Physiology teaches that life can only be maintained in the living organism by a constant equilibrium between its waste and repair. Nutrition is a term by which we describe this double movement of renewal of the molecular structure of the body, and in this general sense only, that nutrition is synonymous with the maintenance of the organism in a stable condition, is it employed here.

This condition of equilibrium is maintained by a regular and constant supply of food.

A food may be defined to be a substance which, after introduction into the body, supplies material for the renewal of its tissues or sustains some of its vital processes. Foods vary greatly in their properties as restorative or constructive agencies, some containing but few essential properties, while others combine almost all of the elements required. As some foods contribute elements for tissue restoration, others are specially concerned in the calorifacient activities of the organism,[948] while others are marked in their tendency to take part, almost exclusively, in special chemical processes.[949]

The various articles used as foods contain nutritive elements combined with innutritious substances. They have been variously classified, but are conveniently divided into

Nitrogen enters largely into the composition of the body, and hence must be abundantly supplied and in combination.

Of the non-nitrogenous elements the most important are fat, sugar, and starch.

The inorganic principles are essential to the process of nutrition. Water, constituting 87 per cent of the bulk of the body, is demanded in constant supply; while the saline substances are necessary for the perfect performance of many of its chemical processes.

It is apparent that no single element can alone carry on the nutrition of the body, and hence variety in the supply of food, as well as sufficiency in its quantity, is essential to normal nutrition. Nor are these the only factors in this complex problem. Proper preparation of food, its supply at necessary temperatures,[950] and other requirements enter into the question of normal or sufficient alimentation.[951]

Alimentation is sufficient when it is so regulated that all the functions of the body are performed in a complete and regular manner. Insufficient alimentation induces a series of phenomena and a result which have been designated “inanition,” or “starvation.”

The exact amount of aliment required by each individual can only be stated in a general way. In the circumstances in which he is placed, the supply must be of such character and quantity as shall be proportionate to the constructive and reparative needs of his body. It is possible, however, to state a mean for the various ages and occupations of life.

Physiologists generally agree that in ordinary conditions of exercise the following represents the amounts of the several food elements necessary for the adult individual daily:

Taking the fatty matters as the unit, the daily allowance would bear the following proportions:

Fats, 1; albuminoids, 2; carbohydrates, 6.

These quantities and especially the fats and carbohydrates, in conditions of hard muscular labor, must be increased; and the proportion would then stand:

Fats, 1; albuminoids, 1.7; carbohydrates, 7.

The division of this amount of food elements into proper portions during twenty-four hours is important. This must be regulated by the habits and other circumstances of the individual.[952]

The occurrence of death solely from privation of food is comparatively rare; yet it is sufficiently frequent to be considered as one of the causes of violent death and to demand investigation, since circumstances may be such as to constitute a homicide from criminal neglect or a suicide from intentional abstinence from food.

“Starvation,” or “inanition,” may be considered as being acute or chronic according as the requisite food has been suddenly and completely or gradually withheld.

ACUTE STARVATION.

The complete deprivation of food induces a series of modifications of the functions of the body, differing somewhat from those developed by a partial and prolonged deprivation. The length of time during which complete absence of food can be endured varies with circumstances. In absolute stoppage of the food supply the acute sensations of hunger pass away after the first one or two days, and are succeeded by profound functional disturbances with weakness and depressing sensations over the epigastric region, accompanied by distressing thirst.[953] The mouth is dry and the tongue heavily coated; the breath is fetid; the skin is harsh, dry, and exhales a disagreeable odor; the feces become more and more scanty until the latter days of life, when diarrhoea usually supervenes; the face and extremities become rapidly emaciated; the person walks with a weak and tottering gait;[954] the urine is small in quantity and very acid; muscular feebleness gradually reaches complete inability to move; ringing in the ears, insomnia and, in some cases, hallucinations[955] with delirium and convulsions precede death, though these latter symptoms are not uniformly observed.[956]

“CHRONIC STARVATION,” “CHRONIC INANITION.”

This form of starvation, met with most extensively during the prevalence of famine, also occurs in conditions demanding legal investigation.

The symptoms are sufficiently constant and characteristic. Emaciation becomes extreme, the skin dry and rough, exhaling a disagreeable odor and often covered with a coating not entirely attributable to filth; the breath is fetid and offensive. With some exceptions, the victim retains his consciousness and ability to move about, muscular efforts becoming more and more feeble; the voice becomes faint; the evacuations infrequent, dry and dark; the urine scanty and high-colored, death occurring suddenly at the end, with delirium in some cases.

The length of time during which these symptoms are developed and their intensity depend mainly upon the amount and character of the aliment actually supplied during the period before death.

Upon the PULSE and CIRCULATION the effects of starvation are manifest in increased frequency and feebleness of the cardiac contractions and lessened force of the cardiac impulse; this is more and more marked as the anÆmic condition becomes profound. In some cases the pulse is greatly reduced in frequency, as well as in force, dropping as low as thirty-seven beats in the minute,[957] and auscultation reveals the existence of cardiac bruits.

In connection with enfeeblement of the circulation, a tendency to hemorrhagic conditions is common, with purpuric and petechial eruptions in some cases.

Temperature.—A subnormal temperature is frequently noted in the progress of chronic wasting disease. In inanition, which in some respects induces a similarly profound disturbance of the functions of nutrition, an analogous lowering of the body temperature occurs. Chossat clearly shows in his experiments the influence of starvation in depressing the body temperature. This abasement of temperature does not remain constant, but daily oscillations appear, differing from those occurring in conditions of normal alimentation.

While the normal diurnal variation in the fully nourished is about 0.3° to 1.0° C. (0.5° to 1.7° F.), in the starving this variation reaches 3.28­­° C. (5.4° F.). This rises to nearly double this amount during the latter days of life, and is greatly increased above this figure during the day preceding death. The temperature at the close falls to a mean of 24.9° C. (76° F.), and at the moment of death has been noted at 18.5° C. (66° F.).

Emaciation.—Loss of weight is the most striking and constant symptom of starvation. The rapidity of its production and its extent are modified by circumstances. A very considerable loss of weight can be sustained by the ordinary individual without a fatal result.

Chossat[958] fully demonstrated the effects of inanition upon the various functions and organs of the body in animals, and has drawn the conclusion that a loss of weight exceeding four-tenths of the entire weight of the body is productive of a fatal result. These deductions may be adopted as applicable to the human species. This statement must be accepted as a mean, as it is capable of variation by circumstances, such as age, obesity, etc.

Death may occur before so great a loss has been reached in some cases, and in the obese the fat may disappear entirely and cause a loss reaching five per cent of the entire weight of the body, in a very fat animal, without a fatal result.

Bouchardat[959] considers that the important question is the extent to which the blood and organs of the body contribute to this loss of weight. Impoverishment of the blood by inanition, which at the time of death has been found to amount to six-tenths of its solid constituents, is one of the most vitally serious elements of this loss; and a relative increase of its watery portion appears, without regard to the employment of water as a beverage.

It must be remembered that in wasting diseases extreme emaciation may occur under a liberal diet, and may continue for a considerable time before death.[960]

The muscular system becomes greatly enfeebled, atrophied, and unable to perform its functions; the loss sustained by the muscles least used being most marked. The extent of muscular power possible in starvation varies in different individuals and in various circumstances.

The vigorous and healthy adult, as a rule, retains muscular power to a greater extent and for a longer period than the child or aged person, under similar circumstances.

Exposure to a rigorous climate, prolonged fatigue, etc., rapidly reduce capacity for muscular effort in conditions of inanition.

The Period at which Death Occurs.

This is influenced by many circumstances. It is difficult to fix an exact period for the duration of life in complete deprivation of food, or acute starvation, and it is certainly more so in chronic inanition, when the modifying circumstances are increased in number and complexity.

A large number of cases of prolongation of life during a period of absolute deprivation of food which has been stated to extend over weeks and even months, cannot be accepted as free from error, and hence are not considered here.

A sufficient number, accurately observed and well attested by unimpeachable authorities, have led to the conclusion that the healthy adult, in a total deprivation of food, can exist for a period not exceeding ten to twelve days. On one of the Inman line of steamers, a young man, aged twenty years, endured absolute deprivation of all food and water during eleven days, recovery following.[961]

Sarah Jacobs, a child of thirteen years (“the Welsh fasting girl”), had been exhibited by her parents as a miraculous being under the pretence that she had eaten nothing during two years.

The child being placed under complete surveillance by four nurses from Guy’s Hospital for eight days, during which period no food was taken, died on the ninth day.

The post-mortem examination showed all organs of the body to be in a healthy condition. The stomach was empty, with the exception of three teaspoonfuls of a thin acid fluid. The intestines were also empty and their walls were not thinned. A layer of fat, half an inch or more in thickness, was found under the skin of the chest and abdomen. The liver was in a healthy condition, as also the kidneys and spleen. The bladder was empty.

The parents were tried on a charge of manslaughter and were convicted of causing death by criminal negligence.[962]

Caspar gives the details of a case observed by him of a man aged thirty-six years, who endured total abstinence from all food for eleven days, recovery following.[963]

Cases are reported of miners who have been imprisoned by accidents in mines for eight, nine, and nine and one-half days, with recovery following rescue at the end of this time.[964]

While the period stated may serve as a maximum limit to which life may be extended in acute starvation, there are circumstances which must be considered as modifying this.

Body Condition.—It need hardly be stated that the individual in perfect health can sustain complete inanition longer than the enfeebled or diseased. The presence or absence of fat modifies considerably the power of endurance.

Age.—Infants bear starvation badly and succumb more quickly than the adult. The aged, while they bear a moderate amount of food better than the young adult, do not endure a complete deprivation for so long a time.

Cold.—The depressing influence of cold upon the vital functions, especially in the young and feeble, renders it a powerful factor in shortening the duration of life in starvation.

The Supply of Water.—When all food is withheld, free use of water as a drink tends to increase the length of the interval before death. In several cases of protracted fasting, the use of water in moderate amount has been resorted to with the apparent result of amelioration of some of the distressing symptoms and lengthening the period of endurance.

Dr. Tanner, a physician, attempted in July and August, 1880, at New York, a complete fast of forty days’ duration, with the exception of the free use of water. In this case absolute abstinence from all nourishment is questioned, as no strict medical surveillance was maintained.

The Italian Succi, at New York, in 1890, undertook a voluntary abstinence from food for forty days, under surveillance, with the use of simple liquids and of some narcotic substance. He completed the fast, but beyond this fact the case is without scientific value.

Catalepsy.—Certain abnormal conditions of the nervous system are met where the activity of the vital functions is very considerably lowered and the various processes of the economy are in a condition of semi-suspension. Cases of this character have been observed where the supply of food has been almost entirely suspended for a period of several days, with but little emaciation and other symptoms characteristic of inanition.

WAS STARVATION ACCOMPANIED BY OTHER ILL TREATMENT?

This question may arise where evidences of starvation are apparent.

Such cases are met among young children neglected or abused by parents or those in whose care they may have been placed, or among the alienated or sick in the care of cruel or unsympathetic attendants.

Infants placed with “wet-nurses” or found in the so-called “baby farms” also furnish cases which fall under this head.

A careful examination into the collateral circumstances of the case, together with the results of a careful post-mortem examination, usually render a positive answer to this question possible.

POST-MORTEM EXAMINATION.

The dead body exhibits appearances quite characteristic.

Emaciation is very marked and sometimes reaches an extraordinary degree, surpassing that of prolonged and wasting diseases.

In extreme cases the fat entirely disappears throughout the body; the omentum and mesentery are entirely devoid of it, as well as the subcutaneous and intermuscular cellular tissue. The muscles are atrophied and the heart is sometimes considerably reduced in size; the liver and kidneys in some cases show great reduction of volume. The spleen also is small and often softened.

The stomach and intestines usually display an extensive thinning of their walls, so much so that their contents may be distinguished through them; their calibre also is frequently found to be diminished, though occasionally they may be distended with gas. Usually they are empty, or contain only a small quantity of bile and fecal matter. In some cases various foreign substances which have been swallowed by the victims to appease hunger have been found in them.

The thinning of the walls, so constantly noted, has been considered as a specially characteristic symptom of starvation.[965]

The congestion, softening, and ulcerations which have been observed in some cases cannot be considered as evidences of starvation or as its results, but rather as being due to an enteritis induced by the ingestion of improper substances.

The gall bladder is usually found filled with dark and inspissated bile. In death by starvation the entire organs of the body exhibit no specific form of disease. Evidences of the existence of an organic affection observed in the post-mortem examination at once raise the question:

WAS DEATH CAUSED BY STARVATION OR DISEASE?

Was the original disease aggravated by a failure to supply the patient with food, or are the lesions observed the result of starvation? A positive conclusion can be reached in such cases by carefully considering the results of a post-mortem examination together with other facts elicited by the inquiry.

Harriet Staunton,[966] a young girl, had been kept in close confinement by four interested persons, and removed in great haste, when in a condition of extreme prostration, to Penge, where she died, on the day succeeding her removal, in a state of extreme exhaustion and emaciation. Fat was absent from every part of the body; the stomach and intestines were empty, contracted, and their walls were greatly thinned.

A small deposit of tubercle was found at the summit of the left lung and a recent deposit of miliary tubercle beneath the arachnoid, upon the surface of one of the cerebral hemispheres. No other tuberculous deposits were found. The opinion given by the physicians making the post-mortem examination was that death resulted from starvation. This opinion was shared by Professor Virchow, of Berlin, who stated that the tuberculous deposits found could not explain the cause of death.

In this case the extreme emaciation, entire absence of fat, thinning of the intestinal walls, etc., were the determining conditions. While extreme emaciation alone is not sufficient to decide the case to be one of starvation, its existence, taken in connection with some of the conditions found constantly in persons known to have died of starvation, is a strongly corroborative fact. Nor can its absence be taken as conclusive evidence that death occurred from other cause than starvation, since in some cases of death from inanition emaciation has not been extreme and in a few cases not at all marked.[967] Instances of this character are reported by Taylor and others.

DISEASES PRODUCED BY STARVATION.

The effect of insufficient alimentation in the production of disease has long been recognized. It is understood that this result follows the deficiency in either quality or quantity. The so-called “famine fever,” prevalent in times of dearth, has afforded extensive opportunity for observation of the effects produced. The symptoms developed are those directly referable to impoverishment of the blood. Pallor, emaciation, nervous depression, derangement of the digestive organs, and muscular enfeeblement appear in every case.

The development of strumous, herpetic, and cutaneous diseases generally is marked.

Of the secondary effects, the cachectic condition induced expresses itself in pulmonary phthisis largely, while in infants and very young children intestinal disorders are specially frequent. Organic diseases already existing are seriously aggravated; wounds fail to heal, become ulcerative and sometimes gangrenous; while all degenerative processes are rapidly hastened to a fatal issue.[968]