In the decades from 1930 to 1970, scientists interested in alcohol metabolism measured the blood or breath alcohol concentration (BAC or BrAC) at various time intervals after the consumption of alcohol. The graphic presentation of those measurements with dots for the vertical y axis as the concentrations and the horizontal x axis as the time produced charts showing the absorption, peak or plateau and elimination phases of alcohol metabolism ( Figure 1).  It is important to notice that the time intervals could vary from a few minutes (5-10) to several minutes (20-30). The dots were connected with straight lines to produce a generally smooth curve.  The implication is that the BAC or BrAC during the time interval is rising or decreasing in a linear fashion.  The following comment from a report in Science is relevant:  “A comparison of statistics to bikinis shows that what is revealed is interesting; but what is concealed is crucial.” In the alcohol measurements what is concealed is that the alcohol concentrations in the interval between the two times often shows  what has been variously termed as a “steeple effect”, short-term fluctuations, spiking or a zig-zag irregular time course of the BAC or BrAC.  The term steeple arises because the graph of a continuous (in time) analysis of  the BAC shows that the BAC which in earlier studies was a straight line between two points in time was, often in fact, a series of sharp peaks and valleys resembling church  steeples.  This was first demonstrated by Leithoff (2) who in 1964 modified an AutoAnalyzer to obtain the continuous analysis of blood alcohol. The AutoAnalyzer was invented by Leonard Skeegs in 1957 and made by the Technicon Corporation (3) for sale to clinical laboratories for analysis of various chemicals such as glucose, urea nitrogen, uric acid and albumin etc. in blood.  It consisted of a peristaltic pump working upon plastic tubing to deliver samples from a sample manifold and to deliver reagents separated by air bubbles. The samples and reagents were pumped through mixing coils and heating coils and eventually to a colorimeter and recorder. Leithoff’s modification consisted of substituting an in-dwelling catheter in the arm of the alcohol consumer for the sampler manifold.  The reagents for the alcohol determination were buffer, DPN (di-phosphopyridine nucleotide) and alcohol dehydrogenase.  Five individuals (1 male 4 female) were given an alcohol load (40 % Schnaps) of 0.8 or 0.9 g/kg body weight.  Figure 2 is a copy of his data clearly showing peaks and valleys in the alcohol metabolism curves for each of the individuals. 

When a new concept is presented, scientists ask: has it found support? is there any contrary data?; or in a more legal sense, has the scientific community accepted it?  Several authors have reported results indicating the corroboration of the short term fluctuations in blood, breath or both. The list includes the following:  Ditt and Forster 1964 (4), Shumate, Crowther and Zwafshon 1967 (5), Terfloth and Wuermeling 1967 (6), Naefe1971 (7), Schmutte 1972 (8), Wehner 1972 (9), Teige et al 1974 (10) Santamaria 1979 (11), Dubowski 1985 (12), Jensen and Burr 1992 (13) and Jones et al 1990 (14).

In addition to the above reports at least two other scientists have reported short term changes in the BAC patterns.  E.P. M. Widmark (15) in a comment on the conversion rate of ethyl alcohol wrote: “In previous works, excessive emphasis has been placed on the absorptive part of the alcohol curve.  Its relatively irregular course due to random changes in absorption rate and the time of the appearance of diffusional equilibrium give no clear picture of the spread and conversion of alcohol in the organism.” Loomis (16) in a study of the rate of decline of the BrAC  shows a chart of results at 10 minute intervals with definite peaks and valleys. 

 Figures 3, 4, 5 and 6 present the data of Teige, Santamaria, Dubowski, and Jensen,respectively.  To date no scientific report has indicated that the short term fluctuations do not occur.  Some reports indicate that during the decreasing phase of ethanol metabolism the fluctuations are not as great as those that occur during the rising phase of alcohol metabolism. Finally, acceptance of the phenomenon of the steeple effect by the scientific community is evidenced by the fact that it has been described in at least two textbooks dealing with medicolegal aspects of alcohol analysis; James G. Garriott (17) in both the 1996 and 2003 editions of his text on the medical-legal aspects of alcohol and Cooper, Schwar and Smith (18) in their 1979 text on alcohol, drugs, and traffic safety.

If the existence of short term fluctuations is accepted, the question is how do they impact on the certainty of the reported blood or breath alcohol test result?  The answer is possible by examination of the graphs to determine the difference in the alcohol concentration between the high and low values of the fluctuations.  Such an examination reveals that the concentrations may vary from 0.01 to 0.05 g/dL. This creates an unacceptable high degree of uncertainty for reported results between 0.08 to 0.25 g/dL (from more than 60% uncertainty to 20% uncertainty if the maximum between the peak and the valley were 0.05 g/dL).  Even if the fluctuation was only half as much (0.025 g/dl), the uncertainty would be sufficient to create considerable doubt of the accuracy of the reported BAC or BrAC measurement. 

Because only one blood sample is obtained for the BAC measurement, it is not possible to determine whether the sample represents a time at the peak, at the valley or in between the fluctuation. One should not accept the argument that the two tubes of blood usually obtained represent duplicate samples.  The two tubes are replicate samples of one blood drawing.  The phlebotomist has applied the tourniquet only once, and has inserted the needle into the vein only once.   The stressful nature of the procedure is a one time stress.  To have a true duplicate sample, it is necessary to repeat the complete process or, otherwise, to remove some pre-analytical uncertainties by inserting a catheter in the vein, initially and allowing several minutes to alleviate the stressful conditions before obtaining two or more timed samples of blood from the catheterized vein. 

That the steeple effect has been accepted scientifically should not be denied.  That the possible uncertainties may vary from grossly unacceptable ranges to lesser but still unacceptable values, likewise should not be denied.  Continued acceptance of results obtained with such known uncertainties is pseudo junk science and should be recognized for what it is!

References

1.  Science  242  p. 1263   (1988).

2. Leithoff,  H. Blutalkohol  2  p. 541 (1964).

3. Whitehead, E. New Medical Devices, Nat’l. Acad. Eng. p. 13-15 (1988).

4. Ditt, J. & Forster, B.  Blutalkohol  2 p.348 (1964).

5. Schumate, R. P., Crowther, R.F., & Zarafshan, J. Forensic Medicine 14 (3) p. 90 (1967).

6. Terflolth, H.P.,& Wuermeling, H.B., Technicon  Symposium on Automation (1967).

7. Naeve, w., Koops, E., Audrlicky, I. , & Brinkman, B., Blutalkohol 8 pp. 451-456 (1971).

8. Schmutte, P., Naeve, w., Wilhelm, F. & Brinmkman, B., Blutalkohol 9 pp.392-399 (1972).

9. Wehner, H. D., Blutalkohol 9 pp. 81-93 (1972).

        10. Teige, K. et al Blutalkohol 11 pp.29-39 (1974).

        11. Santamaria, J. N. St. Vincent’s Hospital, Fitzroy , Australia Dept. of Transport (1979).

        12. Dubowski, K.M. J. Studies on Alcohol Suppl. 10, 98-108 (1985).

                    Dubowski, K.M. Clin.Chem. 22 (7)  p. 1199 (1976).

        13. Jensen, R.E. & Burr, T.R.  Minnesota Forensics Seminar, Orlando , FL Feb. (1992).

        14. Jones, A.W., Jorfeldt, L., Hjertberg, H., & Jonsson, K.A. , J. Forensic Science Society  30 (5)
                   pp. 273-283 (1990). Jones, A.W. in J.C. Garriott 4^th Ed. Medical-Legal Aspects of Alcohol”                     pp.129-132 (2003).

        15. Widmark, E. P.M., in R. C. Baselt’s translation of “Principles and Applications of Medicolegal                   Alcohol Determination”   p.64 (1932).

        16. Loomis, T. A., Quart. J. Studies Alcohol  35 pp. 458-472  (1974)

        17. Garriott, J. C. “Medicolegal Aspects of Alcohol Determination in Biological Specimens” 3rd 

        Ed.  Chapter 3 R.C.Baselt & I.E. Danhof  p.59 (1988). Garriott, J. C. 4^th Ed. Chapter 4 A.W.                 Jones  pp.129-132 (2003).

        18. Cooper, W.E., Schwar, T. & Smith, L.“Alcohol, Drugs, & Road Traffic” pp. 222-234 (1979).

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