CHAPTER VL STARVATION. 330. Starvation by accident or intent. 331. Modes of starvation. 332. Period. 333. Symptoms. 334. Post-mortem findings. 335. Diagnosis of starvation. 330. Starvation by accident or intent.-Starvation assumes a legal importance when it enters into the consideration of cases of maltreatment and neglect, or occurs as a cause of death. A person may starve himself to death, he may perish from the want of proper food, from being unable to procure it, to swallow it, to digest it, or to assimilate it; or he may be purposely deprived of it. Medical evidence can only attempt to establish the fact that a death has been caused by starvation, and can, in many instances, indicate the physical causes of the starvation; but can not, of course, determine whether the starvation was voluntary or enforced. In the case of young children, however, homicidal intentions may be inferred, while on the contrary, in adults starvation is more often suicidal. Possibly associated marks of violence used in restraint, or marks where the person has tried to obtain blood from his own body in lieu of food, could be interpreted as evidence against suicidal intention. 331. Modes of starvation.- The mode of starvation is not always the same. It may be acute, where all nutrition and fluids are suddenly cut off, as in the accidental cases where the person is shipwrecked, shut up in a mine by a landslide, etc., or it may be gradual, where the supply of food is slowly diminished, as in times of famine. In other cases, though no solid food is swallowed, life is prolonged by the use of a little water, or even by a very meager allowance of food. In other cases, again, after a period of total abstinence, the imperative demands of nature are gratified perhaps too freely and too lat: to save life. In infants we may have peculiar deformities of the alimentary tract which prevent the swallowing or absorption of food, as in the cases of closed œsophagus or intestine. 332. Period. The period which a person can go without food depends upon the mode of starvation. The adult in robust health can always live longer than the infant or the aged. Falck' estimates the duration of life of an adult with total abstinence from food and drink as from seven to twenty-one days; but if water be accessible death may not come for two months. Caussé2 recites the instance of a girl who was buried for eleven days by the caving in of the house where she was. At the end of that time she was dug out alive. Glaister3 cites a case of a shipwrecked crew, absolutely without food or fresh water in their small boat. One lived eleven days, one twelve, two fifteen, one eighteen, and the captain twenty-eight days; but he had tied his cravat around the mast, and sucked rain water from it. In the Medical Gazette there is a case of a miner who was entombed, and at first was able to obtain some dirty ditch water; but after the first ten days he was too weak to fetch the water. He was removed alive on the twenty-third day, but died three days later. Wonderful examples of professed prolonged abstinence may be found in abundance in the older works, and are not wanting in our own day. But the numerous cases in which trickery has been detected should make us wholly incredulous of their genuineness. Instances of abstinence for months, and even years, are gravely related; but it is probable that there is no well-authenticated case of entire abstinence from food and drink for more than thirty days, while, on the other hand, it is highly probable that, in the majority of cases, death takes place within a week or ten days. Dr. Gadermann reports a case, however, in which, for twenty-three days, all liquid or solid nourishment was refused, the person being bent upon self-destruction. At the end of this time he ate and drank greedily, which did not, however, avail him; he died shortly afterwards. The body was almost a skeleton. In this case, the author says, there could not be the slightest suspicion of deception. Professor McNaughten has published a case where a man lived fifty-four days on water 'Falck, in Maschka's Handbuch der ger. Med. I., p. 721. For infants, see § 137c, ante. Caussé, Annal. d'Hyg. Pub., 1876, 172; quoted from Times, Feb. 6 and 7, 1866. Medical Gazette, Vol. XVII., pp. 264-389, 1835. "Henke's Zeitschrift, 1848, 3 H. Am. Journ. Med. Sci., Vol. VI, p. 543. alone. In another case, of a prisoner at Toulouse, who resorted to starvation to avoid punishment, life was prolonged to the fifty-eighth day. He drank water occasionally. Valentin refers to the case of a woman who lived seventy-eight days on water and lemon-juice. In another case a man lived sixty days on a little water and syrup of orgeat.8 9 Two very interesting cases of prolonged abstinence in persons afflicted with slight mental derangement, or melancholy, are related by Dr. Taylor, of Ohio. In one, after two periods of fasting, of ten and fourteen days respectively, during the last of which he took neither food nor water, this gentleman, on the fifteenth day, took a little water, and then at intervals a small quantity of milk in it. He died about one hundred days afterwards, having lived in "an almost constant state of abstinence." In the other, a little water was talen on the twelfth day after complete abstinence from food and drink, and a gill every twenty-four hours afterwards for thirty-nine successive days till he died. For the last seventy-two days prior to his death he had no fecal evacuation, but passed urine in small quantities every three or four days. Infants with atresia of the œsophagus usually live three to five days,10 though Theremin cites11 one instance where the infant lived for twelve days. The marked difference betwen duration of life where water is to be had is well illustrated by an experiment by Laborde12 on dogs. He deprived two dogs of all food, but one of them he allowed to obtain water. The dog that got neither food nor water died on the twentieth day; but the one that was allowed water lived forty days without any danger to its health. 333. Symptoms.-The symptoms of starvation show themselves first in the hunger and thirst, which last only two or three days after the food supply is cut off, after which there develops a sense of pressure in the stomach, with nausea. There is a progressive loss of weight, showing itself more in the early days than towards the end. It is apparent in the sunken eyes, depressed cheeks, pointed nose, and in the prominence of the bones all over the body. The abdomer becomes sunken so that it may seem to contain nothing between skin and spinal column. The skin becomes dry, wrinkled, and covered 'Lehrb. der Physiol., Vol. I., p. 218. 10 See Maier, Klebs Patholog. Anat. * Archiv. Gén., Vol. XXVII., p. 180. p. 165. Am. Journ. Med. Sci., Jan. 1851. In "Theremin, Deutsche Zeitschr. f. the same place will be found references Chir., 1877, VIII., 34. to some instances of remarkable absti- "Laborde, Wiener Med. Presse, 1887, nence, given by the editor, Dr. Hays. p. 183. with a dirty-brownish, desquamating material. There is a foul odor given off by the skin and also from the breath. The tongue partakes of the characteristics of the skin, becoming dry, covered with a dirty-brown coat, and sometimes cracked. The bowels move very scantily, if at all, and only at very long intervals. The movements then are small, hard, and dry. The urine becomes scanty, but darker in color and of higher specific gravity. The urea and uric acid decrease with the quantity of urine, the chlorids disappear, and the sodium is greatly reduced. The phosphates continue little diminished, and the potassium is increased. Acetone and acetic acid are enormously increased. Thus, from the urine we see the destruction of the tissues of the body.18 The body temperature becomes subnormal, the pulse more rapid towards the end. The intellect is usually clear to the end, though there are often headache, dizziness, and in some cases, delirium and convulsions before death. The period of delirium is at times preceded or replaced by a state of somnolence. 334. Post-mortem findings. The post-mortem findings show the emaciation developed during life more marked in the cases of long duration (that is, where water has been allowed, protracting the period of starvation) than in the cases of death in a short period of time from complete deprivation of food and nourishment. In fact, in the cases of what may be called acute starvation, a considerable quantity of fat may still remain in the body. In a case described by Haller,1 in a man dying of starvation, there was found in the omentum an inch of fat. The skin is usually wrinkled, and of a dirty-brown color. Rigidity comes on early, as does decomposition. The viscera are anemic and small, the intestines empty, contracted, and very thin walled. The stomach is contracted down to the usual size of the large intestine. The gall bladder is distended with thickened bile. The thymus is reduced to sparse remnants. The loss in weight varies in the different tissues. Falck estimates15 that there is a loss of 97 per cent of the fatty tissues, and that of the other tissues the spleen loses 67 per cent of its weight, the liver 54 per cent, the testicles 40 per cent, the muscles 30 per cent, the blood 27 per cent, the kidneys 26 per cent, and the brain and spinal cord only 3 per cent, and the heart 2 per cent. The proportion of the total body weight that can be lost and still not interfere with the life of the "Hofmann, Ger. Med., 1902. "Falck, in Maschka's Handbuch der Haller, cited in Fodéré's Traité de ger. Med. Méd. Lég., III. person has been estimated at from 25 to 40 per cent. A great deal depends upon the condition of the body before starvation begins. The following is an interesting example of the deception practised in connection with many of the cases of professed long fasts:16 In 1869, a girl, twelve years of age, in Carmarthenshire, Wales, excited a vast amount of interest from the statement that she had lived for two years without eating or drinking, except a drop of water which was placed on her lips every few days. It was also asserted that nothing was evacuated from her bowels, but that every nine days she passed a drachm or two of urine. She occasionally had "swooning fits." The parents positively denied that any food was given her, and many persons believed their account of the case. The girl was confined to bed, but looked fat and rosy. At the request of her father, who expressed a strong desire that the case should be investigated, a committee, consisting of the vicar of the parish, a surgeon, and several gentlemen and respectable farmers, met and determined to have the girl closely watched. For this purpose four nurses were sent from Guy's Hospital, London, one of whom was to be in constant attendance on the case. The watching began on Dec. 9th, and ended with the girl's death on Dec. 17th, 1869. On December 11th, she is reported as not looking as well as usual, but up to the 14th she is stated to have been cheerful and amused herself with reading. On December 12th stains of excrement were observed on her dress. On the 13th she passed a large quantity of urine, and on the 14th and 15th smaller amounts were voided. For three days before death her extremities were cold, and during the last two days she was very restless. She asked for no food and made no confession of imposition. There was no attempt made to force her to take food, but it was offered to her on the day of her death. "She made no reply, but appeared to go off in a fit.” On the same day her father refused to allow the surgeon in attendance to give her food, but afterwards, "when it was too late," he consented. The post-mortem examination was made by Mr. J. Phillips and Mr. Thomas, and the following appearances, due to the acute starvation, were noted:17 "Exterior.-Hair nearly black, long, and plentiful; eyes very sunken, pupils dilated; very handsome features; left cheek still 15 Lancet, London, 1869. "Medical Times and Gazette, Jan. 8, 1870, p. 45. |