BLOOD ALCOHOL AND INTOXICATION: ITS VALUE IN BORDER LINE CASES

BLOOD ALCOHOL AND INTOXICATION: ITS VALUE IN BORDER LINE CASES ALEXANDER O. GETTLER, PH.D., A. WALTER FREIREICH, M.D. AND HARRY SCHWARTZ, B.S. From the Toxicological Laboratories of the Chief Medical Examiners' Offices of Neio York City and Nassau County, New York Law enforcement agencies are increasingly utilizing the blood alcohol content in the determination of intoxication. Some go so far as to allow the alcohol content of the saliva, urine or expired air as prima facie evidence in court. Gettler and Freireich reported that the alcohol content of the blood is in the majority of cases either higher or lower than that found in the brain. Since the alcohol content of the expired air, urine, and saliva depends upon the alcohol content of the blood, it is evident that the former also do not run parallel with the alcohol content of the brain. Any study of intoxication must take into consideration the quantity of alcohol in the brain, since it is the alcohol in that organ that determines the state of inebriety. Very little experimental work, - ' has been done on the relationship of the alcoholic content of the brain and intoxication. Most of the investigations consisted in observing the behavior of subjects and correlating their physiologic abnormalities with the quantity of alcohol in their blood, urine, saliva or expired air. Newman,6 even goes so far as to propose an arbitrary scale of nine stages of drunkenness in dogs which he states, "can be judged with a fair degree of certainty." He then attempts to correlate blood alcohol values with the different stages of this bizarre scale. The purpose of the experiments here presented was to get additional data concerning the relation between the alcohol content of the brain and that of the blood. EXPERIMENTAL 8 dogs weighing between 6 and 0 kg. were used. The animals received no food or fluids for hours preceding the experiment. Their weight was noted and they were given measured quantities of 9. per cent (by weight) alcohol by stomach tube. The total quantity of alcohol given each dog, in grams per kilogram of body weight, is indicated in table. Dogs 0, 6, 8, and 9 were given 00 ml. of olive oil by stomach tube, just before the alcohol was administered. The exact time of insertion of the alcohol into the stomach was noted and the dogs were allowed to live for intervals varying from minutes to 0 minutes (6 hours, 0 minutes), after receiving the alcohol. The animals were sacrificed by placing them in a chamber of illuminating gas. Immediately after death the brain and a specimen of blood from the heart were analyzed for their alcoholic content by the method of Gettler and Tiber, and of Gettler and Freireich, respectively. The results of the analyses are listed in table. The analytical results, charted in table, confirm the findings of Gettler and Freireich that the blood alcohol may be from per cent to 09 per cent of the 6 Downloaded from https://academic.oup.com/ajcp/article-abstract///6/600 on December 0

66 A. O. GETTLER, A. W. FREIREICH AND H. SCHWARTZ brain alcohol. In only three of the dogs (,,) of the entire series did the blood alcohol correspond with the brain alcohol. In the other dogs (90 per cent of the series) the blood alcohol was higher or lower than the brain alcohol. The blood-brain ratios varied from 0.:.0 to..09:.0. It will be observed that in only four of the dogs w r as the blood alcohol less than the brain alcohol. The TABLE ALCOHOLIC CONTENT OF BRAIN AND OP BLOOD AFTER THE ADMINISTRATION OF DEFINITE QUANTITIES OF ALCOHOL DOG AMOUNT OF ALCOHOL OIVEN DURATION BLOOD ALCOHOL BRAIN ALCOHOL BLOOD-BRAIN RATIO 6 S 9 0 6 8 9 0 6 8 gms./kg. min. 8 68 0 8 6 0 6 8 0 8 9 0 60 0 89 0 0 Wt.% 0.090 0.09 0.0 0.0 0.06 0.9 0. 0. 0.068 0.068 0.0 0. 0. 0.0 0.96 0. 0.68 0.8 0.8 0.0 0. 0. 0.6 0.9 0.6 0. 0.8 0.9 Wl.% 0.080 0.09 0.0 0.0 0.0 0.098 0.8 0. 0.060 0.060. 0. 0.80 0.0 0.99 0.6 0.06 0.8 0.9 0.9 0. 0. 0.0 0.8 0.0 0.6 0.6 0.8 0.8..6.0..09. 0. 0.9.....6.0..0 0.9.....86..8 0.98... reason for this lies in the fact that most of our series of dogs were in the absorption stage when the animals were sacrificed. Ellerbrook and Van Gaasbeck obtained blood-brain ratios in human subjects varying from 0.88:.0 to.:.0 and concluded that the blood alcohol is a good index of intoxication. We agree with this statement provided the individual is definitely drunk, having a blood alcohol of the order of 0.0 per cent. In such a case the brain alcohol could be anywhere between 0.6 per cent and 0.9 per cent, and using either the low or high figure, it can be safely stated that a condi- Downloaded from https://academic.oup.com/ajcp/article-abstract///6/600 on December 0

BLOOD ALCOHOL 6 tion of inebriety existed. It is in the border line cases where difficulties present themselves. Some of our courts accept 0. per cent or more of alcohol in the blood as prima facie evidence of intoxication. Should the blood alcohol be found to be 0. per cent, the brain alcohol, using Ellerbrook and Van Gaasbeck's blood-brain ratios, could be anywhere between 0. and 0.9 per cent. Here it would be impossible to state whether the individual was, according to law, intoxicated or not. Using our blood-brain ratio range of 0. to.09, a case having an 0. per cent blood alcohol, may have an alcoholic content of the brain anywhere from 0. to 0. per cent. Therefore, a person having an 0. per cent blood alcohol may or may not be intoxicated according to this law. URINE ALCOHOL AS AN INDEX OF INTOXICATION Many law enforcement agencies are using the alcohol content of the urine as an index of intoxication. The concentration of alcohol in the urine is primarily dependent on the amount present in the blood reaching the renal arteries. In the kidneys the alcohol is filtered through the glomeruli together with the other non-protein substances. An analysis of the glomerular filtrate may show a similar concentration of alcohol as in the blood. However, nothing is known of the fate of the alcohol in its passage through the tubules, whether it is treated as a threshold substance and is reabsorbed, or to what extent it may be a nonthreshold substance. That it is not a completely nonthreshold substance is evident from the ratios obtained, the figures for the urine-blood ratio ranging from.0:.0 to as high as.:.0. In practically all reported cases the urine alcohol content is much higher than that of the blood. This suggests the possibility that the tubules may actively secrete some alcohol, thereby increasing the alcohol concentration of the urine. The alcohol content of the urine on reaching the bladder is subject to further changes. The diluting effect from urine already in the bladder at onset of drinking is self-evident. Lowering of the alcohol content of bladder urine by urine secreted in the postabsorption stage may also occur. It has also been suggested that the bladder mucosa may reabsorb some of the alcohol from the urine. Experimental observations of the relationship between the urine and blood alcohol content have yielded marked variations. Jetter 8 obtained an average urine-venous blood ratio of.:.0 with values ranging from.0:.0 to.:.0. Mozes and Katonak 9 report an average of.6:.0 with a range of 0.6:.0 to.:.0 and Ellerbrook and Van Gaasbeck an average of.6:.0 with a range of 0.69:.0 to.:.0. Although the average urine-blood ratios of various investigators agree quite well, we find that the range of the ratios show marked variations. We are of the opinion that it is erroneous to use averages when confronted with the problem of determining whether a certain specific person is intoxicated or not. The analytical results of various investigators indicate that there is a decided lack of constancy in the urine-blood ratios. Adding to this the variability shown by us in the blood-brain ratio, one must conclude that it is practically Downloaded from https://academic.oup.com/ajcp/article-abstract///6/600 on December 0

68 A. O. GETTLER, A. W. FREIREICH AND H. SCHWARTZ impossible to come to any decision as to the state of intoxication of an individual from a urine alcohol in the border line cases. If the alcoholic content of the urine and the blood is very high, then of course no doubt exists as to the inebriety. BREATH ALCOHOL AS AN INDEX OF INTOXICATION Any alcohol present in the expired air which is not due to contamination from the mucosal surfaces in the mouth and pharynx is entirely dependent on the alcohol content of the blood in the pulmonary arteries. If a definite correlation between the alcohol content of the blood and the alveolar air (even if based on the CO content) could be shown to exist, then the breath alcohol would merely be subject to the same error as that which we have shown in the blood-brain ratio. There is, however, at the present time, no means of ascertaining definitely such a correlation. Bogen 0 and Harger based their results on the assumption that 000 cc. of alevolar air contained a similar amount of alcohol as cc. of blood. On the other hand, Haggard and his associates claim that 00 cc. of alveolar air contain an amount of alcohol equal to that in cc. of blood. SALIVA ALCOHOL AS AN INDEX OF INTOXICATION That alcohol appears in the saliva of people who have been drinking is an accepted fact. The amount of alcohol in the saliva is dependent on the concentration of alcohol in the blood reaching the salivary glands, but what percentage of that alcohol will be secreted together with the salivary excretion is not known. Moreover, what we call saliva is a mixture of secretions of several glands. Which of these secrete the alcohol and to what extent has not been demonstrated. Grave errors may result in attempting to draw conclusions as to the sobriety of a suspect from a saliva alcohol determination. Previous investigators have used the alcohol content of the blood as a criterion for the degree of intoxication, based on observations of the behavior of a series of humans and of animals with varying amounts of alcohol in the blood. The majority of them conclude that definite blood alcohol concentrations in all persons indicate a definite state of intoxication. We have shown that there is no definite correlation between the amount of alcohol in the brain and that in the blood. If we were to accept the blood alcohol as a criterion of intoxication, then we would have to conclude that the quantity of alcohol in the brain has no bearing on the mental faculties involving coordination and judgment. This is an absurdity. SUMMARY. The present study reveals the fact and corroborates the findings reported by Gettler and Freireich on human subjects that the alcohol content of the blood, at any given time, in 90 per cent of the cases, differs appreciably from the alcohol content of the brain, the blood-brain ratio ranging from 0. to.09.. It is fallacious to take an average of a number of blood-brain ratios and because this average ratio approaches unity, conclude that the alcohol content Downloaded from https://academic.oup.com/ajcp/article-abstract///6/600 on December 0

BLOOD ALCOHOL 69 of the brain and of the blood is the same in any particular individual at any given time. The blood-brain alcohol ratio in any particular subject may vary widely from any accepted average.. In border line cases (0. per cent blood alcohol) it is impossible to definitely state, from the alcoholic content of the blood, whether the subject was intoxicated or not.. Since the alcohol content of urine, saliva and expired air depends in part on the alcohol content of the blood, it is equally fallacious to use them as an index of intoxication in the border line cases. () GETTLER, A. O., AND FBEIREICH, A. W.: Determination of Alcoholic intoxication during life by spinal fluid analysis. J. Biol. Chem., 9: 99, 9. () GETTLER, A. O. AND TIBER, A.: The quantitative determination of ethyl alcohol in human tissues. Arch. Path., :, 9. () HARGER, R. N., HULPIEN, H. R., AND LAMB, E. B.: The speed with which various parts of the body reach equilibrium in the storage of alcohol. J. Biol. Chem., 0: 689, 9. () ELLERBROOK, L. D., AND VAN GAAS- BECK, C. B.: The reliability of chemical tests for alcohol intoxication: The importance of the selection of proper material for analysis. J. A. M. A., : 996, 9. () NEWMAN, H. W., AND CARD, J.: Duration of acquired tolerance to ethyl alcohol. J. Pharmacol. & Exper. Therap., 69: 9,96. (6) NEWMAN, H. W.: Acquired tolerance REFERENCES to ethyl alcohol. Quarterly J. of Studies on Alcohol, :, 9. () Vehicle and Traffic Law, New York State, Section 0, Subdivision, amended by Laws of 9, Chap. 6. (8) JETTER, W. W.: Studies in alcohol: I. The diagnosis of acute alcoholic intoxication by a correlation of clinical and chemical findings. Am. J.M.Sc, 96:,98. (9) MOZES, E. B., AND KATONAK, L. J.: One hundred drunken drivers. Ohio State M. J., :, 9. (0) BOGEN, E.: Drunkenness: A quantitative study of acute alcoholic intoxication. J. A. M. A., 89: 0, 9. () HARGER, R. N., LAMB, E. B., AND HUL- PIEU, H. R.: A rapid chemical test for intoxication employing breath. J. A. M. A., 0: 9, 98. () HAGGARD, H. W., GREENBERG, L. A., AND MILLER, D. P.: The alcohol content of lung air as an index of alcohol in the blood. J. Lab. & Clin. Med., 6:, 9. Downloaded from https://academic.oup.com/ajcp/article-abstract///6/600 on December 0