* Chapter X Death from Starvation, Cold and Heat STARVATION Starvation results from the deprivation of @ regular and constant supply of food, which is necessary to maintain the nutritional balance of the body. Starvation is regarded as acute, when the necessary quantity of food and water are suddenly and completely withheld, and chronic, when there is a gradual deficient supply of food. In India, famine deaths due to starvation is well known, though itis not 80 common now. Inanition is the opposite of obesity, while cachexia: simply means severe inanition, Clinical Features In acute starvation, the feeling of hunger lasts for the first thirty to forty-eight hours, succeeded by pain in the epigastrium which is relieved by pressure, and accompanied by intense thirst. After four or five days of starvation, general ‘emaciation and absorption of the subcutaneous fat begins to occur. The eyes appear sunken and glistening, the pipils are widely dilated, the cheeks are hollow and the bony projections of the face becomes prominent. The lips are dry and cracked, the tongue becomes dry and coated with thick fur, and the breath is foul and offensive. The voice becomes weak, faint and inaudible; apathy and fatigue are predominant, The skin is dry, rough, wrinkled and baggy, emitting a peculiar disagreeable odour. The pulse is usually weak and slow, but accelerates on the slightest exertion. The temperature is usually. subnormal, the diumal variation reaching 1,8°C instead of 0.17°C to 0.56°C, as in a normal body, The abdomen is sunken, and the extremities become thin and flaccid with loss of muscular power. Some oedema appears on the face and feet. In the beginning, 295 Scanned with CamScannerMedtical Jurisprutence the patient suffers from constipation, the motion being dry and dark, but later towards death, diarrhoea or dysentery generally supervenes, The urine is scanty, turbid and highly concentrated and shows evidence of acidosis. The loss of weight 1s most marked and constant, The body weight decreases by about 7.4 kg. in the course of ten days.' The loss of two-fifths or 40 per cent of the body weight ordinarily ends in death, Total starvation causes excessive protein breakdown, and may cause fainting due to diminution in the extra-cellular fluid ‘volume because of sodium loss. The brain tissue is the least affected. The intellect remains clear until death though, in some cases delusions and hallucinations of sight and hearing may be met with, Occasionally, delirium and convulsions or coma precedes death, In chronic starvation, the emaciation is more marked and death may occur: after a prolonged period from some inter-current diseases, such as anaemia, ‘malaria, pneumonia, bronchopneumonia, meningitis, enteritis, tuberculosi typhus ete, because of diminished resistance as a result of hypoproteinaemia, Based on the observations made on the prisoners of war in England during 1945, the description of cases of chronic starvation can be divided into two types, namely, dry and wet types of cases. The dry cases were characterised by extreme emaciation, fatigue, mental apathy, diuresis and loss of weight varying, from 39 to 50 per cent of the original weight. In severe cases, the pulse was impalpable, the blood pressure unobtainable and the colour was grossly cyanotic. Slight oedema was seen on the feet. In. wet cases, there was gross oedema, which affected feet, legs, arms and the face, and was frequently associated. with ascites and pleural effusions. Pyrexia and watery diarrhoea was common in both the types of cases.-The men ‘were eunuchoid in appearance and the women in many cases had acquired male characteristics. There were complete loss of moral standards and human kindness. Anaemia was usually present, Fatal Period Death occurs within ten to twelve days, if the person is completely deprived of both swater-and food. Prolonged fasting with free access to water is well tolerated.’ If food alone is withdrawn, life may be prolonged for a longer period, say from six to eight weeks or even more, since some Jain sadhus are reported to have fasted for two to four months without taking anything but boiled water. ‘A middle aged Jain woman, of Mangrol (Saurashtra). died @ 13-day fast which she had undertaken. for self- ation.* puri 1 MT Harrison & Harden, R Mac, Lancet 2: 1340, 1960. 2 Janet Vaugham, Medical Annual, 1946, 326; see also JJ Bose, UN De, and P Mukherjee, MR, Vol 34, May 1946, 143, 3. WL Bloom, Metabolism, 8: 214, 1959. 4 TOL, 9 Oct 1983 296 j Scanned with CamScannerDeath from Starvation, Cold and Heat Professor Bhansali fasted for sixty-two days. During ‘the first fifteen days, he’ took neither food “nor water and walked about 90 miles. During the remaining period of forty-seven days, he took only water. His weight was 116 1bs before he started fasting which was reduced to 63 ‘bs, three days before he broke his fast. ‘Mayor Me Swiney abstained from food in Brixton prison for seventy-five days before he died, while Jaintindra Nath Das, the accused in the Lahore Conspiracy case, died in the Borstall jail after sixty-one days hunger strike. IRA nationalist‘ Raymond McCreesh died on the sixty-first day of ‘hunger strike.® ‘A fifty year old Jain woman successfully completed a one hundred and eight day religious fast. She had only-boiled water during the entire period of fasting.® Age: Children suffer most from want of food. Old People requite less nourishment than young adults, and therefore can withstand the deprivation of food better, but not for a longer period owing to the weakening of the vital functions. Sex: Females can withstand starvation for longer period than males, as they have a relatively greater amount of adipose tissue in their bodies and ‘érdinarily consume less food. Fat inthe female breasts and of the orbit is spared until late, Condition of the Body. During starvation, a man undergoes a series of metabolic adaptations in order to derive energy from the adipose tissues and to conserve his protein reserves. The brain utilises ketoacids, -hydroxybutyrate and acetoacetate to spare’ glucose and protein. It js, therefore, natural that fat and healthy people are likely to endure the withdrawal of food better and longer than thin, lean and weak persons. Environment ofthe Body‘ The effects of a Jare not felt as long as the body meer is maintained by suitable clothing. Exposure to. cold tends.to shorten the period of life. Exposure to excessive heat also. accelerates.the onset of death, if-a sufficient quantity, of water is not available. Starvation is. well bome by those persons, in whom the activity of $ 1E,22 May 1981. € 26 ME, IS Oot I9BI, 7 NEJM, 9 Masch 1970, on. Scanned with CamScannerMedical Jurisprudence their vital functions is lowered, as in the catalepic, On the other hand, active physical exertion during starvation hastens death, Treatment ‘A person who is suffering from prolonged starvation, as the digestive processes becomes very feeble; caution is required while giving food. Solid food should not be given at once, as itis likely to set up an attack of serious indigestion, and even death, It is advisable to give sips of warm water first, followed by fruit juice with glucose, and then gradually small quantities of skimmed milk. Feeds should consist of small quantities at a time, repeated at frequent intervals. ‘Adequate vitamins should be given. The simplest and the most easily digestive liquid foods is advised, and solid foods should be added gradually with care, when the stomach has regained its digestive power. The warmth of the body can ‘be maintained by the application of hot water bottles, and by rubbing the surface gently with stimulating lotions. Diffusible stimulants may be given hypodermically or by the mouth. Postmortem Appearance () External ‘The body is greatly emaciated and emits a disagreeable offensive odour. A careful. examination may reveal evidence of violence, suggesting neglect and cruelty. The eyes are dry, red and open with sunken eyeballs. The cheeks and temples are hollow. The tongue is dry and coated, The skin is dry and shrivelled, and is, sometimes, excoriated or ulcerated, Bedsores are often present. The muscles are pale, soft and wasted, and the fat is almost completely absent in the subcutaneous and intraceltular tissues, as well as in the omentum, mesentery, al around fheintemal organs. Some fats may be present in cases where death cCtrred rapidly from the sudden withdrawal of both food and water. It : ld be remembered, that the entire absence of fat throughout the body is never seen in wasting diseases, such as tuberculosis, diabetes, ete. (i) Internal The brain is usually normal, although it is sometimes pale and soft, The ‘meningeal vessels are congested, and there is frequently some serious effusion in the ventricles. The heart is smaller in'size, and the muscles are’ pale and flabby. The chambers are generally empty. The lungs are pale and collapsed, and exude very little blood when cut. At times, the lungs may be oedematous, and may show hypostatic congestion at the base. The heatt; reduced in size and Weighing 130-150 g, shows brown atrophy. A transparent gelatinous material replaces the sub-epicardial fat. The stomach is small, contracted and empty. It may contain undigested food; if it was given to the deceased shortly before death, in order to avert a suspicion of willful starvation. The mucous membrane | of the stomach and the upper part of the small intestine are more of less stained | 298 Scanned with CamScanner| Death from Starvation, Cold and Heat | with bile. The intestines are empty and contracted, but the lower portion of the large intestine may sometimes contain hard, scyballous faecal matter, and may often present more or less evidence of inflammation. Fat is absent from the mesentery and the omentum. These hollow viscera shows an extensive thinning | and translucency of their walls indicating thereby, that no food has passed through the stomach for a considerable time. Sometimes ulcers can be found in their walls; these are very likely due to irritation resulting from the injudicious ingestion of substances to appease hunger. The atrophied’ liver may show necrosis due to protein deficiency, the spleen, the kidneys and the pancreas are small and shrunken. The gall bladder is usually distended and contains dark, inspissated bile. The urinary bladder is empty. Modi exarnined the body of a twenty year old Mussammat Samita, who’ died about twenty-five days after having received an injury in the neck, which completely divided the larynx and the pharynx, so that no food could pass down the throat. The body was thin and emaciated, and reduced almost to a skeleton. There was no fat arond the breasts which had all atrophied, leaving only the dark nipples. Internal examination showed that the brain was normal and its membranes were congested. The lungs were congested at the bases, and the right lung showed evidence of grey hepatisation. The chambers of the heart were empty. The stomach was corrugated and empty, weighing four ounces. Its mucous membrane was rough, corrugated and congested at places. The small intestine was shrunken and ‘empty, the mucous membrane was pale, except’ at the lower part, where it was congested. The large intestine contained dry faecal matter in its lower part. The liver was small, weighing 34 ounces. The spleen was shrunken and weighed three ounces. The kidneys were congested, each Weighing two ounces. The gall gladder contained dried bile, ‘and the urinary bladder was empty. Medico-Legal Questions, ‘The medico-legal questions areas given below. (i) Whether death was caused by starvation? (Gi) Whether the starvation was suicidal, homicidal or accidental? () Whether Death was Caused by Starvation? v Caution is needed while giving an opinion regarding death, which may have been caused by acute ot chronic starvation, There are. certain. pathological conditions, namely, malignant. disease, progressive muscular atrophy, Addision’s disease, diabetes mellitus, tuberculosis, pernicious anaemia, anorexia nervosa which leads to progressive wasting and emaciation of the body. It is therefore necessary, 10 carefully éxamine all the internal organs and to search Scanned with CamScannerMedical Jurisprudence for the existence of any one of these diseases while holding a post-mortem examination, before one can, give the opinion that death occurred from starvation. 1 (ii) Whether Starvation was Suicidal, Homicidal or Accidental? Suicidal starvation is rare, though it may’be seen among lunatics or prisoners, who may go on a ‘hunger strike’ Voluntary starvation for religious or political reasons is well known. In this connection, it must be remembered ‘that: the forcible feeding of prisoners, when they refuse to take any food on account of passive resistance, is not an assault but is quite lawful. The declaration of Tokyo (1975), that lays down the guidelines for medical officers concerning torture and other cruel, inhuman or degrading treatment or punishment should be referred, when a prisoner refuses nourishment, ‘The medical officer is confronted by two conflicting ethical imperatives; his duty to do all that is in his power.to save life, and his obligation to respect the right ofa rational patient to refuse even a life- saving intervention. This ethical dilemma may be° resolved by different physicians in different ways’and their judgement may be influenced by factors like the age, personality, family status of the prisoners, and the duration of their prison sentence etc. This categorical repudiation of forcible feeding of a prisoner, as enunciated in the Declaration of Tokyo, overlooks some medical and ethical problems. Whether. a prisoner (slowly dying of self-imposed starvation) remains, until the moment of death, in a sound mind to understand the consequences of his act, is questionable, Where :a prisoner refuses nourishment and. is considered by the doctor as: capable of forming an unimpaired and rational judgement conceming the:consequences of such a voluntary refusal of nourishment, s/he shall not be fed artificially. The decisions regarding the capacity of the prisoner to form such’a judgement should be confirmed by at least one or the othet independent doctors, The doctor shall explain the consequences of the refusal of nourishment to the prisoner. The personal opinion of the President of the General Medical Council (GMC), UK is that, feeding a prisoner against his wishes, provided that it is lawful and designed to preserve health would not be regarded as a serious professional misconduct, Similarly, if a practitioner found’‘forcible! feeding- ethically repugnant, he would not be deemed to have acted unprofessionally.* Loss of weight and acidosis are two definite criteria for medical officer to advise forced feeding in a person’ who is on a hunger strike; this will need repeated examination for a careful decision. __ln India, there are instances: where women, ‘who ‘imagine that they are possessed by deities, abstain from food and die as a consequence. Persons watching them would be criminally responsible for abetting suicide, if death - results from this kind of enforced fasting. _ Homicidal starvation is met with in the case of old, helpless, or feeble- minded persons and children ot infants and is usually associated with cruelty, 8 Editorial, MI, PCI, 1974, 00 an 1 Scanned with CamScannerDeath from Starvation, Cold and Heat neglect and deliberate withholding of food. Illegitimate infants are done to death by depriving them of proper food and clothes. Religious Fast and Death A Digambar Jain-monk, Vrashubh Sagar, aged one hundred and eleven years; undertook 'Sellekhana-Samedhi-Maran’ {embracing death by fast). at Kunhalgiri in Marathwada. Acharya Shantisagar was the first to have done so in 1955. ‘The elderly Jain Munis (monks) embrace death by giving up food and water and spend their last days in ‘Amachinan and Dhyanadharana’ (prayer)? The Bombay Children Act 1948 (Bombay Act no LXXI of 1948), provides that whoever having the actual, charge of, or control over, a. child. willfully assaults, ill treats, neglects, abandons, or exposes him or causes or procures him to be assaulted, ill treated, neglected, abandoned or exposed or negligently fails to provide adequate food, clothes or medical aid or the lodging for a child in.a manner likely to cause such child unnecessary mental and physical suffering shall, on conviction, be punished with imprisonment of either description for a term not exceeding two years or with fine which may extend to a thousand rupees or with both. The infliction of reasonable punishments on-a child: for Proper reason, presumably by way of a corrective measures shall not be deemed to be an offense (vide s 48). For the purposes of this Act, a ‘child’ means a boy or girl who has not attained the age of sixteen years. In big cities, small children ate sometimes kidnapped, starved, maimed, blinded and forced to beg and their earnings are taken by the kidnapper. Accidental ‘starvation may occur during’ famines, among shipwrecked seamen and persons entombed in mines, pits due to fall of rocks or wreckage due to a bomb attack. It may also occur due to the obstruction of the passage of food into the stomach from disease, such a8 ankylosis of the jaws, stricture or cancer of the oesophagus or stomach, etc. COLD (HYPOTHERMIA) E ‘The local effects of cold upon the tissues result from three factors. ” (Extreme vasoconstriction, which in a lesser degree, ‘is a protective ‘mechanism for the maintenance of a constant body temperature. (i) Intra or extra cellular formation of ice crystals which creates a Hypertonic space around them—thus drawing more water. “The cells. sandwiched between the ice-crystals suffer damage (ii) Injury, of small blood vessels (arteries, veins and capillaries) ‘with the “© formation of agglutinative thrombi in them. An additional factor may be subsequent excessive heating, which elevates the metabolism beyond that which the damaged blood supply can support. The direct effect of cold are 9 TON, 24 Sept 1983 30 Scanned with CamScanner‘Medical Jurisprudence most evident in the fatty tissues and the myelinated nerve fibres. Indirect effects are prominently those of ischaemic (infarction) incident to vascular damage. Newly bom infants, children and old persons with little reserve of thermotaxic power are very susceptible to the bad effects of cold: Individuals, whose vitality has been lowered from fatigue, want of food, indulgence in alcoholic drinks and previous ill health, are less able to withstand the effects of cold than healthy, well-nourished adults of temperate habits. Hypersensitivity to cold resuls in urticaria, which is a hereditary disorder in some persons. Owing to a greater deposit of subcutaneous fat—a non-conducting material—women are likely to endure cold longer’and better than men are, Dry cold is less harmful in its effects than moist cold air. Cold ‘incteases mean arterial pressure. Angina pectoris patients are usually affaid of cold winds, as the increase in blood pressure increases need of myocardial oxygen. Cold affects persons with chronic obstructive lung diseases as well. Swelling of limbs and scleramia are characteristics of primary cold injuries in infants." The Chinese aggression on the northern borders of India gave a greater impetus to the study of the problems of cold and high altitude, and the beneficial effects of acclimatisation."” Symptoms () Local Erythematous patches on the skin called frostbites (frost-erythems) are caused due to freezing. The frostbite are produced when the skin temperature drops to -8° to -10° C, primarily by impaired local circulation; injury and shock are other causative factors, They may be superficial (the skin and the subcutaneous tissue affected; soft blisters form in twenty-four to thirty-six hours which become hard and black in about two weeks) or deep, which are, serious as tissues and the bone may be involved, Blisters appear within three days to a week. Later, there is a blue or violet discolouration and the formation of sloughs. There may be permanent loss of tissue and infection.”* The exposed parts, such as the ears, nose, fingers and toes, are usually affected. Prolonged exposure of éxtremities to cold sea water or cold trenches (non freezing temperature 10°C) for many hours produces’a condition known as ‘immersion foot or trench foot’, in shipwreck survivors or soldiers. The condition frostbite being a vital action can never occur =X. after death, (i) General There are no bad effects from moderate cold. On the contrary, it invigorates the body, and produces appetite and hunger; but exposure to severe cold continued for a long period produces deleterious effects, especially if the weather is wet or 10 JS Yuetal, Lancet, Dec 1974,791. 11 Symposium on problems of high altitude, Armed Forces Medical College, Poona, 1965. 12. Bradford Washburn, NEJM, 10 May 1962, 974 3 | ui 1 Scanned with CamScannerDeath from Starvation, Cold and Heat damp and a person is not properly clothed to keep up the body heat, or does not ‘get sufficient food or exercise. The muscles become so stiff, rigid and heavy, that the patient is unable to move or raise his limbs. Sometimes, convulsions, hallucinations and delirium ‘occur before death. The lowest deep body temperature tolerated by @ person is 9°C for one hour. Exposure of an inadequately clothed person om mountains or immersion in cold sea after a shipwreck would result in the fall of deep body temperature. At 29°-31°C consciousness is lost. Death occurs at a body temperature below 25°C, from cardiac arrest or fibrillation. A chronic-hypothermia patient has a low setting of his hypothalamic thermostat. Artificial hypothermia may be used for operations on the heart or the brain (when body temperature is lowered to 21°-25°C by cooling the blood or surface of body), Certain drigs, for example, chlorpromazine and. sedatives, may accelerate the onset of hypothermia, Causes of Death Death occurs from a lesser supply of oxygen to the nerve centres and tissues, as haemoglobin is unable to part with it at a lower temperature. In’addition, the utilising capacity of the tissues are reduced. A person exposed to ice water for about twenty to thirty minutes, ordinarily dies from heart standstill or heart fibrillation, unless treated immediately. Treatment The most useful treatment is a rapid and thorough re-warming of the patient using Warm water (40°-42°C) and placing him where he can rest continuously and be comfortable and warm. However, immediate dry warming is given on the abdomien, under the arm-pits or holding the affected parts in warm hands, warm clothes, or warm blankets. The affected parts should never be re-warmed by exercise. Moreover, a frozen part should never be rubbed before, during or after rewarming. Exposure to intense ‘heat; like’ fire or very hot water will produce gangrene. Dirt can be cleaned by sterile warm cotton or a mild non- alcoholic antiseptic. Friction and weight of bed sheets etc, should b¢ avoided, and blisters should never be pricked or opened. The use of broad spectrum antibiotics by the mouth is advised for infections. Anticoagulants are helpful if given early. Later, joints should be moved in a whirlpool bath having a normal ‘body temperature. Surgery. is the Jast resort. Alcohol and tobacco, which interfere with the peripheral circulation, should be avoided, In order to prevent cold injury, one must keep warm, dry and moving and avoid dampness. Postmortem Appearance Postmortem appearances are not characteristic. They aré most likely to be found when hypothermia has continued for some days. 303 Scanned with CamScanner2 Medical Jurisprudence () External ‘The surface of the body is usually pale, marked with irregular, dusky red patches of frost-erythems, especially on the exposed parts. These do not appear ‘on the dependent parts as in the case of postmortem staining, Rigor mortis is slow to appear and hence lasts longer. If a body buried in snow, is found jn a condition of commencing decomposition, death has occurred very likely not from cold, which prevents decomposition, 2 (i) Internal ~ The brain is congested with effusion of serum into its ventricles. The heart contains fluid blood in both the chambers. The lungs and other organs are” congested. Owing to the combination of oxygen with haemoglobin, the blood is — bright red in colour except in the heart, where it appears dark when viewed en ‘masse, Keith Mant has pointed out the forensic importance of finding superficial erosions in the stomach and fat necrosis in the pancreas due to ‘issue anoxia, probably caused by the sludging or clotting of blood in the smaller vessels in cases of death due to accidental hypothermia." Medico-Legal Aspects Death from hypothermia is mostly accidental, though very rare in India. Drunkards may be found dead in streets, when exposed to cold on a winter night. The old and infants are more liable to suffer from hypothermia: Accidental hypothermia occurs in elderly persons living in inadequately warm =. rooms. Old persons when exposed to severe cold, die from hypothermia ii ~ ‘winter. Questions of responsibility as to homicide may arise in cases where infants, insane, aged, sick or wounded persons have died from exposure to cold.‘ Persons suffering from hypothyroidism have a predisposition to hypothermia. ry A newly born miale infant, two or three days old, was found dead from exposure, in the compound of a bungalow in Agra. HEAT The effects produced by exposure to excessive heat are immediate peripheral vasodilation, sweating and increased cardiac output. The’ effects may be considered as follows:'* + (1) heat exhaustion; (2) heat syncope; (3) heat fatigue; (4) heat hyperpyrexia and heat stroke; 304 | Scanned with CamScanner 13 MSL, 1964, 44-45, 14 Lancet, 19 Sept 1964, 637-38.Death from Starvation, Cold and Heat (3) heat cramps, Exposure to the direct rays of the sun may give sunburn-actinic dermatitis, and the individual may be effected while working in a closed, hot and badly ventilated room or factory, especially when the high atmospheric temperature is combined with marked humidity. Ill-nourished, -overexertion to a fatiguing point, such as long marches, over-indulgences in alcohol, mental depression vomiting, diarrhoea, malaria and other fevers, predispose to the attack. (1) Heat Exhaustion Heat exhaustion is caused by dehydration and salt deficiency and is often preceded by prickly heat. Sweating may cause a fluid loss of about three to four litres per hour while doing strenuous Work. The attack may come on suddenly or gradually. In a sudden attack, the patient falls down and dies immediately or within a short period, When the attack is gradual, the first symptoms are ‘giddiness, nausea, anorexia, headache of a throbbing character, dim vision with dilated pupils, insomnia and frequency of micturition. Collapse then supervenes with profuse perspiration, oliguria, a sub-normal temperature, hypotension, rapid irregular and feeble pulse and sighing respiration, Death may dccur from heart. failure,. but usually followed by recovery:. Throughout the attack, consciousness is, asa rule, not ost. (2) Heat Syncope Heat syncope is a circulatory phenomenon induced by posture or exercise oF both. . _ “@) Heat Fatigue Heat fatigue may be transient and shows deterioration in the performance of a skilled task, while chronic hot climate fatigue shows a feeling of inefficiency. (4). Heat Hyperpyrexia and Heat Stroke, Sun Stroke Heat hyperpyrexia. is due to impaired functioning of the heat regulating } mechanism, while heat stroke is due to its failure; the distinction between the | __$o is somewhat arbizary* The, symptoms supervene all of a sudden in a person exposed to extreme beat during summer prior to acclimatisation, especially if he has been fatigued by prolonged and extreme exertion. However, in some cases, prodromal symptoms, such as a feeling of heat, headache, confusion, disorientation, emotional outburst, giddiness, nausea and_vomiting, locomotor. disturbances, excessive thirst and polyurea, may be experienced. Insensibility soon sets in, and the patient may be struck with a temperature of 40°C. The temperature rapidly rises and may reach 44°C or 46°C. Sweating is 15. A Classification of Heat ness—A memorandum of the Medical Research Council BMJ, 28 June 1958, 1534. ane Scanned with CamScannerMedical Jurisprudence usually absent and the skin is hot and dry. The face is flushed and the pupils are first dilated and insensitive to light, but becomes contracted towards death. When the patient is in a state of shock, there is hypotension, tachycardia, and hurried and stertorous respiration. The urine which is usually scanty, brownish and turbid contains indican and evidence of acute tubular necrosis. Death may occur from syncope, but usually results from asphyxia and coma, followed often by convulsions and delirium, The shortest fatal period is five minutes,'° which may be prolonged to three days". After Effects Afier recovery from heat hyperpyrexia, the patient becomes very susceptible to variations of temperature and usually complains of headache, loss of memory, mental confusion and nervous irritability. Sometimes, the patient may suffer from epilepsy or insanity for the rest of his life, (5) Heat Cramps Heat cramps occur especially among workers in boiler rooms, ship stokers, miners and cane cutters who work in hot conditions and perspire profusely during prolonged exposure. Itis often precipitated by drinking unsalted water. The cramps are caused by the loss of sodium chloride in the blood due to excessive sweating. They are very severe and painful and affect the muscles of the extremities and the abdomen. Treatment In heat exhaustion, the person is shifted to a cooler atmosphere and given supporting measures, including intravenous glucose saline. In heat hyperpyrexia, surface cooling measures should be taken to reduce the temperature immediately. The patient should be unclothed and placed immediately in a bath tub of ice cold water and the extremities massaged until the deep body temperature comes down to about 37.7°C. After removal from the bath, he should be wrapped in wet sheets, sponged with tap water or cold water and placed under one or two electric fans. Ifthe temperature is found rising, ice bag should be applied to the head, and ice should be rubbed all over the body or the patient should be again immersed in the cold bath. Ice-water enemata may be employed with benefit. Vene-section may be necessary when the symptoms of intense asphyxia are evident. Dehydration is corrected with intravenous or intragastric fluid drip and noradrenaline and corticosteroids are added for peripheral circulatory failure; oxygen and artificial respiration may be needed, JN Berry et al, from his experience at the Heat Sttoke Centre, Nagpur, also recommends chlorpromazine 100 mg parentally to an adult." $ Shibolet et 16 Lancet, 1870, Vol Il, 316, 17 Katzebach, New York Medical Journal (NYMJ), Vol XII 18 Jour ofthe Association of Physicians of India (JAP), Vol IX, 1961, 756. 306 4 Scanned with CamScannerDeath from Starvation, Cold and Heat al,” recommends intravenous pethidine, ‘chloropromazine and promethazine 100mg each in'200 ml of 5% glucose while the patient is being cooled, to prevent conviisions and shivering, | In heat cramps, one gram of sodium chloride well diluted in water, should be given every hour, Sedatives should be administered to relieve the pain of the cramps and a gentle massage is good forthe patient. Postmortem Appearance @ ~~ External Rigor mortis is well marked, but comes on early and passes off rapidly, followed immediately by putefaction, Petechial and livid patches are found on the skin, (i) Internal The brain and its meninges are congested, and the ventricles contains serum, There may be actual haemorthages in the brain. The nerve cells in the grey matter show degenerative changes, The lungs are congested and oedematous. he right side of the heart and pulmonary arteries are dilated, and gorged with dark fluid blood, and the left side is empty and contracted. The spleen is congested and sometimes enlarged. The liver and the kidneys may show a cloudy swelling and even petechial haemorrhages. Liver damage results from hypoxia and direct thermal injury.” Medico-Legal Importance ‘There is no medico-legal importance attached to the deaths occurring from heat stroke, as they are all accidental. However, the medical man may have to hold a postmortem examination on such a body, if it is found lying dead on the roadside or ina railway caiage sit sometimes happens on hot summer days. ‘The police is bound to send such cases for autopsy. In the case of KE Lieut Clark, IMD, Mrs Fulham and others were charged under s 302, IPC with having murdered Mr Fulham and Mrs Clark. It was proved from the letters produced that under instructions from Lieut Clark, Mrs Fulhams simulated -heat apoplexy in her husband in such a way by the judicious administration of poison (a mixture of beladonna or atropine and possibly cocaine), that the medical officers of the military hospital at Meerut were completely deceived and they treated him as a case of sun stroke, It may be mentioned that at the same time, some fatal cases of heat stoke had already occurred in the wey ee 19 Editorial, Lancet, 6 July 1968, 32. 20 American Joumal of Medicine, Aug 1970. Scanned with CamScannerMedical Jurisprudence military hospital and’ the knowledge of these cases led Mrs Fulham to write to Clark at Agra to send her some poison which, when administered to.her husband, would produce symptoms simulating heat stroke. A book of medical jurisprudence found in the possession of Clark at the time of his arrest, which was brought to Modi during the course of the trial at Agra. The symptoms described under certain poisons, such as arsenic, belladonna, cocaine, gelsemium, etc had all been underlined with lead pencil Suggesting that he had made a special study of these Poisons, most of which were alleged to have been administered to Mr Fulham on different occasions. 308 Scanned with CamScanner