Forensic Toxicology in

Postmortem Investigations
Tech Com: by Alphonse Poklis, Ph.D., D.A.B.F.T.
Toxicology

Simply stated, toxicology is the study of poisons Case 1

and concentrates on the chemical and physical
A man was f o u n d dead in bed w i t h an e m p t y pint bottle of
properties of toxic substances. The 16th century l i q u i d p h e n o l next to h i m . Corrosive burns were noticed on the
physician, Paracelsus, suggested that: "All substances face, a r o u n d the m o u t h and on the hands. It was assumed that
are poisons; there is none which is not a poison. The death was due to suicidal ingestion of p h e n o l . Toxicologic
right dose differentiates a poison from a remedy." analysis demonstrated the presence of a large a m o u n t of p h e n o l
in the s t o m a c h ; however, the brain, b l o o d and liver analyses
Today, toxicology has been expanded to include gave negative results, indicating that the poison had been
administered after the man was dead. Subsequent investigation
a diverse range of interests including evaluation of
revealed that the man's wife had a secret lover. The lover had
the risks involved in the use of food additives, suffocated the husband w i t h a p i l l o w ; t h e n lover and w i f e , w i t h the
pesticides and cosmetics, and studies concerned aid of the t u b i n g f r o m an enema bag, had p o u r e d the p h e n o l
with occupational poisonings, environmental pollu- d o w n the esophagus and into the stomach of the dead m a n . '
t i o n , the effects of radiation, and biological and
chemical warfare. However, it is the forensic toxi- Case 2
cologist w h o has held the title of toxicologist for
A policeman patroling the waterfront noticed a man w i t h a large
the longest period of time. b u n d l e , about to t h r o w it into the river. U p o n o p e n i n g the b u n d l e ,
the officer discovered the torso of a w o m a n . The head, arms and
The complete investigation of the cause or causes legs were missing. They w e r e discovered d u r i n g the next few days
of sudden death is an important civic responsibility. in various parts of the city. The man was held for q u e s t i o n i n g at
Establishing the cause of death rests with the medical the district police station. The suspect t o l d the f o l l o w i n g story:
examiner, coroner or pathologist, but success in The w o m a n was his c o m m o n - l a w w i f e . They had been d r i n k i n g
arriving at the correct conclusion frequently is and had q u a r r e l e d . He then left the house. O n returning the
next m o r n i n g , he f o u n d his wife dead on the floor. He was afraid
dependent upon the combined efforts of the pa-
that the police w o u l d charge him w i t h m u r d e r , so he d i s m e m b e r e d
thologist and the toxicologist. The cause of death in her and was attempting to dispose of the remains w h e n the
cases of poisoning cannot be proven beyond con- officer a p p r e h e n d e d h i m .
tention without toxicologic analysis which establishes
M e a n w h i l e , neighbors living in the same house discovered that
the presence of the toxicant in the tissues and body illuminating gas was c o m i n g f r o m the r o o m in w h i c h the t w o lived.
fluids of the deceased. Investigation disclosed that a coffee pot on the gas stove had
boiled over, p u t t i n g out the gas flame. The gas filled the r o o m .
Many drugs or poisons do not produce any Toxicologic analyses of the wife's b l o o d gave a 63% carbon
characteristic pathologic lesions, and their presence m o n o x i d e saturation, and analysis of the brain showed an ethanol
concentration of 0.35% indicating alcohol intoxication. The man
in the body can be demonstrated only by chemical
was evidently telling the t r u t h . The w o m a n was intoxicated, and in
methods of isolation and identification. If toxicologic trying to make some coffee, had not noticed that it had boiled over
analyses are avoided, deaths due to poisoning may and extinguished the flame. She was then o v e r c o m e by carbon
be erroneously ascribed to some entirely different m o n o x i d e and collapsed. The man was cleared of the m u r d e r
cause, or poisonings may be designated as the cause charge but was held for d i s m e m b e r i n g a h u m a n body. 2

of death w i t h o u t any definite proof. Such erroneous

Often the toxicologist is able to furnish valuable
diagnoses may have significant legal and social con-
evidence concerning the circumstances surrounding
sequences as illustrated by the following cases.
a death by demonstrating the presence of ethanol in
victims of automotive or industrial accidents, or the
Alphonse Poklis, Ph.D., D.A.B.F.T., is Assistant Professor in
Forensic and Environmental Toxicology, Department of Pathology, presence of carbon monoxide in fire victims. The
at St. Louis University School of Medicine, St. Louis, Missouri. degree of carbon monoxide saturation of the blood

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 may indicate whether the deceased died as a result crystalline tetrahydrocannabinol (THC) are generally
of the burns or was dead before the fire started, since f o u n d to be lysergic acid diethylamide (LSD) or
arson is c o m m o n l y used to conceal homicide. A phencyclidine (PCP). The latter, PCP, has played an
poorly understood exception to this rule are the increasingly significant role in automotive accidents
victims of flash fires. 3 Licit or illicit psychoactive and has caused a number of deaths due to fatal
drugs also can play a significant role in the circum- intoxications. The recent death of a young man in the
stances associated w i t h sudden or violent death. metropolitan St. Louis area as a result of fatal intoxica-
tion with a rare hallucinogenic amphetamine deriva-
At times, a negative toxicologic finding is of
tive, methylenedioxyamphetamine (MDA), d e m o n -
particular importance in assessing the cause of death,
strates the dangers of misrepresentation in the illicit
as in the next case.
drug market. The victim believed he was ingesting
a mixture of LSD, morphine and amphetamine. If not
Case 3 consumed in large doses, it is doubtful that ingestion
A man living in a small t o w n o n the border of one state had an of this mixture w o u l d have led to a fatal outcome.
illegitimate son by a w o m a n w h o lived in the a d j o i n i n g state.
The w o m a n ' s m o t h e r requested that the man marry her daughter Prior knowledge of medically administered drugs
or at least support the c h i l d . He agreed to support the child and left can save the toxicology laboratory a great deal of
w i t h the baby. T w o weeks later the baby was f o u n d floating in a
t i m e , effort and expense, as exemplified in the
nearby river. The man was taken into custody, and w h e n questioned
he admitted that he killed the c h i l d . He stated that he had put the following case.
infant into a bag containing rags soaked w i t h c h l o r o f o r m ,
placed the sack in the back of his vehicle and driven toward his
h o m e across the state border. He said he d i d not k n o w w h e n the
Case 4
child actually d i e d . The man was well versed in matters of criminal
A man r e t u r n i n g f r o m a business trip discovered his w i f e in bed
law, for a defendant must be tried in the state w h e r e the m u r d e r
w i t h another man. A quarrel broke out between the t w o m e n , and
is c o m m i t t e d .
although the exact sequence of events is u n k n o w n , the husband
An autopsy was p e r f o r m e d and the organs sent to a toxicologist. shot the o t h e r man. The wife's lover was reported t o be a f r e q u e n t
No c h l o r o f o r m was detected in any of the organs. Particular user of cocaine. W h e t h e r or not he was under the influence of
attention was given to the brain since this organ absorbs most the d r u g at the time of the shooting was to be a significant factor
readily and w o u l d retain, for many months after d e a t h , any in the legal p r o c e e d i n g of the case. The initial analysis of the
c h l o r o f o r m that may have been administered. Marks of violence fluids and tissues of the deceased failed to disclose the presence
were f o u n d on the neck and face of the c h i l d . C o n f r o n t e d by of cocaine; however, lidocaine was detected in the b l o o d . O f t e n
this evidence the man admitted that he killed the baby by other local anesthetics such as procaine or lidocaine are used to
strangulation and t o l d w h e r e he c o m m i t t e d the murder. 2 " c u t " illicit cocaine. As a result of this f i n d i n g , all analyses were
repeated w i t h the utmost care. Again negative results for cocaine
or benzoylecgonine w e r e o b t a i n e d . Later it was learned that the
Investigation Prior to Analysis lidocaine had been administered in the emergency r o o m of a
local hospital just prior to the man's death.
Before starting a toxicologic analysis, the toxicolo-
gist should have the following i n f o r m a t i o n : age, sex
and weight of the deceased; the approximate time of Specimens and their Collection
ingestion or exposure to the toxicant; prior drug use
by the deceased; and, if applicable, any symptoms Probably no other area causes as much disturbance
displayed prior to death or medications administered to the smooth w o r k i n g relationship between the
by professional personnel d u r i n g treatment for the pathologist and toxicologist as the type and quantity
intoxication. It should be kept in mind that unless of specimen collected and submitted for analysis.
empty prescription vials or containers of toxic ma- Often the quality and quantity of such specimens
terial are f o u n d in close proximity to the patient, vary tremendously in similar cases. In a medical
clinical symptoms prior to death are seldom indica- examiner's office where autopsies and toxologic
tive of intoxication. A recent review of clinical im- testing are performed in the same building, problems
pressions of intoxicated patients compared to labora- of this nature can be dealt with easily. However,
tory findings revealed that in only 59%of the cases, there seems to be an inverse relationship between
were the drugs suspected f o u n d . 4 In 35% of these the quality of specimens and the distance between
cases, additional drugs were present. In 39% of the the autopsy and the laboratory, which often cripples
cases, drugs other than those suspected of inducing the effectiveness of state coroner or medical
the observed intoxication were present. In only 2% examiner systems where specimens are sent to a
of the cases were drugs or toxicants not detected. central laboratory for examination. An all too
c o m m o n request to "examine for the presence of all
It must also be kept in mind that illicit drug drugs and poisons" when only 10 ml of blood is
preparations are notorious for containing ingredients supplied is an unreasonable request, usually the
other than those they are reputed to contain. Many result of poor communication between the patholo-
powders or preparations sold as mescaline or gist and toxicologist. The only solution to this

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 problem revolves around more effective and exten- The tungstic acid and direct extraction methods
sive communication between the parties involved. are useful for barbiturate analysis, but the yield of
many basic drugs (e.g., imipramine, amitriptyline)
The need for diversity in sources of sample
is poor. Direct extraction is particularly unsuited for
collection (blood, urine, bile, liver, brain) is due to
extracting drugs which form conjugated metabolites
toxicokinetic factors. Drugs and other toxicants
such as morphine, amitriptyline and phenylbutazone.
display varying affinities for body tissues and fluids.
This renders some specimens particularly useful for A m m o n i u m sulfate may be effective for the extrac-
the detection of certain toxicants while other speci- tion of basic drugs but is not applicable to the
mens may be of no value. After an injection of analysis of barbiturates or other acidic drugs.
heroin, the drug is rapidly biotransformed to
Acid digestion is excellent for the extraction of
morphine which clears the blood rapidly, is con-
protein-bound or conjugated drugs, such as pheno-
jugated in the liver and rapidly excreted in the bile.
thiazines, imipramine, quinine and m o r p h i n e ; how-
Small amounts of both free and conjugated mor-
ever, the method causes hydrolysis or decomposition
phine may be excreted in the urine. Therefore, blood
of many other drugs, such as cocaine, bella-
is of little value in postmortem screening pro-
donna alkaloids, benzodiazepines and propoxy-
cedures to determine morphine or heroin use. Urine
phene. Each of these methods must also be
may be useful, but bile is certainly the specimen
evaluated for the propensity of the extracting sol-
of choice.
vents to form emulsions with tissue components,
the amount of natural body constituents co-extracted
Case 5 with the toxicant, and other physical and chemical
Two y o u n g men burglarized a veterinarian's office and stole parameters. Hence, the toxicologist must use a
many medicinal preparations. The next evening one of the men complex and often time-consuming approach to
was f o u n d dead in a motel r o o m . The body was sitting in a
what seems at first glance a simple p r o b l e m :
chair, vomit covered the front of the deceased, and on the floor
next to the chair was an empty syringe and a half-empty vial of
removal of drugs from the liver.
Innovar V e t " " . Innovar"", an intravenous anesthetic, contains a
mixture of fentanyl and d r o p e r i d o l . The veterinary product
The pathologist w h o performs the medicolegal
contains about 20 times the dose per milliliter than that used in autopsy has the primary responsibility for the collec-
human surgical procedures. No autopsy was p e r f o r m e d . The tion and preservation of proper samples for toxico-
coroner sent the f o l l o w i n g items to the state toxicology labora- logic analysis. Specimens necessary for complete
t o r y : the vial of Innovar V e t " " , v o m i t , t w o milliliters of b l o o d , and toxicologic analysis are presented in Table I. In
all clothes f r o m the deceased, as well as several empty bottles of
certain instances, additional specimens may be
soft drinks, a half-empty bottle of whiskey, a sleeping bag,
several o p e n e d bags of snack f o o d and a glass f r o m the motel needed, such as hair or bone in suspected chronic
r o o m . Because of an insufficient quantity of body fluid samples, poisoning from metallic compounds.
the laboratory was able to establish only that the vial contained
Innovar V e t " " and that the deceased contained no detectable Each individual specimen should be placed in a
amount of a l c o h o l . separate container. Glass jars with screw tops (Mason
jars) are most useful for tissue, although sealed
A large quantity of sample is necessary for thorough
plastic bags are acceptable. Specimens should be
toxicologic analysis, because a procedure which
taken prior to embalming, as this process may
extracts or identifies one c o m p o u n d or class of
destroy or dilute the toxicants present and render
compounds may be ineffective in extracting or
their detection impossible. While many toxicants
identifying another. An appreciation of this problem
may be detectable in embalmed tissue, evaluation of
may be obtained by briefly reviewing the toxicologic
the quantitative results of analysis is difficult or
approach to the analysis of the liver in the "general
impossible.
u n k n o w n " case.
Sodium fluoride should be added to one tube of
There are generally five major methods of drug
blood intended for the analysis of ethanol, carbon
extraction from liver specimens: 1) Stas-Otto, 2)
monoxide and sugars. No preservative should be
tungstic acid, 3) ammonium sulfate, 4) acid digestion,
added to the tissue specimens. Blood and urine
and 5) direct extraction. The Stas-Otto method was
samples should be kept refrigerated and tissue speci-
developed before the turn of the century and is based
mens frozen. If the specimens are to be transported
on the ability of acidified ethanol to precipitate pro-
over a considerable distance to the laboratory, they
tein and simultaneously dissolve or extract alkaloidal
should be packaged with dry ice. If not shipped in
poisons. The method produces good recoveries of
dry ice, the putrefication of the samples may greatly
basic drugs (e.g., quinine, codeine, strychnine), but
hinder the toxicologic analysis.
recoveries of acidic drugs such as barbiturates are
very poor. The procedure takes several days to pro- The pathologist should label each container and
duce a final extract.
the identification should bear the date and time of

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 autopsy, the name of the decedent, the identity of
Table I—Specimens Necessary in Cases Requiring
the sample and the signature of the pathologist. It is A Complete Toxicologic Analysis
imperative that an adequate chain of custody of the
specimens submitted to the laboratory is maintained. 1. Blood Samples: Preferably two separate samples should
be submitted.
In most jurisdictions, blood is the sample com- a. Sample with no preservative: about 100 milliliters
monly chosen for analysis in legal medical cases, (3 oz).
particularly for ethanol determinations. If no autopsy b. Sample with preservative (sodium fluoride): oneortwo
tubes (15 milliliters) for alcohol and carbon monoxide.
is performed, blood is often obtained from the heart
by puncturing the chest wall with a long needle. 2 Urine Sample
a. One tube with preservative (sodium fluoride).
Erroneously high ethanol levels may result from this b. The total remaining urine with no preservative.
manner of sample collection if the needle nicks the
3 Stomach and Contents
esophagus or if internal injury has ruptured the
4. Liver Sample: about one half to two thirds of the total
stomach and diaphragm, resulting in a bathing of the
weight.
thoracic cavity with gastric contents. When no
5. Bile Sample: complete amount available.
autopsy is performed, blood drawn from the femoral
vein or cerebrospinal fluid taken from the cisterna 6. Brain Sample: about one half of the total weight.
magna is preferable. 7. Kidney Sample: one whole organ.
8. Sample of wash water used to rinse the containers
At autopsy, blood is usually obtained from the (homicides).
heart. The heart should be gently massaged before 9. Miscellaneous: Other tissues which may be available
taking the sample in order to promote mixing of the (cerebrospinal fluid, lung, heart, spleen, vitreous humor).
blood in the chambers. A high or low hematocrit may
lead t o erroneously high or low ethanol results.
Ethanol is distributed in the body according to the an understanding of the chemical basis of the pro-
water content of the tissues and fluids. Therefore, cedures used to perform toxicologic analyses.
plasma contains about 10% more ethanol than whole
b l o o d . In cases of suspected ethanol intoxication, the Use of Toxicology Results
brain may be considered preferable to blood for
analysis since there is less chance of contamination, To best utilize the results of toxicologic analysis,
and the physiological effects of ethanol are due to its the pathologist should familiarize himself with the
action on the central nervous system. capabilities of the toxicology laboratory. While the
pathologist is knowledgable concerning the meaning
Source of Misunderstanding of the results of toxicologic analysis for barbiturates,
carbon monoxide, ethanol and other c o m m o n
A major source of misunderstanding about the
toxicants, he may find the toxicologist a valuable
toxicologists' specimen needs is related to the
information source on less frequently encountered
advances in instrumentation and automation in the
toxicants, and time-exposure or dose-tissue level
routine clinical chemistry laboratory. A physician
relationships. In 1975, the American Board of
may submit several milliliters of serum t o the clinical
Forensic Toxicology was created t o examine and
laboratory and within a few hours have the results of
certify forensic toxicologists. O n e of the stated
a dozen analyses. This is often not the case in post-
objectives of the board is " t o make available t o the
mortem toxicology. It must be remembered that the
judicial system, and other publics, a practical and
clinical chemist is analyzing for naturally occurring
equitable system for readily identifying those per-
compounds known to be present, usually in high
sons professing to be specialists in forensic toxi-
concentrations. Many of these analyses involve the
cology w h o possess the requisite qualifications
measurement of enzyme activity which requires only
and competence." Thus the concerned pathologist
minute specimen quantities. The procedures are
may assess the toxicologist's qualifications by in-
generally automated, specific and easy t o perform.
quiring about the toxicologist's certifications.
However, there are no such automated, specific
procedures for identifying or accurately differ- It is imperative that postmortem toxicologic
entiating the thousands of drugs or toxicants which analyses be performed or directly supervised by
may cause or contribute to death. Toxic levels of qualified forensic toxicologists, since the patholo-
toxicants in postmortem specimens may be ex- gist's evaluation and final diagnosis may be d o m i -
tremely l o w ; this may be due to the high degree of nated by the toxicology report. Too often, important
toxicity of some compounds or the biotransforma- and complicated analyses are performed by labora-
tion of toxicants which d o not cause death i m - tory technicians or qualified chemists with little, if
mediately and are metabolized before the termina- any, understanding of the problems associated with
tion of life occurs. Thus the toxicologist must have forensic toxicology.

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 Case 6 case involving co-ingestion of alcohol and diazepam,
The body of a y o u n g soldier, reported A W O L , was discovered the former laboratory w o u l d report concentrations
in a d e c o m p o s e d c o n d i t i o n beneath a b u i l d i n g . The tissues were of diazepam, nordiazepam and other metabolites.
sent to an "analyst" w h o reported that they contained a large The latter laboratory w o u l d only report diazepam
amount of a m p h e t a m i n e . The analyst had p e r f o r m e d a Beyer- levels. The spectrophotometric method used by the
Skinner chemical test and recorded an ultraviolet spectrum of a
latter w o u l d have measured the parent drug and all
basic extract. These tests were the basis of his " i d e n t i f i c a t i o n of
a m p h e t a m i n e . " The pathologist, f r o m this f i n d i n g , suggested its metabolites as diazepam. Hence, the diazepam
amphetamine poisoning as the cause of death. O n the basis of this level obtained from the first laboratory w o u l d be
report, an intensive investigation was started to d e t e r m i n e h o w much lower than that obtained from the second
the deceased obtained the d r u g and w h e t h e r or not he was a laboratory. Therefore, it is imperative to consider the
k n o w n a m p h e t a m i n e user. M e a n w h i l e , portions of the tissue were
" m e t h o d o l o g y factor" before interpreting the toxi-
properly analyzed by a toxicologist w h o identified the " a m p h e t a -
m i n e " as phenylethylamine, a c o m m o n c o m p o n e n t of putrefied
cology results.
tissue. The b o d y of the dead man, in fact, contained no drugs.
Phenylethylamine, f o r m e d d u r i n g d e c o m p o s i t i o n by decarboxyla- Summary
t i o n of phenylalanine, gives a positive Beyer-Skinner reaction and
has the same ultraviolet spectrum as amphetamine. 5
The success or failure of the forensic toxicolo-
gist in detecting toxicants which may have con-
The pathologist should also inquire as to the tributed to death is often dependent not only on
general "detection limits" of the procedures used in his own abilities, but on the completeness of the
the laboratory. The analytical methods used in investigation of the circumstances of death and the
toxicology often vary between laboratories and will specimens which are p r o v i d e d . A l t h o u g h the
greatly influence the reported results. forensic toxicologist often works w i t h the dead, he
stands in service to the living.
A laboratory using electron-capture gas chroma-
tography as a screening procedure for benzodiaze-
References
pines will detect "therapeutic levels" of this drug
in many cases. However, a laboratory analyzing for 1. Freimuth, H.C., Personal Communication.
2. Gettler, A.O., 1956. The Historical Development of Toxicology. J,
the same compounds by ultraviolet spectropho- Forens. Sci. 1:3.
tometry will detect only potentially toxic levels. This 3. Hirsch. C S . et al., 1977. Carboxyhemoglobin Concentrations in
variance in analytical capability has a direct effect Flash Fire Victims. Am. J. Clin. Pathol. 68:317.
4. Teitelbaum, D.T., et al.. 1977. Nonconcordance between Clinical
on the reported involvement of drugs or toxicants in Impression and Laboratory Findings in Clinical Toxicology. Clin.
a sudden death. Toxicol. 10:417
5. Goldbaum. L.R., et al., 1963. The Practice of Identification in Analytical
For example, using the laboratories above and a Toxicology. J. Forens. Sci. 8:286.

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