Accidental mechanical asphyxia of children in Germany between 2000 and 2008.

Accidents constitute one of the greatest risks to children, yet there are few medical reports that discuss the subject of accidental asphyxia. However, a systematic analysis of all documented cases in Germany over the years 2000-2008 has now been conducted, aiming at identifying patterns of accidental asphyxia, deducing findings, defining avoidance measures and recommending ways of increasing product safety and taking possible precautions. The analysis is based on a detailed retrospective analysis of all 91 relevant autopsy reports from 24 different German forensic institutes. A variety of demographic and morphological data was systematically collected and analysed. In 84 of the 91 cases, the sex of the victim was reported, resulting in a total of 57 boys (68 %) and 27 girls (32 %). The age spread ranged between 1 day and 14 years, with an average of 5.9 years. Most accidents occurred in the first year of life (20 %) or between the ages of 1 and 2 years (13 %). In 46 % of cases, the cause of death was strangulation, with the majority occurring in the home environment. In 31 % of all cases, the cause of death was positional asphyxia, the majority resulting from chest compression. In 23 % of cases, the cause of death was aspiration, mainly of foreign bodies. Today, accidental asphyxiation is a rare cause of death in children in Germany. Nevertheless, the majority of cases could have been avoided. Future incidence can be reduced by implementing two major precautions: increasing product safety and educating parents of potentially fatal risks. Specific recommendations relate to children's beds, toys and food.

Model cannons causing lethal traumata.

Model cannons are usually considered to be harmless toys; therefore no legal regulations are required. Nevertheless, suicidal intentions or playful experimentation can turn this toy into a lethal weapon. This paper describes two cases of misuse of model cannons, leading to severe injuries and consequently death: the first case was the result of a suicidal intention, where the cannon caused a bullet injury into the forehead with marked signs of close-firing and intensive brain damage. The second case was an accidental event, where the cannon induced an entry wound at the left chest wall with surrounding carbonization and a fatal rupture of the heart. Circumstances of the lethal situations and mechanisms of the cannons leading to fatal injuries including ballistic considerations are described. The report is supported by a thorough literature research.

Transforming growth factors (TGF-alpha and TGF-beta1) in the determination of vitality and wound age: immunohistochemical study on human skin wounds.

In continuation of former investigations on proinflammatory cytokines, in the present study the relevance of the transforming growth factors TGF-alpha and TGF-beta1 was evaluated for the diagnosis of vitality and wound age. Paraffin sections from human skin wounds due to sharp force influence, which had been collected in operations and autopsies, were investigated using immunohistochemistry. The wound age varied from a few minutes to a maximum of 6 weeks with focus on the early post-traumatic interval up to 5h. Samples from uninjured skin were available as controls. TGF-alpha (n=74) was weakly expressed in normal skin and showed a marked increase in epidermal reactivity after a wound age of approximately 10 min. The maximum was between 30 and 60 min. TGF-beta1 (n=51) revealed constitutional expression only in connective tissue. An increase of immunohistochemical reaction was partially detected even in classical stab wounds (wound age of several minutes). The immunohistochemically detectable signal concerned--presumably due to an infiltration with TGF-beta-rich thrombocytes--large parts of the traumatized skin and also the epidermal layers (cellular and interstitial marking). TGF-beta1 peaked after a post-traumatic interval of 30-60 min. Both factors, especially TGF-beta1, remained detectable in elevated levels also in older wounds with an age of days to weeks (network in granulation tissue). TGF-alpha and TGF-beta1 can efficiently contribute to the estimation of vitality and wound age based on the evaluation of cytokine patterns. In particular, this applies to TGF-beta1 because of its easier evaluation and rapid up-regulation. Similar to other cytokines, the parallel investigation of control skin from the same individual must be recommended to eliminate variation in the basal expression.

Multiple skeletal muscle metastases from malignant pleural mesothelioma.

A 54-year-old male patient (occupational asbestos exposure over 27 years) died 2 years and 4 months after the diagnosis of malignant pleural mesothelioma of the right side, despite twice undergoing pleurectomy and radiotherapy. The autopsy revealed a locally advanced pleural mesothelioma of both sides involving the pericardium, heart, right diaphragm, liver and peritoneum. Disseminated metastases in numerous lymph nodes and a hematogenous metastatic spread into both lungs, the thyroid gland, peritoneum and skeletal musculature were found. The left temporal muscle and proximal limb skeletal muscles of the right upper arm and both thighs exhibited multiple metastases measuring up to 7 cm in diameter. Microscopically, a biphasic type of mesothelioma was detected. To our knowledge this is the first extensive case report on muscle metastases in malignant mesothelioma. Reviewing the literature, it is thought that in the presented case the long survival time of the patient and his protracted preterminal immobility could have contributed to the unusual formation of multiple skeletal muscle metastases.

Death during percutaneous transluminal coronary angioplasty (PTCA) and the medicolegal aspects.

Coronary embolisation is a very rare complication of the clinically widespread method of percutaneous transluminal coronary angioplasty (PTCA). The well-documented case of a 64-year-old male patient is presented comparing angiographic and morphological findings. The occluded left anterior descending artery (LAD) was successfully dilated during PTCA. Simultaneously the circumflex artery showed acute occlusion. The patient fell into cardiac shock and died after attempted resuscitation and agonal installation of extracorporeal circulation. The autopsy revealed severe residual stenosis of the proximal LAD by parietal thrombosis and occlusion of the proximal circumflex artery by an unattached intraluminal thrombus (0.8 x 0.3 x 0.2 cm) which had been dislocated during PTCA. Autopsy thus confirmed the clinical presumption of coronary embolism and, in addition, disclosed a previously unknown perforation of the femoral artery which had occurred during agonal installation of extracorporeal circulation and contributed to death via severe retroperitoneal hemorrhage. The case is discussed under the aspects of clinical quality control by forensic pathological investigations.

Pulmonary micromorphology in fatal strangulations.

Pulmonary histopathology was studied in a group of 106 fatal strangulations including cases of hanging (n = 55; typical, n = 20; atypical, n = 35), ligature strangulation (n = 12), throttling (n = 15), combinations of throttling and ligature strangulation (n = 7) and other compressing force against neck (n = 17). The control group (n = 10) consisted of cases of sudden cardiovascular death. The following results were obtained: intra-alveolar edema of different degree and strong hyperemia could be regularly observed in nearly all cases, especially in fatal hanging (apart from the control cases, in this group the highest mean lung weights were observed). Further frequent histological patterns were perivascular and intra-alveolar hemorrhages, local dystelectasis and focal emphysema. Alterations of the lung vessel contents could be detected in a varying extent: fat embolism (n = 7), mainly of minor degree, embolism of bone marrow tissue (n = 5) and intravascular cell accumulations (n = 22). Embolism of fat and bone marrow tissue was nearly always restricted to cases with accompanying blunt force or resuscitation measures. Whereas only 4 out of 55 cases of hanging revealed intravascular cell accumulations (including different types of leukocytes and immature bone marrow cells), 18 out of 51 cases with the other forms of strangulation exhibited this phenomenon. These accumulations mainly occurred in a discrete and widely scattered manner, appeared in 3 out of 10 control cases (resuscitation measures) as well, and were limited to cases with either protracted courses or accompanying blunt violence. The following conclusions are drawn: the regularly observed general changes of lung microstructure (e.g. edema, hyperemia) are undoubtedly non-specific for strangulation; the alterations of blood vessel contents may serve as a general vitality marker, if resuscitation measures are excluded, but not as an evidence of strangulating force. In cases without signs of blunt force they point to protracted agony courses (shock equivalents).

Multiple cardiac rhabdomyoma with exclusively histological manifestation.

Rhabdomyomas of the heart are rare lesions and usually exhibit macroscopic tumour nodules at autopsy. The uncommon death of an apparently healthy 2 1/2-month-old female infant is described. Post-mortem examination revealed normal gross cardiac morphology and exclusively histological manifestation of multifocal rhabdomyoma. The microscopic and immunohistochemical features are demonstrated. Tuberous sclerosis, frequently associated with this type of hamartoma was not present. The case confirms again the importance of additional histological investigations in unexpected fatalities in infancy: beside the clarification of death, autopsy may obtain a prophylactic function in the detection of possibly genetically determined diseases such as cardiac rhabdomyoma.

The quantitative alteration of the DNA content in strangulation marks is an artefact.

UNLABELLED: It is frequently difficult to prove the vitality in cases of fatal hanging. Using impulse cytophotometry, Müller et al. (Krim. Forens. Wiss. 44, 1981) reported on possibly vital alterations of the DNA content in five strangulation marks (hypodiploidy). The objective of the present study was to perform a re-evaluation by means of current methods of quantitative DNA analysis. The investigation included 24 cases of hanging (typical, n = 11; atypical, n = 13). DNA was extracted by use of phenol/chloroform and quantitated photometrically in relation to the tissue weight. In addition, skin specimens were examined histologically and their water content was determined. The mean DNA content of strangulation marks was 3.2 micrograms DNA/mg tissue, that one of uninjured skin (control) 1.4 microgram DNA/mg tissue. The ratio of DNA content between strangulation grooves and control skin varied from 1.2 to 5.2 (average: 2.4) implicating apparently elevated DNA levels in strangulation marks. Histology revealed typical changes with absence of leukocyte infiltration suggesting mechanical compression of DNA containing layers. The additional determination of the water content emerged-in dependence on the macroscopic appearance, dried or non-dried-reduced values for strangulation marks (average: 42% vs. 66%). Statistical analysis demonstrated a significant correlation between elevated DNA content and reduced water content of strangulation marks. CONCLUSION: the markedly elevated DNA content of strangulation marks is interpreted as an artefact due to drying of the skin with a reduction of the water content (and weight) in the course of mechanical cutaneous alterations (compression). Therefore, quantitative changes in the local DNA content of the groove have no importance as a sign of vitality in fatal strangulations.

Assessment of postmortem blood alcohol concentrations by ethanol levels measured in fluids from putrefactive blisters.

It was the aim of the present study to investigate whether the postmortem blood alcohol concentration (BAC) can be assessed by means of ethanol values measured in fluids from putrefactive blisters. Fluids from one or two putrefactive blisters were collected in 45 putrefied corpses (postmortem interval: 3-23 days, graduation of the degree of decomposition into four stages) and compared with femoral vein blood or femoral muscle. Ethanol and so-called putrefactive alcohols were determined in all samples by double GC-measurements. The results were converted to the medium water content of blood of 80%. The investigations revealed a significant correlation between the ethanol values of femoral blood/muscle and putrefactive blister fluid (PBF) (r = 0.725, P < 0.001). With the exception of one case, PBF values of 0.11% or more (n = 11) corresponded to minimum blood/muscle concentrations of 0.085%; PBF values of more than 0.15% (n = 8) corresponded to blood/muscle levels of at least 0.159%. Regression analysis revealed the formula BAC (in %) = 0.785 X ethanol (PBF) +0.011. Relevant concentrations of putrefactive alcohols such as 1- and 2-propanol and l-butanol only occurred in cases with far advanced decomposition. Ethanol levels determined in fluids from different putrefactive blisters of the same body also demonstrated a significant correlation (r = 0.791, P < 0.001). Ethanol concentrations determined in PBF must be judged with caution, but PBF values > 0.15% point to corresponding blood levels with a high degree of probability, at least where advanced putrefaction is excluded.

Exhumations: synopsis of morphological and toxicological findings in relation to the postmortem interval. Survey on a 20-year period and review of the literature.

Before an exhumation the question of its possible success usually arises. This paper aims to act as an aid by providing comprehensive lists ("expectation catalogues") of morphological and toxicological findings with their corresponding postmortem intervals. All organ systems are included. The results are based on the retrospective evaluation of 46 exhumations performed at the Cologne Institute of Forensic Medicine in a 20-year period (1974-1994) and a review of the literature. In our own material (34 males, 12 females, age range: 2 days-91 years) the postmortem interval varied from 6 days to 20.5 years. Exhumations were performed by order of criminal courts (n = 28), social insurances (n = 13) and private persons (n = 5). Main indications were problems of causality in social and civil law (n = 14), suspected intoxications (n = 10), possible medical malpractice (n = 7), criminal aspects of traffic accidents (n = 7) and identifications (n = 5). The expectation catalogues include the following remarkable items (with postmortem interval) from our own material: coronary thrombosis (3.5 months), granulation tissue in myocardial infarction (3.5 months), myocardial fibrosis (2.5 years), coronary sclerosis (7.5 years), femoral vein thrombosis and pulmonary embolism (3.75 months), pneumonia (3 months), pulmonary emphysema and chronic bronchitis (2.5 years); detection of strangulation marks (2 months); preservation of bone marrow histology (3 months), gastrointestinal tract in continuity (7.5 years), macroscopic and histological cerebral structures (17 years); toxicological detection of phenobarbital (6 weeks), CO-Hb (9.5 weeks), chlorprothixene (5.5 years), diazepam (7.5 years), furosemide (7.5 years) and parathion (E 605) (17 years). The cause of death could be clarified with sufficient certainty in 36/46 cases (78%). Exhumation problems could be answered completely in 39 cases and partly in seven further cases. On the whole this review again underlines the importance and value of this special kind of body examination even after long postmortem periods.

Immunohistochemical characterization of alveolar macrophages and pulmonary giant cells in fatal asphyxia.

UNLABELLED: It is in dispute whether the occurrence of numerous alveolar macrophages and in particular pulmonary giant cells in cases of fatal asphyxia is associated with agonal activation and proliferation. The nature of these alveolar cells was investigated in selected fatalities with protracted final oxygen lack using immunohistochemistry (APAAP method) and a semi-quantitative graduation. The study included opiate-involved deaths (n = 22), fatal strangulations (n = 10) and a control group of sudden cardiovascular deaths (n = 10). Positive immunohistochemical reactions were observed with the monoclonal antibodies PG-M1 (general marker of macrophages, detection of nearly 100% of pulmonary macrophages and giant cells in all subgroups) and 25 F 9 (late stage inflammation marker, detection of pulmonary macrophages/giant cells in 70%/50% of opiate-involved fatalities, 70%/20% of strangulations and 40%/30% of control cases). The antibodies LN-4 (macrophages), 27 E 10 (early stage inflammation marker), AMH 152 (activated macrophages) and MIB 1 (proliferation marker) did not react with these cell populations. CONCLUSIONS: pulmonary giant cells and numerous alveolar macrophages are not restricted to asphyxia. Their appearance is not of pathognomonic value for this diagnosis. Both cell types seem to be of heterogeneous nature (different functional state) as only one marker was expressed by all cells. The results do not suggest prefinal immigration, mobilization or proliferation of alveolar cells, but rather point to a longer pre-existence of macrophages and giant cells in pulmonary tissue (25 F 9 as late stage inflammation marker positive).

Individualization of fresh and stored human urine samples by PGM1- and Gc-subtyping.

After 50- to 200-fold concentration by ultrafiltration, 56 fresh urine samples from healthy individuals (26 men, 30 women) and eight samples from corpses were subjected to isoelectrofocusing methods. All the urine samples tested could be correctly typed in both the phosphoglucomatase 1 (PGM1) and Gc system when compared to reference blood samples. The activity of urinary PGM1 revealed intraindividual and interindividual variations. To our knowledge this is the first report of PGM1 detection in urine. A systematic storage experiment over a period of 6 months was carried out at different temperatures (-20 degrees C, 4 degrees C, 20 degrees C); furthermore, aging of urine samples from 4 months to 4 years was investigated. The heterogeneous typing results were as follows. For Gc: after a storage period of 6 months positive results could be obtained in approximately 40% of those samples that were stored frozen (-20 degrees C) or in a refrigerator (4 degrees C). Some samples, however, showed negative analyses already after a 1 month storage period. At room temperature positive results could be achieved up to 3 months. Additional bands can appear in pherograms of urine samples stored at room temperature or in a refrigerator; they may cause misinterpretation, dependent on the original Gc-type. The maximum storage time compatible with successful Gc-typing was 1 year. For PGM1: this polymorphism could be regularly detected up to 1 week, and in some cases up to 1 month, in urine samples stored at 4 degrees C. The PGM1 activity gradually decreased; there were no additional or variant bands.

Combination of fatal digoxin poisoning with endocardial fibroelastosis.

This is the first report in the forensic literature of a combination of fatal digoxin poisoning with endocardial fibroelastosis (EFE). Typical morphological features of EFE as the cause of clinically diagnosed cardiomyopathy were present in the autopsy of a 3-year-old girl, including cardiac hypertrophy and marked thickening of the left-sided endocardium, consisting of numerous elastic and collagenic fibres. After exclusion of cardiac and cerebral causes of death, accidental digoxin intoxication was proved. Postmortem toxicological analyses by fluorescence polarization immunoassay (FPIA) disclosed digoxin levels of 71 micrograms/kg (femoral vein blood), 77 micrograms/kg (cardiac blood), 255 and 221 micrograms/kg (cardiac muscle of the right and left chamber), 163 micrograms/kg (psoas muscle), 91 micrograms/kg (lung), 222 micrograms/kg (liver) and 520 micrograms/kg (kidney). The results are compared with the antemortem digoxin concentration of 39 ng/ml serum. The case is discussed from its unusual morphological and toxicological aspects, with special consideration of possible medical malpractice.

Fatal outcome in a case of pontocerebellar hypoplasia type 2.

Pontocerebellar hypoplasia (PCH) is a very rare congenital (autosomal recessive) condition with fetal onset. Only a few cases have been published on the basis of both clinical data (symptoms/neuroradiological imaging) and autopsy results. This paper reports on such a case involving a 1.5-year-old male infant. The child suffered from severe psychomotor delay, extrapyramidal dyskinesia and epileptic seizures, but did not exhibit signs of spinal muscular atrophy as related to PCH type 1. Magnetic resonance imaging (MRI) at the age of 6 months demonstrated olivo-pontine and bilateral cerebellar hypoplasia. The boy was unexpectedly found dead. Autopsy disclosed a severe aspiration of gastric contents as the final cause of death. The neuropathological examination confirmed PCH type 2 (according to Barth [Brain Dev., 15 (1993) 411-422]) with marked microcephaly and olivopontocerebellar hypoplasia. Histologically, decreased density of olivo-pontine neurons, reduction of granular and Purkinje's cell layers of the cerebellum, slight astroglial proliferation and fragmented appearance of the dentate nuclei were observed. The immunohistochemical expression pattern was determined using antibodies against glial fibrillary acidic protein, synaptophysin and neurofilament protein. Summarizing, typical features of PCH type 2 were present and proved by clinical course, MRI and autopsy. Despite severe symptoms due to a natural disease this rare neurogenetic entity can become of forensic interest, when sudden unexpected death occurs.

Quantitative analysis of proinflammatory cytokines (IL-1beta, IL-6, TNF-alpha) in human skin wounds.

Proinflammatory cytokines play an important role in the mediation of inflammation and trauma. They could be useful for the determination of vitality and wound age. In the present study, 144 human skin wounds due to sharp force were investigated. The material was collected during operations (N=96) and postmortem examinations (N=48). The wound age varied from several seconds or minutes to 9 days. Control skin was available in each individual. The tissue specimens were homogenized and extracted in a solution of PBS and protease inhibitors. Interleukin-1beta (IL-1beta), interleukin-6 (IL-6) and tumour necrosis factor alpha (TNF-alpha) were measured by quantitative ELISA analysis. Statistical evaluation was performed by the t-test using the quotients of levels (wound sample/control skin). In surgical specimens the cytokine levels revealed a clear tendency to increase with wound age. IL-1beta in early skin wounds (24 h, P<0.05). The quantitative analysis of proinflammatory cytokines in wound extracts can contribute to the determination of vitality and wound age, in particular in the very early post-traumatic interval (classic stab wounds).

Immunohistochemical detection of fibronectin in postmortem incised wounds of porcine skin.

Fibronectin plays an important role in tissue repair and wound healing. Previous literature reports indicated that fibronectin could be a marker of vitality for wounds with a survival time of more than a few minutes. In order to verify these findings were performed immunohistochemical investigations on the expression of fibronectin in incised wounds of porcine skin inflicted into various anatomical regions in the early postmortem interval (0-5 min after circulatory arrest). Tissue specimens were collected 12-14 h postmortem and investigated for fibronectin on paraffin sections (alkaline phosphatase and monoclonal anti-alkaline phosphatase procedure). A markedly positive expression of fibronectin (not only next to the wound margin and clearly stronger than in normal undamaged skin) could be demonstrated in eleven out of 36 samples. A moderately positive fibronectin reaction was detectable in seven further specimens. Muscular contraction bands were observed in nine out of 36 specimens. The various reaction patterns of fibronectin cannot be finally explained, but are probably due to a passive transudation of skin tissue by blood components from injured vessels. As a result of these investigations the specificity and validity of fibronectin as a parameter of vitality has to be questioned. Fibronectin immunohistochemistry again reveals that the validity of parameters as vital criteria decreases when their manifestation time is short; postmortem/supravital induction seems to be possible resembling vital reactions in these cases.

Fatal and non-fatal injuries caused by crossbows.

Today in modern times, traumatic injuries caused by crossbows are a rarity. The largest collection of cases so far is presented in this study, consisting of four fatalities (two homicides and two suicides) and two non-fatal injuries (grievous bodily harm and an accident). All the victims were male having an age between 31 and 54. The weapons, which were used, were mainly high-performance precision crossbows with telescopic sights and hunting bolts. The parts of the body involved were the facial/head area in three of the cases and the thorax in three of them. There were either deep or total penetration injuries to the cranium and thorax with the bolt remaining in the wound in four out of six cases. The persons with non-fatal crossbow injuries exhibited comparatively few symptoms, despite the sometimes extensive involvement of the interior of the cranium (cerebrocranial penetration, in one instance). The two cases of suicide favoured the body areas often found with gun-users. The aetiological classification of crossbow injuries may be difficult after the removal of the bolt. The external morphology is strongly dependent on the type of tip used. Multiple-bladed hunting broadheads produce radiating incised wounds, whereas conical field tips produce circular to slitlike defects. Correspondingly, the external injuries can be reminiscent of the effects of a violent attack by sharp force or of a gunshot wound. The possibility, supported by clinical data, that the victim might have the ability to act or even to survive for a period of time, even with penetration of the brain, should be taken into account when the cause of death is being investigated.

Pulmonary histopathology and survival period in morphine-involved deaths.

For an evaluation of the survival period in morphine-involved deaths, changes of pulmonary histopathology were investigated in a total of 90 morphine-associated fatalities. Although pulmonary histopathology proved to be heterogeneous, several distinctive histological patterns emerged. While the subgroup with short courses of intoxication ( < 1 h, n = 15) was mostly characterized by slight/moderate alveolar edema (12/15), severe hemorrhages (12/15) and marked acute emphysema (9/15), the phenomena of massive edema (8/15), missing/slight hemorrhages (8/15) and absent/slight emphysema (11/15) dominated in the group with intermediate survival times (1-24 h, n = 15). Intravascular leukocyte accumulations (shock equivalent) occurred in the first group only once, but in the group with the longer survival time in 10 of 15 cases. Delayed deaths ( > 24 h, n = 4) were mainly characterized by purulent bronchitis/pneumonia. Those fatalities (n = 56) that could not be classified by anamnestic data were assessed by histological criteria. In comparison with the evaluation of the survival period by toxicological analyses, concordance was found in 46 cases. Pulmonary histopathology is not a tool for an exact graduation of survival time, but the combination of several key parameters can provide criteria for a differentiation between short ( < 1 h) and longer courses of intoxication.

Medico-legal aspects of doping.

Abuse of anabolic steroids is an increasing problem not only among athletes but also body-builders and teenagers. A fast-developing black market has been established since the opening of the borders to eastern Europe. Medico-legal aspects of doping are addressed with particular reference to toxicology and pathology. Constituents of anabolic steroids bought on the black market were identified using gas chromatography/mass spectrometry; the products did not contain the expected ingredients in 35% of cases. Long-term effects and fatalities because of anabolic steroid abuse are reported here based on our own case material and a literature review. In our own cases, severe cardiovascular side-effects developed after long-term abuse of Dianabol (methandrostenolone) and Oral-Turinabol (chlordehydromethyltestosterone), i.e. myocardial infarction, stroke, organomegaly and/or severe atherosclerosis. The pathogenesis of cardiovascular complications (cardiotoxic effect, risk of atherosclerosis, thrombogenic risk) is discussed based on the available literature reports following fatal outcome after the abuse of anabolic steroids.

[Gamma-glutamyltransferase and blood alcohol level--criteria for alcohol risk in automobile drivers. A critical comment on the guidelines for medical-psychological studies of first-time alcohol offenders]. / Gamma-Glutamyltransferase (GGT) und Blutalkoholspiegel-Kriterien für die Alkoholgefährdung von Kraftfahrern. Eine kritische Auseinandersetzung mit den Richtlinien für medizinisch-psychologische Untersuchungen (MPU) bei erst-malig alkoholauffälligen Kraftfahrern.

GGT and blood alcohol concentration (BAC) were measured of 2,655 male car drivers using alcoholized their cars during the year 1991 in the area of the city of Cologne. The results were evaluated statistically together with other parameters like age, time of taking blood sample and behaviour while drunken. BAC was 1.6% and more in 30.5% of all cases. Half of them had levels of 2.0% and higher. GGT in serum was increased (> 28 U/l) at 29.5% of the drivers, in 6% even above 100 U/l. 53% were younger than 31 years. Medium BAC and part of GGT higher than 28 U/l were remarkable lower in this group than at the older ones. 50% of all car drivers with blood alcohol levels above 2.0% have alcohol problems regarding GGT. Problem drinkers were found among the younger ones to an extent of 15%, but of 50% among the drivers older than 40 years. But also 25% of all with a BAC lower than 1.6% showed increased GGT levels. They remain undetected on account of the present instructions of MPA though there is a great danger repeating drunken driving. On the other side nearly 50% of those driving with an BAC of 1.6% or more are no driving drinkers regarding GGT but have to undergo MPA. The recommendation of the 30. German Traffic Courts Meeting in 1992 to determine other indicators of alcohol habituation in the blood samples taken after drunken driving like GGT and methanol should be taken in a corrected setting of the instructions. This would regard fairer the problems of an individual case. The connection of MPA with the height of BAC and other circumstances seen as indicators for extraordinary alcohol habituation is a wrong way and unnecessary if alcoholism markers are used like GGT, CDT and methanol.