Definitions
Starvation: is the result of irregular or continuous deprivation of nutrients (food alone, or food
and drink both) necessary for the maintenance of the body.
Inanition: It refers to the exhausted state due to prolonged undernutrition caused by lack of
assimilation of food by the tissues.
Neglect: Failure by person responsible to provide for the individual's basic needs like food, care,
shelter or medical attention. It can be a form of child abuse. In general, neglect is an act of
omission.
TYPES OF STARVATION:-
1) Acute starvation or total fasting:-which results from sudden and total withholding of
food, or food and drink.
2) Chronic starvation or malnutrition:- which results from prolonged, but gradual and
continuous deficiency in the intake of food and nutrients.
MODE OF STARVATION:-
A) Failure of Taking Food:-
i. Ignorance: Lack of knowledge of gross nutrition value of foodstuff, particularly
among uneducated masses.
ii. Diseased conditions: Low intake (e.g., diabetes), loss of appetite (e.g., major
depressive disorder), deficient absorption (e.g., celiac disease) or inability to eat (e.g.,
carcinoma esophagus).
iii. Deliberate (neglect): Deliberate improper feeding, or withholding of food in case of
unwanted baby, old, a invalid or diseased family member.
iv. Circumstantial: Accidents (e.g., shipwreck, air crash or colliery entombment) or
famine.
B)Refusal to Take Food:-
i. In observance of religious rituals which is common in India.
ii. Intentional fasting as a form of protest against some alleged injustice-hunger
strike or fast-unto-death.
iii. Mental illnesses, like schizophrenia or anorexia nervosa.
SIGNS AND SYMPTOMS:-
ACUTE STARVATION:- In the beginning, there is initial feeling of hunger and hunger pains
for first 2 days with craving for food wearing off very rapidly. Intense thirst is felt along with
epigastric pain and subsequent loss of sense of thirst. This is followed by both mental and
physical lethargy, fatigue, irritability, loss of libido and progressive loss of weight. Later,
emaciation sets in and the body emits an offensive odor. As the starvation continues, the lethargy
becomes extreme, with mental impairment, loss of self-respect and interest in everything.
Characteristic findings:-
Skin: Dry, dirty, lusterless, loose, cracked and inelastic with increase of pigmentation, creases
and wrinkles.
Face: Eyes-shruken, pupils-dilated, lips-dry and cracked, cheek-shallow with prominent malar
bones
Tongue: Dry, furred and coated, foul smelling breath.
Temperature: Hypothermia with sensitivity to cold.
Blood pressure: Hypotension.
Pulse:- quick, weak and feeble.
Abdomen:- concave, prominent ribs and hip bones.
Bowel: Constipated in early phase, followed by diarrhea and dysentery.
Renal: Oliguria with concentrated, highly acidic urine.
Muscle: Atrophy leading to weakness.
All bony joints and bones look prominent.
Cause of death: Dehydration with progressive cardiac insufficiency. Loss of 40-50% of original
body weight usually leads to death.
CHRONIC STARVATION:-
Anemia (first sign), hypoproteinemia, emaciation, weak pulse and blood pressure, cyanosis, and
edema of feet, legs and face with ascitis, hepatitis, diarrhea or Dysentery.
Reduced resistance to infections in general, and development of bronchopneumonia,
tuberculosis and enterits along with poor wound healing.
In females, irregular menstruation can occur.
Loss of weight is very rapid in the first place, but becomes slower after 3 months.
In the terminal stages, adults may experience a variety of neurological and psychiatric
symptoms, including hallucinations and convulsions, as well as severe muscle pain and
disturbances in heart rhythm.
Cause of death: Prolonged caloric deficiency with subsequent complications, such as multiple
organ failure, severe sepsis and ventricular fibrillation are major causes of death.
Fatal Period:-
Total withholding of food and water: 14-21 days.
With total deprivation of food only: 3-6 weeks (8-12 weeks in some
Factors influencing the fatality:-
Age: Children and infants are most vulnerable. Old person stands starvation better.
Sex: Women stand starvation better than men due to their body fat.
Body condition: Fatty and healthy individual stands starvation better.
Environmental factors: Exposure to cold and extreme heat shortens life.
Intercurrent infection: It may cause early death.
Physical exertion: It will enhance the effects of starvation.
POSTMORTEM FINDINGS:-
Internal Examination:-
• Loss of adipose tissue from omentum, mesentery and perirenal fat stores
•Atrophy of organs(except brain) with reduction
In size.
•Heart is small from brown atrophy.
•Lungs are pale and collapsed.
•Stomach and intestine shows atrophy of all coats and mucosa is stained with bile.
•Bowel contain offensive watery fluid and gas
• Liver is atrophied show necrosis due to protein deficiency
•Spleen is shrunken
•Gall bladder is distended with bile
•Kidneys shows atrophy of nephrons
•Blood volume is markedly reduced
• There may be some evidence of some incurrent disease.
External examination:-
• In children, skeleton shows spinal curvature, rickets and dental defects
•Face is pale, the skin inelastic and pigmented
•Edema around ankles and inside the thighs, in wet type there is marked edema, ascites and
pleural effusion.
• Eyes are sunken, cheek bones appear prominent
•Hair is dry, and brittle
•Tongue is dry and thickly coated.
•Nails are brittle and ridged.
•Limbs are almost skeletal.
•Ribs are prominent.
•Abdomen is scaphoid.
MEDICO-LEGAL QUESTIONS:-
Q. Whether the death was caused by neglect and starvation?
The diagnosis of neglect and starvation is done on the basis of history and postmortem findings.
Before opining on starvation as cause of death, the doctor should rule out tuberculosis,
carcinoma, stricture of esophagus, anorexia nervosa, radiation sickness, pernicious anemia,
inflammatory bowel disease and Addison’s disease (chronic adrenocortical insufficiency).
Q. Whether it was suicidal/homicidal/accidental starvation?
If the diagnosis of death as a result of starvation is established, the underlying cause of starvation
has to be determined: any pre-existing disease or deliberate withholding of food or neglect.
Suicidal: Some individuals starve voluntarily for the fulfillment of their grievances. Sometimes,
prisoners, mentally-ill or hysterical women may refuse to take food. Fasting may also be
undertaken to attract public attention.
Homicidal: These cases are related to elderly person or victims of child abuse. It is mostly seen
in illegitimate children who are starved to death, by depriving them of food and exposing to
severe cold.
Accidental: It may occur during famine, shipwreck or trapped in mines or landslides during
earthquakes.
• Deaths caused by starvation are mostly natural deaths in India, accidental cases are also
common.
• It relatively rare in the US/industrialized countries. For the most part, they occur either as a
result of child abuse, fasting or in mentally-ill person.
