Forensic Science, 7 (1976) 31-40 0 Elsevier Sequoia S.A., Lausanne - Printed in the Netherlands
DEATHS RESULTING G. MCLLHOFF
31
FROM DRUGS OF ABUSE*
and Gg. SCHMIDT
Institute of Forensic Medicine, Heidelberg (Received November 10,1975;
University (F.R.G.)
accepted January 8, 1976)
SUMMARY This report covers 40 narcotics fatalities from the Northbaden area (Federal Republic of Germany) that came to the Institute of Forensic Medicine, Heidelberg University for autopsy in the years of 1968-1973. Information is given on pathological anatomic and toxicologic findings. A biographical, sociological, psychiatric and criminological catamnesis gave important insight in determinants, motivations, development and course of drug dependence in this area. Basic details are shown and critically evaluated.
INTRODUCTION
In 1966, the drug wave already apparent in U.S.A. and Scandinavia arrived in the Federal Republic. From 1968 to 1973, there was a constant increase in this particular form of 20th Century epidemic [l, 6, 11, 16, 17, 391. Since 1974 the number of new addictions has decreased and there is a slight decreasing tendency in the consumption of mild drugs, in particular in respect to the cannabis group. However, the core of the consumers of hard drugs increases constantly. According to estimates the Federal Republic has a total of 20 000 declared opiate addicts to be taken into account, and approximately 200 000 seriously endangered individuals. In BadenWuerttemberg alone the number of “risks” is estimated at 30 000. The North Baden area with nearly two million inhabitants (Heidelberg-Mannheim-Karlsruhe), due to its geographical situation and tourist attraction soon became a center of the drug wave. The concentration of juveniles in the university cities was certainly a decisive factor. Since 1972, an intensity of heroin, cocaine and LSD transactions was noted. Additionally in correlation, there was a clearly marked increase of violent crime in the surroundings of the dealers. At the present, there are 300 individuals in Heidelberg alone who are to be classified as addicts and therefore most endangered individuals. This apparent epidemic - and from the view point of forensic medicine, critical situation - was reason to investigate the motives, development and consequences of this development in the border areas of this scene. *Paper presented at the Seventh International September 8-12, 1975.
Meeting of Forensic
Sciences, Zurich,
32 MATERIAL
AND METHODS
We report on 40 narcotics fatalities from the years of 1968 to 1973 that were examined in our institute in a pathological, anatomic and toxicological respect. To widen our view, court files, medical records and all available personal notes of the deceased were exploited. The course of the disease was discussed with the attending physicians; and the family background was explored in detail. We defined a narcotic fatality as an incident with direct or indirect correlation between the long standing use of substances within the meaning of the narcotics law, ensuing drug dependence and death.
PATHOLOGICAL
AND ANATOMIC RESULTS
All 40 drug fatalities were physically weakened and undernourished at the time of death. The group of the “fixers” (group I) showed great negligence (scabies, pediculi pubis, capitis et vestimentorum, pyodermia, pollution, etc. ). The “pill addicts” (Group II) showed numerous hematomae at the extremities and at the trunk, there were emphatic symptoms of toxically conditioned coordination disorders as seen predominantly among barbiturate -and bromcarbamide dependent individuals. The pathological and anatomic diagnosis is shown in Tables I, II and III. At this point, it should be mentioned at least briefly that we were able to prove the pulmonary findings of Duberstein and Kaufmann, Siegel and Bleistein and other workers [4, 13, 34, 351 by means of this material. The condition of the gastro-intestinal tract was analogous to that described by Baden and others. Brain damages as described by Strassmann et al. were present rather distinctly in some cases. We did not find extensive cerebro-
TABLE I The pathological and anatomic diagnosis of Group I (“fixers”) Cause of death and anatomic findings
Number of cases -
Central respiratory and circulatory asphyxia Death by asphyxia, aspiration of thyme Endocarditis tricuspidalis, pneumonia, pulmonary infarction and pulmonary abscess Acute failure of the left ventricle, chronic fibroid myocarditis, pulmonary oedema Acute pneumonia resulting in heart and circulatory failure Bleeding to death from stabbing into the heart with scissors Death by hanging Poisoning resulting in failure of the right ventricle Traffic accident: asphyxia involving bilateral pneumothorax and bleeding to death
11 2 1 1 1 1 1 1 1
33 TABLE II The pathological and anatomic diagnosis of Group II (pill addicts) Cause of death and anatomic findings
Number of cases
Toxic heart and circulatory failure involving central asphyxia Death by drowning in bath following ingestion of barbiturates Poisoning by E-605 (organophosphorus compound) Death by hanging
15 1 1 1
TABLE III The pathological and anatomic diagnosis of Group III (other drugs) Number of cases
Cause of death and anatomic findings Acute heart failure following trichloroethylene Presumed intoxication by tablets
poisoning
1 1
atrophical processes, in particular in the area of the third ventricle, as mentioned by Fliegen and Zerssen. Enlargements of the lymphatic ganglion were found in particular in the regional outlet of paravenous injections with diffuse lymphocyterian or hyperplastic changes of the germ centers. Toxicologic
examination
(see also, refs. 2, 15, 22, 23, 31, 32)
This revealed in all cases involving the “pill addicts” clear indication of the preparation used in a particular case in respect to quantity and quality. The proof of opiates in part was negative as to the fixers for the known reason that it is hard to proof opiates postmortem in blood or organs. The attribution to this group was made on the anamnesis, fresh and old injection marks that were proven as well as the other autopsy findings. Distribution
of age and sex
The 20 persons in Group I were of an average age of 22 years and 4 months and only 2 of them were married. The ratio between men and women was 13:7. Of the 18 cases in Group II 5 died between 16 and 27 years of age, 4 between 32 and 39 years of age, and 9 between 44 and 58 years. The ratio of the sexes was 4:16 male:female and 8 of the women were married. Altogether, two thirds of all patients did not reach their 29th year, among them two 16 year olds and one 17 year old. The 2 cases in Group III consisted of 2 young men who had practiced “sniffing” and abused hashish and LSD.
34
Sociological
findings
In a sociological respect, workers were under-represented in all groups. Independent individuals, on the other hand, mainly represented the “pill addicts”. Thirteen of the deceased discontinued their schooling or studies and 11 of them at that time were abusing drugs. Twenty-one persons no longer pursued their jobs once addicted. Twelve of them, one year before death, and 8 of them immediately prior to death, were holding a paid job or attending school. Socialization conditions such as pregnancy, birth, childhood, family situation, parents and friends were investigated under a biographical aspect. It was disclosed that in 5 of the cases the gravidity was unwanted, 4 of the deceased had sustained minor intrapartal trauma, 6 of them had suffered a serious physical illness (nutrition disorders) prior to their third year of age, and 5 of the patients had long lasting psychic behavioral disorders, predominantly retardation. Twelve of the patients under investigation were single children, and 10 were the last born children, also to them a similarly accentuated attendance by the next of kin applies. Broken home situations were found in 22 cases. Further unfavorable conditions for child development were, illegitimate birth, frequent change of friends, marital conflicts of the parents, divorces, new partners of the mother or father with resulting affective tensions - stepfathers in particular proved to be disturbing factors. Education
The education of almost all young drug addicts was detrimentally influenced by a strong permissiveness and a pedagogic weakness of orientation on the part of the parents. There was no noticeable financial need in any case, the deceased predominantly belonging to the social middle class. Fear of confrontation and loss of confidence and affection prevented the parents from stopping known unfavorable developments. It was a general tendency to clear the path of the children from all obstacles, not to give any prohibitions or to postulate strict behavioral norms. In a sexual respect, the tendency of an enforced liberalization was answered in the affirmative. In many cases, over-protective mothers dominated against unsecure and primarily psychologically unstable fathers who were too weak to carry through their point. Among such fathers were 10 who were inclined to the abuse of alcohol. In 6. cases, the father was dead, in 2 seriously ill and in some cases suffering from a long lasting overburden of professional obligations. Four marriages were divorced; here the anti-authoritarian, inconsequent education dominated, ,with strong effects. In agreement with the psycho-analytical and psychiatric experience in this field by such workers as S. Freud, Rado and LSwenfeldt [7, 8, 12, 18, 19, 21, 27, 28, 36, 42-451 it was shown also that lack of guidance and of direction lead to an increased generation conflict, instability and aggravated processes of self assertion of the juveniles. The socio-cultural consequences thus resulting will be dealt with subsequently. (G. Mollhoff and A. Gerber [ 10, 241.)
35
Love disappointments, in particular as far as intimate contacts in early puberty were concerned, often had a catalytic function for the final fixation on promiscuity in the surroundings of the scene. In 13 cases, such psychic trauma existed at the time the first opiates were “shot up”. Firm ties with nondrug addicts broke rather fast, or the partner succumbed to the magnet effect or the virulency of the specific surroundings. With the start of regular use of drugs, many factors brought about alienation of the patients to their families. This attitude was rather ambivalent, only one third in the end broke off communication beyond repair. Juveniles identified themselves rather fast with conspicuous “cool types” of the scene and parallel to this development, there was frequently a change of friends and acquaintances. The next associates were, even in communes, not very reliable and did not offer adequate inter-human report. The increasing narrowing of the personal relations in retrospect is depicted as consequence of cerebra-organic, toxic damages, as well as intrinsic psychosocial process in the sub-culture [3, 5, 9, 14, 20, 25, 29, 30, 40, 411 . Somatic
diseases
Those in particular with strong physical external symptoms were reported in 8 cases. Clinical records showed gastro-duedenitidis and orthostatic circulatory disorders, phobic heart ailment and minor gynecological impairment. The drug career of the fixers (Group I) predominantly started before the 18th year (1 case at 13 and 3 cases at 14 years), always with cannabis preparations. More than half of these juveniles, with an increasing polytoxicomania, arrived at hard drugs of the opiate type, which without exception were injected. The period of time from the first contact with narcotics to intravenous application was between 1% to 2% years. The drug career on average was between 3 and 5% years. Survival after beginning of fixing was 2 years as a mean. Additionally, hashish, amphetamines, hallucinogenic drugs such as LSD, barbiturates and tranquilizers were used to build up the effect of the drug or to alleviate their disturbing side effects. The pill addicts (Group II) used predominantly barbiturates and bromcarbamides; in addition, these users took analgesics and ataractics. The drug consumption lasted between 5 to 10 years and 4 of the deceased in addition used alcohol to increase the effects. It was relatively easy for the second group to obtain the means for their drug activities. Financially it was not expensive; the family physician prescribed the desired preparation generously to patients or their relatives, in a rather uncritical manner. At times these preparations were available for sale without prescription. The fixers disclosed 14 cases of different criminal structure in respect to procurement. Twenty financed their own consumption at least partially by dealing, 6 of them were to be attributed to the small intermediate dealer group and 3 patients showed “detour criminality” (breaking into pharmacies). Seven of the deceased had previous convictions
36
for one or several violations of the narcotics law. Ten users had easy access to narcotics through friends or close relatives (see also, refs. 33, 37 and 38). Treatment
in Clinical Hospitals
Upon admission to hospital physical ailments were generally prominent and to some extent these enforced admission. The 14 fixers suffered from a somatic deprivation, chronic bronchitis, gastro-intestinal disorders, liverparenchymal damages, cardiac and circulatory weakness and often very distinctly marked physical irregularities. In 10 cases a chronic-aggressive hepatitis was determined in different phases. Only 4 of the patients lasted out the treatment over a month, but even they, after relief of the most severe impairment, tended to return to the old environment of the drug scene. Almost all resumed the abuse of opiates that same date in the old manner. *Ten pill addicts at least displayed abstinence for a longer period of time but still the attraction of the pathogenic surroundings was so strong that they did succumb to it. Our catamnestic psychiatric investigations confirmed the clinical experience that the premorbid structure of personality is of vital importance for the development of a dependence on drugs. Many of the deceased suffered primarily from deep psychogenic disorders which in part were not recognized, or not adequately rated by the environment as to their specific importance. A review of these facts is presented in tables IV, V and VI. Also the course of these diseases showed that the pathogenesis was decisively influenced by intraphysical disorders of the ego or super-ego development, narcissistic and regressive processes. Apparent traits were lack of object and ego representation, narrowed mastering of emotions and reduced frustration tolerance and impressed phenomenologically as infantile, sensitive, easily vulnerable or timid-reserved behavior. Protests against the “dying society of the last capitalist era” were not prominent with respect to theme or cause and otherwise there were no engagements of any bearing in a political respect. Merely, in individual cases, passing, socio-critical impulses were found, which were to be attributed to ideological efforts of self-aid groups. Even prior to making contact with drugs, many fixers had only comparatively low standard interests not reaching beyond everyday problems. Boredom and an inner aimlessness characterized the horizon of experience of these juveniles. However, there is no doubt that exogenous afflictions such as promotion barriers in school and profession, tensions in the primary groups and financial difficulties were of vital importance in particular cases, for the beginning or further course of the drug dependence. The strong interdependence of exogenous and endogenous factors is reflected also in the large number of 17 proven suicides. Presumably the number of the autoagressions is nearly 100% higher. At any rate, an intent to commit suicide could be ruled out with certainty in only 6 cases (4 deaths of natural causes, 2 accidental deaths). The anamnesis of 19 deceased revealed formal suicidal
37 TABLE IV Psychiatric investigation of Group I (“fixers”) Diagnosis
Number of cases
Schizophrenia, paranoid type Deep reactive depression
3 3
TABLE V Psychiatric investigation of Group II (pill addicts) Diagnosis
Number of cases
Schizophrenia, simple type Endogenous depression Reactive depression Neurotic development (including 1 border-line case) Abnormal personality (psychopathic personality)
1 3 6 3 2
TABLE VI Psychiatric investigation of Group III (other drugs) Diagnosis
Number of cases
Abnormal psychic development (transvestitism) Symptomatic psychosis (LSD produced release)
1 1
attempts and 4 others had seriously stated in conversation that they intended to commit suicide. Narcotics fatalities thus are, also in a psychodynamic respect, the ultimate point of a pathological development, a course of ailment, suicide-inclined with a certain cogency (see G. Mollhoff). The out-patient medical treatment of our cases was, generally speaking, not very satisfactory. Treatment was only cursory and in the border areas of the drug scene was administered by not sufficiently trained physicians. There was not only a lack of willingness on the part of the drug addicts to undergo treatment but unfortunately there was also a lack of efficiency and psychiatric qualification on the part of the therapist, to master such a complex event. In the foreground there were group activities which in part were greatly influenced by political tendencies of the day and ideological outlooks. Clinical treatment was administered in a psychiatric university clinic and in a big, out-of-town psychiatric state clinic. The dominant factor
38
of the therapy was the somatic withdrawal of drugs which was then followed, in Heidelberg, by a psycho-therapeutically oriented after-treatment. In part, out-patient treatment was administered in release institutions. In retrospect, it may be said that this extra-mural therapy started from unrealistic, ideologically fixated premises. The groups in these phases became more and more ends in themselves and the discussions gradually played themselves out in evaluations of problems of a socio-critical aspect. There were homogenizing effects and simultaneously a climate of fixated narrowing and concentration of regressions. Clear decisions and aims at reintegration into social reality were not made; furthermore, these circles were lacking professional supervision and consequent delimitation towards criminal border zones of the dealers and other delinquents (see Bschor, H. Ebermann, G. Mijllhoff [3, 5, 25, 261). It is worth emphasising that one of the medical group leaders was sentenced to long-term imprisonment for drug trafficking a few months after he left one of these institutions. Release from hospitals was partly made in an uncritical manner “on own request” contrary to medical advice, and still in the somatic phase of withdrawal. Seven of these patients then received prescriptions for methadon preparations “ad manum aegroti”, partly over many weeks. There is no question about iatrogeneous support of addiction in many cases, not only with respect to the Heidelberg scene but also outside of this series of examination. In addition, however, it can be assumed with certainty for our group of persons, that practicing doctors paved the way for addiction. Methadon preparations were handed out over months without strict indication and without efficiency control (no toxicologic tests), merely on the statement of the patient. In addition, on the other hand, some friends and relatives by lenient or unappreciative action hindered the intended withdrawal. It is depressing to note that a co-operation between therapist and relatives was not sought and partly even knowingly avoided. The reasons for this conduct are to be seen in unreflected identification with the patient, extremely permissive attitude of the physician and probably also ideological prejudice.
REFERENCES 1 E. Baden, Die Rauschgiftsiichtigkeit, Lecture given in Heidelberg on July 3, 1972. 2 W. Braun and A. Donhardt, Vergiftungsregister. Haushaltsund Laborchemikalien, Arzneimittel Symptomatologie und Therapie, Georg Thieme, Stuttgart, 1970. 3 F. Bschor, Sozialmedizinische Probleme der Drogenszene, In J. Hoffman (ed.), Zur Therapie Siichtiger, Lambertus, Freiburg, 1973. 4 W. Doerr, Spezielle pathologische Anatomie I, Heidelberger Taschenbiicher, Vol. 69, Springer, Berlin, 1970, pp. 343, 354. Selbsthilfe-Einrichtungen bediirfen der Aufsicht, 5 H. Ebermann, Drogensiichtige: Dtsch. Aerztebl., 71 (1974) 709-713. 6 N. Eddy, H. Halbach, H. Isbell and M. Seevers, Drug dependence: its significance and characteristics, Bull. W.H.O., 32 (1965). 7 0. Fennichel, The Psychoanalytic Theory of Neurons, Norton, New York, 1945.
39 8 K. Fliege and D. v. Zerssen, Irreversible brain damage as a consequence of drug addiction, Paper read at the 5th World Congress of Psychiatry, Mexico City, NOV. 2% Dec. 4, 1971. 9 R. Furger, Sucht beim Jugendlichen, Schweiz. Rundsch. Med. (Praxis), 60 (1974) 1010-1013. 10 A. Gerber, Inaugural dissertation, 1975. 11 H. Hafner, Zur Epidemiologie von Alkohol- und Drogen-Abhangigkeit, Fortschr. Med., 91 (1973) 617-621. 12 D. Hartmann, A Study of drug-taking adolescents. Study of the Child, 24 (1962) 3844397. 13 K. Heilmann, P. Linhart and A. Weizel, Morphologische Aspekte des Leberschadens bei Rauschmittelsucht und -missbrauch, Dtsch. Med. Wochenschr., 96 (1971) 453457. 14 M. Helpem and Y. M. Rho, cited by E. Baden [l], Deaths from narcotism in New York City, N.Y. State J. Med., 66 (1966) 2391-2408. 15 W. Keup, Abusus von Pharmaka: Neue Aspekte der Behandlung, Aerztl. Praxis, 25 (1973a) 3167-3171. 16 P. Kielholz, in F. von Laubenthal (ed.), Sucht und Missbrauch. Ein kurzgefasstes Handbuch fur Aerzte, Georg Thieme, Stuttgart, 1972. I7 P. Kielholz and D. Ladewig, Die Drogenabhangigkeit des modernen Menschen, J. F. Lehmanns, Munich, 1972. 18 H. Kohut, Narzismus, Suhrkamp, Frankfurt a.M., 1973. 19 E. Liihrssen, Psychoanalytische Theorien iiber Suchtstrukturen, Suchtgefahren, 4 (1974). 20 H. C. Leuner, Ueber den Rauschmittelmissbrauch Jugendlicher, Dtsch. Aerztebl., 68 (1971b) 2809-2816. 21 H. Lowenfeld und Y. Lowenfeld, Die permissive Gesellschaft und das Ueber-Ich, Psyche, 24 (1970) 706-720. 22 H. J. Mallach and E. Wirth, Ueber ttidliche Vergiftungen mit Carbromal und Bromisoval, Med. Welt, 24 (1973) 212-214. 23 S. Martens, Amphetaminismus. Rauschmittel. Missbrauch und Wirkungen Abhangigkeit erzeugender Drogen, Urban und Schwarzenberg, Berlin, 1971. 24 G. Miillhoff, Suicid in rechtlicher und versicherungsmedizinischer Sicht, Med. Habil. Schrift, University of Heidelberg, 1970. 25 G. Miillhoff, Einige aktuelle sozielmedizinische Probleme bei Rauschmittelsiichtigen (I und II), Der Med. Sachverst., 69 (1973) 30-34 and 70 (1973) 12-15. 26 G. Mollhoff, Versicherungsmedizinische Bewertung von Rauschmittelabhangigen, Z. Rechtsmed., 74 (1974b) 1-8. 27 S. Rado, Psychoanalyse der Pharmakothymie, Z. Psychoanalyse, 20 (1934) 16--32. 28 H. A. Raskin, Drug Dependence. Wayne State Univ. Press, Detroit, 1970. 29 H. Remschmidt and I. Dauner, Klinische und soziale Aspekte der Drogenabhangigkeit bei Jugendlichen, Med. Klin., 65 (1970) 1993-1997, 2041-2047, 2078-2081. 30 H. A. Rosenfeld, in I. Scheid (ed.), Drogenabhlngigkeit, Nymphenburger, Munich, 1972. 31 H. Siegel and P. Bleistein, Continuing studies in the diagnosis and pathology of death from intravenous narcotism, J. Forensic Sci., 15(2) (1970). 32 M. Steinke, Ueber das Schniiffeln, einer Sonderform jugendlichen Rauschmittelmissbrauchs, Oeff. Gesundh.-Wesen, 34 (1972) 703-707. 33 G. Strassmann, W. Stumer and M. Helpern, Gehirnschldigungen, insbesondere Linsenkernerweichungen bei Heroinsiichtigen, nach Barbituratvergiftung, Splittod nach Erhangen und Herzstillstand in der Narkose, Beitr. Gerichtl. Med., 25 (1969) 236242. 34 Gg. Schmidt, Forensisch wichtige Vergiftungen. Schlafmittel. In A. Ponsold (ed.), Lehrbuch der Gerichtlichen Medizin, 3rd Edn., Georg Thieme, Stuttgart, 1967, pp. 419-426.
40 35 Gg. Schmidt, Schlafmittel-Intoxikationen. Lecture given at the 53rd annual meeting of the Deutsche Gesellschaft fur Rechtsmedizin, Gottingen, Sept., 1974. 36 H. Thielicke, Anthropologische Grundtatbestiinde in individuellen Konfliktsituationen, Z.f. ev. Ethik, Heft 3, (1974) 129-145. 37 E. Trube-Becker, Zum Tod bei Drogenabusus. Lecture given at the annual meeting of the Deutsche Gesellschaft fiir Rechtsmedizin, Munich, 1973. 38 M. Vamosi, Gerichtsmedizinische Gesichtspunkte iiber die durch Drogeneinfluss verursachten Todesfiille. (Eine Analyse der Drogentodesfiille in Stockholm 19699 1972). Lecture given at the annual meeting of the Deutsche Gesellschaft fiir Rechtsmedizin, Munich, 1973. 39 A. Wagner, Rauschgift-Drogen, Verstiindliche Wissenschaft, Vol. 99, Springer, Berlin, 1970. 40 K. Wanke, L. Siillwold and B. Ziegler, Jugend und Rauschmittel. Pravention, Therapie und Rehabilitation. Rehabilitation, 23 (1970a). 41 K. Wanke, B. Ziegler and L. Siillwold, Empirische Untersuchungen zum Rausqhmittelmissbrauch in Frankfurt. Ref. gehalten anlPss1. d. Kongr. d. Dtsch. Gesellsch. f. Psychiatr. u. Nervenheilk. in Bad Nauheim, Oct. 1970b. 42 C. H. Wessels, Psychologische Motive des Drogenmissbrauchs. Med. Klinik, 69 (1974) 1015-1026. 43 Expert committee on addiction - producing drugs. W.H.O. Techn. Rep. Ser. 273, 3 (1964). 44 L. Wurmser, Drug Abuse -- Nemesis of Psychiatry in the American Scholar, 41 (1972) 393-397. 45 L. Wurmser, Entwicklung und Bedeutung der Rauschgiftsucht in den U.S.A., Schweiz. Med. Wschr., 104 (1974) 189-197.
DEATHS RESULTING G. MCLLHOFF
31
FROM DRUGS OF ABUSE*
and Gg. SCHMIDT
Institute of Forensic Medicine, Heidelberg (Received November 10,1975;
University (F.R.G.)
accepted January 8, 1976)
SUMMARY This report covers 40 narcotics fatalities from the Northbaden area (Federal Republic of Germany) that came to the Institute of Forensic Medicine, Heidelberg University for autopsy in the years of 1968-1973. Information is given on pathological anatomic and toxicologic findings. A biographical, sociological, psychiatric and criminological catamnesis gave important insight in determinants, motivations, development and course of drug dependence in this area. Basic details are shown and critically evaluated.
INTRODUCTION
In 1966, the drug wave already apparent in U.S.A. and Scandinavia arrived in the Federal Republic. From 1968 to 1973, there was a constant increase in this particular form of 20th Century epidemic [l, 6, 11, 16, 17, 391. Since 1974 the number of new addictions has decreased and there is a slight decreasing tendency in the consumption of mild drugs, in particular in respect to the cannabis group. However, the core of the consumers of hard drugs increases constantly. According to estimates the Federal Republic has a total of 20 000 declared opiate addicts to be taken into account, and approximately 200 000 seriously endangered individuals. In BadenWuerttemberg alone the number of “risks” is estimated at 30 000. The North Baden area with nearly two million inhabitants (Heidelberg-Mannheim-Karlsruhe), due to its geographical situation and tourist attraction soon became a center of the drug wave. The concentration of juveniles in the university cities was certainly a decisive factor. Since 1972, an intensity of heroin, cocaine and LSD transactions was noted. Additionally in correlation, there was a clearly marked increase of violent crime in the surroundings of the dealers. At the present, there are 300 individuals in Heidelberg alone who are to be classified as addicts and therefore most endangered individuals. This apparent epidemic - and from the view point of forensic medicine, critical situation - was reason to investigate the motives, development and consequences of this development in the border areas of this scene. *Paper presented at the Seventh International September 8-12, 1975.
Meeting of Forensic
Sciences, Zurich,
32 MATERIAL
AND METHODS
We report on 40 narcotics fatalities from the years of 1968 to 1973 that were examined in our institute in a pathological, anatomic and toxicological respect. To widen our view, court files, medical records and all available personal notes of the deceased were exploited. The course of the disease was discussed with the attending physicians; and the family background was explored in detail. We defined a narcotic fatality as an incident with direct or indirect correlation between the long standing use of substances within the meaning of the narcotics law, ensuing drug dependence and death.
PATHOLOGICAL
AND ANATOMIC RESULTS
All 40 drug fatalities were physically weakened and undernourished at the time of death. The group of the “fixers” (group I) showed great negligence (scabies, pediculi pubis, capitis et vestimentorum, pyodermia, pollution, etc. ). The “pill addicts” (Group II) showed numerous hematomae at the extremities and at the trunk, there were emphatic symptoms of toxically conditioned coordination disorders as seen predominantly among barbiturate -and bromcarbamide dependent individuals. The pathological and anatomic diagnosis is shown in Tables I, II and III. At this point, it should be mentioned at least briefly that we were able to prove the pulmonary findings of Duberstein and Kaufmann, Siegel and Bleistein and other workers [4, 13, 34, 351 by means of this material. The condition of the gastro-intestinal tract was analogous to that described by Baden and others. Brain damages as described by Strassmann et al. were present rather distinctly in some cases. We did not find extensive cerebro-
TABLE I The pathological and anatomic diagnosis of Group I (“fixers”) Cause of death and anatomic findings
Number of cases -
Central respiratory and circulatory asphyxia Death by asphyxia, aspiration of thyme Endocarditis tricuspidalis, pneumonia, pulmonary infarction and pulmonary abscess Acute failure of the left ventricle, chronic fibroid myocarditis, pulmonary oedema Acute pneumonia resulting in heart and circulatory failure Bleeding to death from stabbing into the heart with scissors Death by hanging Poisoning resulting in failure of the right ventricle Traffic accident: asphyxia involving bilateral pneumothorax and bleeding to death
11 2 1 1 1 1 1 1 1
33 TABLE II The pathological and anatomic diagnosis of Group II (pill addicts) Cause of death and anatomic findings
Number of cases
Toxic heart and circulatory failure involving central asphyxia Death by drowning in bath following ingestion of barbiturates Poisoning by E-605 (organophosphorus compound) Death by hanging
15 1 1 1
TABLE III The pathological and anatomic diagnosis of Group III (other drugs) Number of cases
Cause of death and anatomic findings Acute heart failure following trichloroethylene Presumed intoxication by tablets
poisoning
1 1
atrophical processes, in particular in the area of the third ventricle, as mentioned by Fliegen and Zerssen. Enlargements of the lymphatic ganglion were found in particular in the regional outlet of paravenous injections with diffuse lymphocyterian or hyperplastic changes of the germ centers. Toxicologic
examination
(see also, refs. 2, 15, 22, 23, 31, 32)
This revealed in all cases involving the “pill addicts” clear indication of the preparation used in a particular case in respect to quantity and quality. The proof of opiates in part was negative as to the fixers for the known reason that it is hard to proof opiates postmortem in blood or organs. The attribution to this group was made on the anamnesis, fresh and old injection marks that were proven as well as the other autopsy findings. Distribution
of age and sex
The 20 persons in Group I were of an average age of 22 years and 4 months and only 2 of them were married. The ratio between men and women was 13:7. Of the 18 cases in Group II 5 died between 16 and 27 years of age, 4 between 32 and 39 years of age, and 9 between 44 and 58 years. The ratio of the sexes was 4:16 male:female and 8 of the women were married. Altogether, two thirds of all patients did not reach their 29th year, among them two 16 year olds and one 17 year old. The 2 cases in Group III consisted of 2 young men who had practiced “sniffing” and abused hashish and LSD.
34
Sociological
findings
In a sociological respect, workers were under-represented in all groups. Independent individuals, on the other hand, mainly represented the “pill addicts”. Thirteen of the deceased discontinued their schooling or studies and 11 of them at that time were abusing drugs. Twenty-one persons no longer pursued their jobs once addicted. Twelve of them, one year before death, and 8 of them immediately prior to death, were holding a paid job or attending school. Socialization conditions such as pregnancy, birth, childhood, family situation, parents and friends were investigated under a biographical aspect. It was disclosed that in 5 of the cases the gravidity was unwanted, 4 of the deceased had sustained minor intrapartal trauma, 6 of them had suffered a serious physical illness (nutrition disorders) prior to their third year of age, and 5 of the patients had long lasting psychic behavioral disorders, predominantly retardation. Twelve of the patients under investigation were single children, and 10 were the last born children, also to them a similarly accentuated attendance by the next of kin applies. Broken home situations were found in 22 cases. Further unfavorable conditions for child development were, illegitimate birth, frequent change of friends, marital conflicts of the parents, divorces, new partners of the mother or father with resulting affective tensions - stepfathers in particular proved to be disturbing factors. Education
The education of almost all young drug addicts was detrimentally influenced by a strong permissiveness and a pedagogic weakness of orientation on the part of the parents. There was no noticeable financial need in any case, the deceased predominantly belonging to the social middle class. Fear of confrontation and loss of confidence and affection prevented the parents from stopping known unfavorable developments. It was a general tendency to clear the path of the children from all obstacles, not to give any prohibitions or to postulate strict behavioral norms. In a sexual respect, the tendency of an enforced liberalization was answered in the affirmative. In many cases, over-protective mothers dominated against unsecure and primarily psychologically unstable fathers who were too weak to carry through their point. Among such fathers were 10 who were inclined to the abuse of alcohol. In 6. cases, the father was dead, in 2 seriously ill and in some cases suffering from a long lasting overburden of professional obligations. Four marriages were divorced; here the anti-authoritarian, inconsequent education dominated, ,with strong effects. In agreement with the psycho-analytical and psychiatric experience in this field by such workers as S. Freud, Rado and LSwenfeldt [7, 8, 12, 18, 19, 21, 27, 28, 36, 42-451 it was shown also that lack of guidance and of direction lead to an increased generation conflict, instability and aggravated processes of self assertion of the juveniles. The socio-cultural consequences thus resulting will be dealt with subsequently. (G. Mollhoff and A. Gerber [ 10, 241.)
35
Love disappointments, in particular as far as intimate contacts in early puberty were concerned, often had a catalytic function for the final fixation on promiscuity in the surroundings of the scene. In 13 cases, such psychic trauma existed at the time the first opiates were “shot up”. Firm ties with nondrug addicts broke rather fast, or the partner succumbed to the magnet effect or the virulency of the specific surroundings. With the start of regular use of drugs, many factors brought about alienation of the patients to their families. This attitude was rather ambivalent, only one third in the end broke off communication beyond repair. Juveniles identified themselves rather fast with conspicuous “cool types” of the scene and parallel to this development, there was frequently a change of friends and acquaintances. The next associates were, even in communes, not very reliable and did not offer adequate inter-human report. The increasing narrowing of the personal relations in retrospect is depicted as consequence of cerebra-organic, toxic damages, as well as intrinsic psychosocial process in the sub-culture [3, 5, 9, 14, 20, 25, 29, 30, 40, 411 . Somatic
diseases
Those in particular with strong physical external symptoms were reported in 8 cases. Clinical records showed gastro-duedenitidis and orthostatic circulatory disorders, phobic heart ailment and minor gynecological impairment. The drug career of the fixers (Group I) predominantly started before the 18th year (1 case at 13 and 3 cases at 14 years), always with cannabis preparations. More than half of these juveniles, with an increasing polytoxicomania, arrived at hard drugs of the opiate type, which without exception were injected. The period of time from the first contact with narcotics to intravenous application was between 1% to 2% years. The drug career on average was between 3 and 5% years. Survival after beginning of fixing was 2 years as a mean. Additionally, hashish, amphetamines, hallucinogenic drugs such as LSD, barbiturates and tranquilizers were used to build up the effect of the drug or to alleviate their disturbing side effects. The pill addicts (Group II) used predominantly barbiturates and bromcarbamides; in addition, these users took analgesics and ataractics. The drug consumption lasted between 5 to 10 years and 4 of the deceased in addition used alcohol to increase the effects. It was relatively easy for the second group to obtain the means for their drug activities. Financially it was not expensive; the family physician prescribed the desired preparation generously to patients or their relatives, in a rather uncritical manner. At times these preparations were available for sale without prescription. The fixers disclosed 14 cases of different criminal structure in respect to procurement. Twenty financed their own consumption at least partially by dealing, 6 of them were to be attributed to the small intermediate dealer group and 3 patients showed “detour criminality” (breaking into pharmacies). Seven of the deceased had previous convictions
36
for one or several violations of the narcotics law. Ten users had easy access to narcotics through friends or close relatives (see also, refs. 33, 37 and 38). Treatment
in Clinical Hospitals
Upon admission to hospital physical ailments were generally prominent and to some extent these enforced admission. The 14 fixers suffered from a somatic deprivation, chronic bronchitis, gastro-intestinal disorders, liverparenchymal damages, cardiac and circulatory weakness and often very distinctly marked physical irregularities. In 10 cases a chronic-aggressive hepatitis was determined in different phases. Only 4 of the patients lasted out the treatment over a month, but even they, after relief of the most severe impairment, tended to return to the old environment of the drug scene. Almost all resumed the abuse of opiates that same date in the old manner. *Ten pill addicts at least displayed abstinence for a longer period of time but still the attraction of the pathogenic surroundings was so strong that they did succumb to it. Our catamnestic psychiatric investigations confirmed the clinical experience that the premorbid structure of personality is of vital importance for the development of a dependence on drugs. Many of the deceased suffered primarily from deep psychogenic disorders which in part were not recognized, or not adequately rated by the environment as to their specific importance. A review of these facts is presented in tables IV, V and VI. Also the course of these diseases showed that the pathogenesis was decisively influenced by intraphysical disorders of the ego or super-ego development, narcissistic and regressive processes. Apparent traits were lack of object and ego representation, narrowed mastering of emotions and reduced frustration tolerance and impressed phenomenologically as infantile, sensitive, easily vulnerable or timid-reserved behavior. Protests against the “dying society of the last capitalist era” were not prominent with respect to theme or cause and otherwise there were no engagements of any bearing in a political respect. Merely, in individual cases, passing, socio-critical impulses were found, which were to be attributed to ideological efforts of self-aid groups. Even prior to making contact with drugs, many fixers had only comparatively low standard interests not reaching beyond everyday problems. Boredom and an inner aimlessness characterized the horizon of experience of these juveniles. However, there is no doubt that exogenous afflictions such as promotion barriers in school and profession, tensions in the primary groups and financial difficulties were of vital importance in particular cases, for the beginning or further course of the drug dependence. The strong interdependence of exogenous and endogenous factors is reflected also in the large number of 17 proven suicides. Presumably the number of the autoagressions is nearly 100% higher. At any rate, an intent to commit suicide could be ruled out with certainty in only 6 cases (4 deaths of natural causes, 2 accidental deaths). The anamnesis of 19 deceased revealed formal suicidal
37 TABLE IV Psychiatric investigation of Group I (“fixers”) Diagnosis
Number of cases
Schizophrenia, paranoid type Deep reactive depression
3 3
TABLE V Psychiatric investigation of Group II (pill addicts) Diagnosis
Number of cases
Schizophrenia, simple type Endogenous depression Reactive depression Neurotic development (including 1 border-line case) Abnormal personality (psychopathic personality)
1 3 6 3 2
TABLE VI Psychiatric investigation of Group III (other drugs) Diagnosis
Number of cases
Abnormal psychic development (transvestitism) Symptomatic psychosis (LSD produced release)
1 1
attempts and 4 others had seriously stated in conversation that they intended to commit suicide. Narcotics fatalities thus are, also in a psychodynamic respect, the ultimate point of a pathological development, a course of ailment, suicide-inclined with a certain cogency (see G. Mollhoff). The out-patient medical treatment of our cases was, generally speaking, not very satisfactory. Treatment was only cursory and in the border areas of the drug scene was administered by not sufficiently trained physicians. There was not only a lack of willingness on the part of the drug addicts to undergo treatment but unfortunately there was also a lack of efficiency and psychiatric qualification on the part of the therapist, to master such a complex event. In the foreground there were group activities which in part were greatly influenced by political tendencies of the day and ideological outlooks. Clinical treatment was administered in a psychiatric university clinic and in a big, out-of-town psychiatric state clinic. The dominant factor
38
of the therapy was the somatic withdrawal of drugs which was then followed, in Heidelberg, by a psycho-therapeutically oriented after-treatment. In part, out-patient treatment was administered in release institutions. In retrospect, it may be said that this extra-mural therapy started from unrealistic, ideologically fixated premises. The groups in these phases became more and more ends in themselves and the discussions gradually played themselves out in evaluations of problems of a socio-critical aspect. There were homogenizing effects and simultaneously a climate of fixated narrowing and concentration of regressions. Clear decisions and aims at reintegration into social reality were not made; furthermore, these circles were lacking professional supervision and consequent delimitation towards criminal border zones of the dealers and other delinquents (see Bschor, H. Ebermann, G. Mijllhoff [3, 5, 25, 261). It is worth emphasising that one of the medical group leaders was sentenced to long-term imprisonment for drug trafficking a few months after he left one of these institutions. Release from hospitals was partly made in an uncritical manner “on own request” contrary to medical advice, and still in the somatic phase of withdrawal. Seven of these patients then received prescriptions for methadon preparations “ad manum aegroti”, partly over many weeks. There is no question about iatrogeneous support of addiction in many cases, not only with respect to the Heidelberg scene but also outside of this series of examination. In addition, however, it can be assumed with certainty for our group of persons, that practicing doctors paved the way for addiction. Methadon preparations were handed out over months without strict indication and without efficiency control (no toxicologic tests), merely on the statement of the patient. In addition, on the other hand, some friends and relatives by lenient or unappreciative action hindered the intended withdrawal. It is depressing to note that a co-operation between therapist and relatives was not sought and partly even knowingly avoided. The reasons for this conduct are to be seen in unreflected identification with the patient, extremely permissive attitude of the physician and probably also ideological prejudice.
REFERENCES 1 E. Baden, Die Rauschgiftsiichtigkeit, Lecture given in Heidelberg on July 3, 1972. 2 W. Braun and A. Donhardt, Vergiftungsregister. Haushaltsund Laborchemikalien, Arzneimittel Symptomatologie und Therapie, Georg Thieme, Stuttgart, 1970. 3 F. Bschor, Sozialmedizinische Probleme der Drogenszene, In J. Hoffman (ed.), Zur Therapie Siichtiger, Lambertus, Freiburg, 1973. 4 W. Doerr, Spezielle pathologische Anatomie I, Heidelberger Taschenbiicher, Vol. 69, Springer, Berlin, 1970, pp. 343, 354. Selbsthilfe-Einrichtungen bediirfen der Aufsicht, 5 H. Ebermann, Drogensiichtige: Dtsch. Aerztebl., 71 (1974) 709-713. 6 N. Eddy, H. Halbach, H. Isbell and M. Seevers, Drug dependence: its significance and characteristics, Bull. W.H.O., 32 (1965). 7 0. Fennichel, The Psychoanalytic Theory of Neurons, Norton, New York, 1945.
39 8 K. Fliege and D. v. Zerssen, Irreversible brain damage as a consequence of drug addiction, Paper read at the 5th World Congress of Psychiatry, Mexico City, NOV. 2% Dec. 4, 1971. 9 R. Furger, Sucht beim Jugendlichen, Schweiz. Rundsch. Med. (Praxis), 60 (1974) 1010-1013. 10 A. Gerber, Inaugural dissertation, 1975. 11 H. Hafner, Zur Epidemiologie von Alkohol- und Drogen-Abhangigkeit, Fortschr. Med., 91 (1973) 617-621. 12 D. Hartmann, A Study of drug-taking adolescents. Study of the Child, 24 (1962) 3844397. 13 K. Heilmann, P. Linhart and A. Weizel, Morphologische Aspekte des Leberschadens bei Rauschmittelsucht und -missbrauch, Dtsch. Med. Wochenschr., 96 (1971) 453457. 14 M. Helpem and Y. M. Rho, cited by E. Baden [l], Deaths from narcotism in New York City, N.Y. State J. Med., 66 (1966) 2391-2408. 15 W. Keup, Abusus von Pharmaka: Neue Aspekte der Behandlung, Aerztl. Praxis, 25 (1973a) 3167-3171. 16 P. Kielholz, in F. von Laubenthal (ed.), Sucht und Missbrauch. Ein kurzgefasstes Handbuch fur Aerzte, Georg Thieme, Stuttgart, 1972. I7 P. Kielholz and D. Ladewig, Die Drogenabhangigkeit des modernen Menschen, J. F. Lehmanns, Munich, 1972. 18 H. Kohut, Narzismus, Suhrkamp, Frankfurt a.M., 1973. 19 E. Liihrssen, Psychoanalytische Theorien iiber Suchtstrukturen, Suchtgefahren, 4 (1974). 20 H. C. Leuner, Ueber den Rauschmittelmissbrauch Jugendlicher, Dtsch. Aerztebl., 68 (1971b) 2809-2816. 21 H. Lowenfeld und Y. Lowenfeld, Die permissive Gesellschaft und das Ueber-Ich, Psyche, 24 (1970) 706-720. 22 H. J. Mallach and E. Wirth, Ueber ttidliche Vergiftungen mit Carbromal und Bromisoval, Med. Welt, 24 (1973) 212-214. 23 S. Martens, Amphetaminismus. Rauschmittel. Missbrauch und Wirkungen Abhangigkeit erzeugender Drogen, Urban und Schwarzenberg, Berlin, 1971. 24 G. Miillhoff, Suicid in rechtlicher und versicherungsmedizinischer Sicht, Med. Habil. Schrift, University of Heidelberg, 1970. 25 G. Miillhoff, Einige aktuelle sozielmedizinische Probleme bei Rauschmittelsiichtigen (I und II), Der Med. Sachverst., 69 (1973) 30-34 and 70 (1973) 12-15. 26 G. Mollhoff, Versicherungsmedizinische Bewertung von Rauschmittelabhangigen, Z. Rechtsmed., 74 (1974b) 1-8. 27 S. Rado, Psychoanalyse der Pharmakothymie, Z. Psychoanalyse, 20 (1934) 16--32. 28 H. A. Raskin, Drug Dependence. Wayne State Univ. Press, Detroit, 1970. 29 H. Remschmidt and I. Dauner, Klinische und soziale Aspekte der Drogenabhangigkeit bei Jugendlichen, Med. Klin., 65 (1970) 1993-1997, 2041-2047, 2078-2081. 30 H. A. Rosenfeld, in I. Scheid (ed.), Drogenabhlngigkeit, Nymphenburger, Munich, 1972. 31 H. Siegel and P. Bleistein, Continuing studies in the diagnosis and pathology of death from intravenous narcotism, J. Forensic Sci., 15(2) (1970). 32 M. Steinke, Ueber das Schniiffeln, einer Sonderform jugendlichen Rauschmittelmissbrauchs, Oeff. Gesundh.-Wesen, 34 (1972) 703-707. 33 G. Strassmann, W. Stumer and M. Helpern, Gehirnschldigungen, insbesondere Linsenkernerweichungen bei Heroinsiichtigen, nach Barbituratvergiftung, Splittod nach Erhangen und Herzstillstand in der Narkose, Beitr. Gerichtl. Med., 25 (1969) 236242. 34 Gg. Schmidt, Forensisch wichtige Vergiftungen. Schlafmittel. In A. Ponsold (ed.), Lehrbuch der Gerichtlichen Medizin, 3rd Edn., Georg Thieme, Stuttgart, 1967, pp. 419-426.
40 35 Gg. Schmidt, Schlafmittel-Intoxikationen. Lecture given at the 53rd annual meeting of the Deutsche Gesellschaft fur Rechtsmedizin, Gottingen, Sept., 1974. 36 H. Thielicke, Anthropologische Grundtatbestiinde in individuellen Konfliktsituationen, Z.f. ev. Ethik, Heft 3, (1974) 129-145. 37 E. Trube-Becker, Zum Tod bei Drogenabusus. Lecture given at the annual meeting of the Deutsche Gesellschaft fiir Rechtsmedizin, Munich, 1973. 38 M. Vamosi, Gerichtsmedizinische Gesichtspunkte iiber die durch Drogeneinfluss verursachten Todesfiille. (Eine Analyse der Drogentodesfiille in Stockholm 19699 1972). Lecture given at the annual meeting of the Deutsche Gesellschaft fiir Rechtsmedizin, Munich, 1973. 39 A. Wagner, Rauschgift-Drogen, Verstiindliche Wissenschaft, Vol. 99, Springer, Berlin, 1970. 40 K. Wanke, L. Siillwold and B. Ziegler, Jugend und Rauschmittel. Pravention, Therapie und Rehabilitation. Rehabilitation, 23 (1970a). 41 K. Wanke, B. Ziegler and L. Siillwold, Empirische Untersuchungen zum Rausqhmittelmissbrauch in Frankfurt. Ref. gehalten anlPss1. d. Kongr. d. Dtsch. Gesellsch. f. Psychiatr. u. Nervenheilk. in Bad Nauheim, Oct. 1970b. 42 C. H. Wessels, Psychologische Motive des Drogenmissbrauchs. Med. Klinik, 69 (1974) 1015-1026. 43 Expert committee on addiction - producing drugs. W.H.O. Techn. Rep. Ser. 273, 3 (1964). 44 L. Wurmser, Drug Abuse -- Nemesis of Psychiatry in the American Scholar, 41 (1972) 393-397. 45 L. Wurmser, Entwicklung und Bedeutung der Rauschgiftsucht in den U.S.A., Schweiz. Med. Wschr., 104 (1974) 189-197.
