an increase of approximately 10% compared to the former investigation [2]. There is a high incidence of liver diseases and the figures demonstrate a doubling in 7 years [2]. Compared to the former investigation, there is equality between the sexes when it comes to patho-anatomic findings in the liver. It is not surprising that 57% were acutely intoxicated at the time of death. This is in concordance with the former investigation [2]. Compared to the earlier investigation, ischaemic heart disease dominates among the natural causes of death, while it is in concordance with the Scottish material [3]. Also in concordance with others, is the inflammatory disease of the lungs frequency. It should be emphasized that only two deaths were due to acute haemorrhagic pancreatitis and that liver diseases also only accounted for two cases, one of hepatic failure and one of exsanguination from ruptured varices. These low figures are probably due to the fact that many alcoholics die in hospital after prolonged illness and were therefore not subjects for medico-legal investigation. This could also explain that cirrhosis was quite infrequent in the present material (18%). In the suicide group, 75% were acutely intoxicated, which is not surprising [2,3]. The most common methods employed were violent procedures (shooting, suffocation) while overdose only was used in one-third. This is not in concordance with others [2,3] but the figures are small. In the accident group, death from simple intoxication accounted for 16 cases (28%) and alcohol combined with drugs for another 12 cases (21%) which lead to the conclusion that alcohol intoxication played an important role in almost half of the accident cases (49%). This is not in accordance with the Scottish experience [3], where simple intoxication accounted for 77% and only very few poisonings were due to alcohol and drugs combined. This difference might be explained by differences in drinking habits in the two areas [l]. In concordance with the experience in other investigations, only two accidents occurred in traffic and both were pedestrians [2,3]. These persons are so far down in the socioeconomic scale that they have no access to motor vehicles. In the group of simple intoxication, the BAC was below 0.3% in three cases (Table 7) which all showed significant co-existing conditions such as hypothermia (2) and ischaemic heart disease (1). It is surprising to note a preponderance of females (56%) especially compared with the male dominance in the group of combined poisonings (Table 8). An interesting group comprises of the 16 cases in which the manner of death was not determined. Age and sex distribution is in concordance with the entire group while the percentage of intoxication was much lower than that of the entire material - 29% compared to 57%. In two cases, the cause of death was demonstrated but it was not possible to conclude if the death was suicidal or
178
accidental. In another three cases, inhalation of vomit could explain the death completely or partly. Finally, there were two insufficiently investigated cases where no toxicology was performed because the police refused to finance the examination. This demonstrates an unsatisfactory side effect of the “privatization” of the medico-legal service which took place from January 1, 1986 in Denmark. Those cases could easily be poisoning cases but that is just an assumption, which cannot be proved. There remain nine cases (7.4%) in which it is impossible, despite extensive examinations, to establish a cause of death and therefore also a manner of death. Three of those cases demonstrated fatty liver and the BAC was very low or zero. The well-known hypothesis of hypoglycaemia should be kept in mind. In another three cases, there was evidence of epileptic seizures, so the explanation of the death might be epilepsy. One of the remaining three cases was suffering from diabetes and diabetic coma could not be ruled out as well as simple intoxication. Due to decomposition, chemistry was not possible. The remaining two cases occurred in mentally unstable persons, one of which showed totally negative investigation and the other a sublethal concentration of paracetamol in the blood. Even in well examined series of cases, there is always a minority of obscure cases in chronic alcoholics [2,3], and more research is needed to elucidate those cases. References 1 T. Thorsen, One Hundred Years of Alcohol Abuse, Alkohol- & Narkotikartiet, Copenhagen, 1990 (in Danish). 2 J. Simonsen, Chronic alcoholics in a forensic material. Manedsskr. Prakt. Laegegem., 61(1983) 353-360 (in Danish). 3 J.C. Clark, Sudden death in the chronic alcoholic. Forensic Sci. Znt., 36 (1988) 105-111.