Starvation means withholding of food or food and drink from or by an individual.
Acute or complete starvation – When food is totally withheld for a continuous period, it is acute and complete starvation.
Chronic or partial starvation or malnutrition – When food intake is deficient, either quantitatively or qualitatively or both, then that is called chronic or partial starvation or malnutrition.
Signs and symptoms of acute starvation –
In the beginning phase, hunger, followed by hunger pain, thirst, weakness and lack of concentration are the chief features. Hunger pain is more marked by 2nd and 3rd days. Constipation and oligurea with increased frequency of micturition is there, by this period. By 3rd day, blood sugar, blood pressure, pulse rate and cholesterol level fall. Pulse is weak but on exertion the pulse rate is much increased. By this time, loss of body weight is appreciable. Gradually, there is emaciation, loss of subcutaneous fat with sunken eyes, cheeks and abdomen. The bones and particularly the joints become prominent. The skin is dry and dirty, lips are dry and cracked. There is thick, scanty salivation, coated tongue. Then there is wasting of muscles, which are rather flaccid with occasional cramps. The scanty urine has a high specific gravity, is turbid in appearance, and strongly acidic in reaction. When the condition progresses towards the worst, the person is unable to move and speak, the temperature which was slightly raised earlier, now falls. At the terminal phase, there may be mental confusion.
In acute starvation, first the reserve carbohydrate of the body, then the reserve fat and lastly the protein are gradually lost due to use.
Cause of death in acute starvation is mostly due to cardiovascular failure. Occasionally, death may occur due to failure of the other vital functions of the body. In cases, where the person survives for a reasonably long period, death may obviously occur due to intercurrent infection. But general debility remains the main cause precipitating the death.
Fatal period – In case of acute starvation, if there is simultaneous deprivation of water then death may occur within 7 – 10 days. In case of deprivation of food alone a person may survive for weeks. The maximum recorded period of survival during starvation of food alone is a few days more than 2 months. Generally, loss of 40% body weight becomes fatal, but much depends on season, age, sex and body condition.
This condition results from partial deprivation of food, either quantitatively or qualitatively for some short or long period. This may lead to deficiency of many bodily constituents including carbohydrate, fat, protein and also vitamins and minerals. This gradually decreases body weight, involving loss of carbohydrate first, then fat and lastly protein. The body fats and the muscles are gradually wasted and the body is emaciated. The abdomen and cheeks are sunken, the bones and joints are prominent. The skin is dry, in-elastic and often infected. The hair is lusterless. There may be ascitis. There may be intercurrent infections. Chronic infection like tuberculosis may add to the cachectic condition. There is occasional hunger pain. Various deficiency syndromes may appear.
Death in case of chronic starvation or malnutrition usually occurs due to intercurrent infection, different deficiency syndromes and general debility.
Though 40% loss of the body weight is likely to cause death, yet in case of chronic starvation, it was noticed in the concentration camp in Holland during the 2nd world war that, the body weight of some victims of chronic starvation there, reduced to less than 15% of their original weight. These victims were rightly termed as “living skeleton”.
Postmortem appearance –
(a) In case of acute starvation –
External – The body is emaciated, hair lusterless, eyes sunken and may be half open, cheeks sunken with prominent malar bones, lips dried and cracked, tongue coated, pale appearance of the skin, faint postmortem stain, early appearance and disappearance of rigor mortis, lack of subcutaneous fat with prominence of bones and pints, occasional oedema of the ankles, dirty, dry, lusterless and inelastic skin are the common features. There are wasting of the muscle and much loss of the body weight.
Internal – Lack of subcutaneous, omental and other distributions of fat is very much conspicuous and a constant feature. The tissues are pale. Organs are also pale. Spleen is smaller in size. Liver shows degenerative changes. The stomach wall is thin and the mucous membrane may show superficial ulceration. The stomach may contain bile-stained mucous and sometimes stones, soil, grass, swallowed by the victim during life. The gall bladder is much enlarged in size and contains thick bile. The intestinal wall is quite thin and is transluscent. Blood vessels on the wall of the intestine are less prominent. The intestinal canal contains bile-stained, mucoid, fluid or semi-fluid faecal matter. The rectum may be empty. The meningeal spaces may contain more fluid than average.
(b) In case of death due to chronic starvation –
The external findings are almost similar to those in case of acute starvation. Deficiency signs may be more conspicuous. The abdomen may be protruded due to ascitis. Signs of devitalisation and intercurrent infection is more common.
Among the internal findings, in addition to what is found in acute starvation, there will be more substantial evidence of degenerative changes in the liver and other organs. Sign of infection, like that of pulmonary tuberculosis may be there. There may be patchy ulceration of the mucus membrane of the intestine.
Medicolegal aspects –
Acute starvation deaths are mostly accidental in nature, which may occur in scores or hundreds, in circumstances of natural calamities, like, flood, cyclone and earthquake. Other accidental starvation deaths may occur inside a mine, in a desert or in the victims of house collapse. Suicidal acute starvation deaths have occurred in circumstances of protest “hunger strike” against some alleged injustice. Homicidal starvation deaths are very rare and the victims are either unwanted newborn infants or old debilitated persons or an enemy kept confined in an untraceable place.
Chronic starvation deaths, in the opinion of the author, is in most circumstances are the result of social injustice, inequity and poverty. Let the society decide whether these deaths should be termed homicidal, accidental or natural. Chronic homicidal starvation deaths also occur as a result of cruelty where the victims are usually old and disabled. In these cases, other signs of maltreatment or negligence may be present on the body. Accidental malnutrition deaths occur in diseased conditions like stricture oesophagus and malabsorption syndrome cases.