CHAPTER X
DEATH FROM STARVATION, COLD, HEAT, BY LIGHTNING AND ELECTRICITY
DEATH FROM STARVATION
Death from starvation may be due to the total withdrawal of food, to prolonged insufficiency, defective quality, inability to swallow it, and inability to retain it.
Death from starvation may occur during famines, amongst ship-wrecked sailors, and persons entombed in mines or pits, and is due to sheer privation. It may follow criminal starvation, wilful refusal to take food as a form of suicide, and it has been noted in cases of hysteria and lunacy.
It may result from mechanical hindrance to the entrance of food into the body from ankylosis of the jaws, or its passage through the alimentary tract from stricture of the œsophagus or stomach, from cancer or cicatrisation after injury from swallowing corrosive substances. Amongst other diseases, tuberculosis, malignant disease, and diabetes mellitus are the chief which produce external appearances of starvation.
In the withdrawal or deprivation of food for criminal purposes the victims are usually old, helpless, or feeble-minded persons, or young children.
Symptoms.--These depend on the previous state of nutrition. Starvation may be regarded as acute when death occurs within fourteen days from the withdrawal of food, chronic when at a longer period.
The symptoms of hunger vary: they are said to pass off in forty-eight hours, but may last for several days acutely.
The body temperature falls below normal, and the fall may be two or three degrees before death. The pulse gradually increases in frequency day by day. The chief sign is loss of body weight. Chossat‘s experiments on pigeons showed that when they were totally deprived of food, the surplus fat of the body was lost first, then the fatty coverings of internal organs, the interstitial fat of muscles last of all; the muscles themselves also wasted. A peculiar odour like acetone emanates from those who have been starved, and towards and after death the odour is putrescent.
In addition to the above signs, there are anæmia, sunken, glistening eyes with dilated pupils, prominence of bony projections, pale and dry lips and tongue, parched mouth and throat, weakness of the voice, sunken abdomen, wasted limbs, constipated bowels, urine scanty and turbid. There are pains in the abdomen, relieved by pressure; great thirst, a dusky, dry skin, occasionally purpuric eruptions, exhaustion, ultimately delirium ending in death.
=Post-mortem Appearances.=--There is emaciation of the whole body, dry, wrinkled skin of a brown colour; the muscles are flabby and wasted, the abdomen sunken, the eyes red and open; this appearance is not common in death from other causes. The mouth and throat are dry even to aridity. The heart, lungs, and blood-vessels are collapsed, and contain but little blood. The abdominal viscera are shrunken and without enveloping fat. The omentum is devoid of fat, and clear; the gall bladder is full of dark bile; the urinary bladder may be quite empty. The stomach and intestines are collapsed, contracted, and empty, and the walls extremely thinned.
=Diagnosis.=--The absence of any other cause of death--such as cancer of the stomach, stricture of the œsophagus, &c.--and the previous history of the case will assist in forming an opinion, care being taken not to confound the results of wasting disease with those due to starvation.
=Legal Relations.=--The question of death from starvation may be raised in a case of infanticide by omission. Although rare as an act of homicide, it must be remembered that the law does not require the absolute deprivation of food to be proved, but only that the necessary quantity and quality of food has been withheld; but malice at the same time must be proved. In cases of infanticide by starvation, the mother and not the father is responsible for the proper feeding of the child; but in the case of an apprentice, the master and not his wife is bound to supply proper food to such apprentice.
In questions of survivorship, and in criminal cases, the medical witness may be asked how long a person may survive after complete withdrawal of food. Little is known as to the length of time required to cause death by starvation, but it is certain that life may be prolonged for some time without food, if water be allowed. Starvation is less rapid in its effects if the body be kept warm. In a case recorded in the _Lancet_, a man who had been shut up in a coal-mine for twenty-three days, with only a little dirty water to drink, lived three days after his liberation, and then died of exhaustion. In adults the average is from seven to ten days without water. Tidy (_Legal Medicine_, vol. i. p. 392) is of the opinion that the young die first, then adults, and the aged last. Taking into account the enfeebled vitality of the aged, it is more probable that the young or middle-aged adult would survive the longest. Where water is freely obtainable, life may be prolonged to the fifty-eighth day (_Foderé_, vol. ii. p. 276) or even more.
Apart from age, account must be taken of the condition of the person in reference to bodily health prior to the withdrawal of food.
The following tables, showing the average weight and height of children up to twelve years of age, are from the Report of the British Anthropometric Committee (1883):
Male Children
+------------+-----------+ | Age. | Weight in | | | Pounds. | +------------+-----------+ | At birth | 6.8 | | One month | 7.4 | | Two months | 8.4 | | Three “ | 9.6 | | Four “ | 10.8 | | Five “ | 11.8 | | Six “ | 12.4 | | Seven “ | 13.4 | | Eight “ | 14.4 | | Nine “ | 15.8 | | Ten “ | 16.8 | | Eleven “ | 17.8 | | Twelve “ | 18.8 | +------------+-----------+
+------------+-------------------+-------------------+ | | Height in Inches. | Weight in Pounds. | | Age. +----------+--------+---------+---------+ | | Female. | Male. | Female. | Male. | +------------+----------+--------+---------+---------+ | One year | 27.5 | 33.50 | .... | 18.8 | | Two years | 32.33 | 33.70 | 25.3 | 32.5 | | Three “ | 36.23 | 36.82 | 31.6 | 34.0 | | Four “ | 38.26 | 38.46 | 36.1 | 37.3 | | Five “ | 40.55 | 41.03 | 39.2 | 39.9 | | Six “ | 42.88 | 44.00 | 41.7 | 44.4 | | Seven “ | 44.45 | 45.97 | 47.5 | 49.7 | | Eight “ | 46.60 | 47.05 | 52.1 | 54.9 | | Nine “ | 48.73 | 49.70 | 55.5 | 60.4 | | Ten “ | 51.05 | 51.84 | 62.0 | 67.5 | | Eleven “ | 53.10 | 53.50 | 68.1 | 72.0 | | Twelve “ | 55.66 | 54.59 | 76.4 | 76.7 | +------------+----------+--------+---------+---------+
Table of Ages, Heights, and Weights of Males and Females from 13 to 30-35 Years of Age +---------------+------------------------+-----------------------+ | | Males. | Females. | | +------------+-----------+-----------+-----------+ | Years of Age. | Height in | Weight in | Height in | Weight in | | | Inches. | Pounds. | Inches. | Pounds. | +---------------+------------+-----------+-----------+-----------+ | 13 | 56.91 | 82.6 | 57.77 | 87.2 | | 14 | 59.33 | 92.0 | 59.80 | 96.7 | | 15 | 62.24 | 102.7 | 60.93 | 106.3 | | 16 | 64.31 | 119.0 | 61.75 | 113.1 | | 17 | 66.24 | 130.9 | 62.52 | 115.5 | | 18 | 66.96 | 137.4 | 62.44 | 121.1 | | 19 | 67.29 | 139.6 | 62.75 | 123.8 | | 20 | 67.52 | 143.3 | 62.98 | 123.4 | | 21 | 67.63 | 145.2 | 63.03 | 121.8 | | 22 | 67.68 | 146.9 | 62.87 | 123.4 | | 23 | 67.48 | 147.8 | 63.01 | 124.1 | | 24 | 67.73 | 148.0 | 62.70 | 120.8 | | 25-30 | 67.80 | 152.3 | 62.02 | 120.0 | | 30-35 | 68.00 | 159.8 | 61.15 | 120.8 | +---------------+------------+-----------+-----------+-----------+
Recapitulation of the Post-mortem Appearances of Death by Starvation
1. _In the Body generally._--Marked general emaciation of the body. The skin is dry and shrivelled, sometimes more or less covered with unhealthy-looking pimples, the muscles soft, reduced in size, and free from fat. A peculiar fœtid acrid odour is given off from the body.
2. _In the Solid Viscera of the Thorax and Abdomen._--The liver is small, the gall-bladder distended with bile, and the heart and kidneys deprived of any surrounding fat. All the internal organs are shrivelled and bloodless.
3. _In the Stomach and Intestines._--The stomach in some cases is quite healthy, but more or less stained with bile; in others it is found collapsed, contracted, empty, and the mucous membrane more or less ulcerated. The intestines are thin, contracted, empty, and so shrunken that the canal is almost obliterated. According to the late Dr. Duncan, the intestines are frequently found inflamed and ulcerated.
DEATH FROM COLD
This form of death is rare in England, but is more common in countries where the winters are severe. Anything that depresses the vital powers renders the individual more or less susceptible to cold; such, for instance, as drunkenness, previous illness, or deficiency in the amount of food. The following _post-mortem_ appearances are given by Ogston, who holds that they point, in the absence of any other obvious cause of death, “if not with absolute certainty, yet with high probability,” to death caused by cold:
1. An arterial hue of the blood generally, except when viewed in mass within the heart; the presence of this coloration not having been noted in two instances.
2. An unusual accumulation of blood, as in Quelmalz and Cappel‘s cases, on both sides of the heart, and in the larger blood-vessels of the chest, arterial and venous.
3. Pallor of the general surface of the body, and anæmia of the viscera most largely supplied with blood. The only exceptions to this were moderate congestion of the brain in three cases, and of the liver in seven of them.
4. Irregular and diffused dusky-red patches--“frost erythems”--on limited portions of the exterior of the bodies, encountered in non-dependent parts, these patches contrasting forcibly with the pallor of the skin and general surface.
These signs are not so well marked in children as in adults. The late Sir Benjamin Brodie considered that the effect of cold is to destroy the principle of vitality equally in every part, and that it does not exclusively disturb the functions of any particular organ. The fact of a body being found frozen is no proof that death has been brought about by cold.
Symptoms.--Exposure to severe cold produces loss of energy, lethargy, followed by drowsiness, with an intense desire to sleep, which, if gratified, passes on to stupor and coma. There may be delusions before the coma. The primary cause of death is attributed to the lessened dissociation of oxygen from the hæmoglobin to the tissues, and a lessened power of the latter to utilise it.
=Diagnosis.=--The general appearance of the deceased, and the absence of any other cause of death, together with the appearances just mentioned, will assist in forming an opinion on this difficult subject. The body lies as if in a deep and calm, sleep, without any external appearance to guide us as to the cause of death, except perhaps a swelling of the extremities, which has come on prior to death. If a body be found buried in snow, and putrefaction present, death did not in all probability take place from cold, provided that the cold has been severe and continuous. Death from cold is generally accidental, except in newly-born children, when it may be either accidental or homicidal, according to circumstances.
When freezing of the body has taken place prior to the onset of _rigor mortis_, the latter comes on after the body thaws. This, combined with the other _post-mortem_ signs given above, affords evidence of the strong probability that death had resulted from exposure to cold. In view of the red colour of the skin being similar to that caused by poisoning with CO, a spectroscopic examination of the blood should be made.
DEATH FROM EXPOSURE TO HEAT
The results from exposure to excessive heat manifest themselves in various ways. Any condition which may lessen the resistance of the body to external heat predisposes to heat-stroke; such as privation, fatigue, mental emotions, alcohol, over-eating, and especially previous attacks of the disease.
=Sunstroke= occurs in those who work under the direct rays of the sun, when the air is hot, still, and humid.
=Heat-stroke= or thermic fever affects those working in places which are excessively hot and confined, as in glass-works, foundries, stoke-holds, boiler-houses, sugar-refineries, paper-mills, &c.
=Heat exhaustion= and prostration are brought about in a similar manner, but the effects are not the same, and usually transient and less severe.
Sunstroke or heat-stroke may occur in two forms, the _asphyxial_ or _apoplectic_, and the _hyperpyrexial_; it is also classified as sthenic or asphyxial, and asthenic or syncopal.
_Asphyxial_ sunstroke or _heat apoplexy_ is probably the least frequent; prodromal symptoms are headache, vertigo, disturbances of vision, dyspnœa, and dry skin. In some cases sudden unconsciousness, with or without convulsions, may occur, and death rapidly follows.
The coma may not be profound; there may be nausea and vomiting of dark material, bounding pulse, stertorous breathing, contracted pupils, and frequent micturition. The body exhales a “mousey odour.” There may be involuntary dejection, with the same pungent odour, and very watery. Delirium is present in some cases. The temperature may be subnormal, or rise to 102° F., occasionally even to 106° F. When fatal, the coma deepens, the pulse becomes rapid and feeble, and there is Cheyne-Stokes respiration.
In _Hyperpyrexial_ cases the symptoms are similar to the asphyxial, but the temperature may reach 110-115° F., and in profound coma death takes place from asphyxia. A subconscious or automatic state, in which the person may go on working, may precede the “stroke.”
In cases which are not so rapid, pneumonia, meningitis, cardiac and respiratory paralysis may occur and prove fatal.
_Heat exhaustion_ may be more gradual in its onset, or come on suddenly. Prodromal dizziness, faintness, nausea, headache, drowsiness, epigastric and lumbar pains may precede the prostration and muscular weakness. Fever supervenes, a rapid pulse, and in severe cases collapse. Consciousness is seldom completely lost, and in favourable cases is quickly regained. When there is marked prostration the heart may fail.
The condition known as _heat prostration_ is a milder form, in which there is little or no fever, and the circulation remains good.
After suffering from an attack of heat-stroke certain sequelæ have been noted. The patients are rendered sensitive to slight elevations of temperature, and, during warm weather, experience chromatopsia, headaches, irritability, irascibility, and even delirium. Epilepsy and insanity may persist during life. Fiske from his investigations concludes that the habits of those working in hot atmospheres, and the degree of temperature, are not nearly so important as the absence of thorough ventilation as causative factors in the disease.
=Post-mortem Appearances.=--_Rigor mortis_ comes on early, and is pronounced and disappears quickly. Putrefaction is early in onset. The brain and cord, the lungs and spleen and splanchnic area exhibit venous engorgement.
The blood is fluid, and the red corpuscles crenated. Extravasations of blood may be present in the skin, the serous membranes, and cavities, the superior sympathetic ganglia, and the vagi and phrenics. The left ventricle is markedly contracted, the right dilated and filled with blood.
Van Gieson records acute parenchymatous degeneration of the whole of the cerebro-spinal nervous system, with chromatolysis of the cells. Parenchymatous changes may be present in the liver and kidneys.
DEATH BY LIGHTNING AND ELECTRICITY
LIGHTNING
Death is not always immediate. Sometimes the clothes have been torn off the body with scarcely any personal injury. _Metallic articles, especially steel, worn or carried about the person become magnetic_ and may be fused. The lesions which may be met with after lightning-stroke are varied, and may comprise wounds of almost any description; simple, compound, or comminuted fractures of bones; burns in the form of streaks, patches, lines, or arborescent markings; ecchymoses; singeing of the hair; impressions of metallic articles on the skin. Apart from the lesions noted above, the following symptoms may be present: deafness, blindness, paralysis, loss of memory, delirium, and convulsions. Not infrequently those killed by lightning are found in the same position that they occupied during life. The question may arise as to whether the deceased died by lightning or violence. The presence of a storm at the time when death is stated to have occurred, and other attendant circumstances, will in most cases point to the true cause of death. Metallic articles should be examined with regard to their electric state. Dr. Honiball tenders this caution: “Be not too sure that in every body found dead after a thunderstorm, and where no marks upon it are found, that death was due to lightning-stroke, for it may happen that death was due solely to cardiac syncope owing to sudden and startling fright.”
=Post-mortem Appearances.=--Apart from the external injuries, when present, _post-mortem_ rigidity comes on early. The head and neck may be purplish in colour, the eyes partially open and suffused, with variable pupils. The internal signs are not characteristic. The membranes and vessels of the brain may be hyperæmic. The blood has been said to be very fluid, but it may be coagulated. The internal organs may be torn, bones may be fractured, and blood-vessels ruptured.
Industrial Electricity
With the increased use of electricity for motive power and illumination instances of injury and even death have occurred, and probably will become more frequent. One of the most important safeguards of the body against the effects of electricity is its high degree of resistance, especially if the body surface be dry. Moisture of the body surface lessens the resistance and increases the liability to injurious effects.
The body is a bad conductor; it is said to be three million times less than mercury, and fifteen million times less than copper; the nerves conduct like metals. The danger of electric shocks depends upon the amount of current passing through the body, the kind of contact, and the insulation of the body at the time. Moisture of the body or clothes will increase the effects of the shock. Much depends upon the quality, duration, strength, and density of the current, and the direction in which it passes.
The continuous current is less severe than the interrupted, and the alternating is the most powerful in its effects. An alternating current of 300 volts has caused death, and one of 1500 volts would certainly prove fatal, whereas for the continuous current it would take 3000 volts to prove fatal.[13] Cases are recorded when with good contact even so low as 65 volts has proved fatal. The Board of Trade forbids the introduction into dwelling-houses of currents of more than 250 volts, unless for special purposes and with special permission.
[13] Cunningham, _New York Med. Journ._, 1890, p. 287.
As the current enters or leaves the body it may cause local injury. Tetanic muscular contractions with pain, and pain from stimulation of nerve endings in the skin with erythema may occur. Burns produced by electricity may be accompanied by much local destruction of tissue and slow healing.
There may be ascending neuritis from injury to nerves.
The shock may cause insensibility with pallor and stertorous breathing; the skin is moist, the eyes suffused, and the pupils dilated.
Death is due to (1) inhibition of the medulla oblongata, or (2) direct
## action on the heart muscle. According to the researches of Cunningham,
currents which traverse the whole body transversely or longitudinally produce fibrillary contraction of the heart muscle. When the current passes through the brain, medulla, and upper cord it may cause death by respiratory paralysis. Those who have recovered from severe shock describe the sensation as peculiar rather than painful.
_Post-mortem Appearances._--These include the local injury, if any, at the point or points of contact, some hyperæmia of the internal organs, œdema of the lungs, and fluidity of the blood. The general appearances are those of asphyxia. Kratter considers that external burns in association with subpericardial and subpleural ecchymoses, and especially subendocardial petechiæ, also the presence of congestion of the bronchi, strongly indicate death from electricity.
Minute hæmorrhages may occur in the meninges, and in the fourth and other ventricles. Changes have also been described in the cells of the central nervous system in experiments upon animals.
_Treatment._--The current should be switched off at once; the patient should be removed from the conductor, the rescuer being protected with some insulating material, the attempt should not be made bare-handed.
Stimulation, warmth, and artificial respiration should be resorted to. After respiration has been re-established, friction should be applied to the body. The treatment should be persevered in for several hours. Signs of life may not be seen for two hours. Venesection may be desirable.
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