Death as a Result of Starvation

Diagnostic Criteria
  • Burkhard Madea
Part of the Forensic Pathology Reviews book series (FPR, volume 2)


Fatal starvation is a rare cause of death in industrialized countries but this entity may become of major medicolegal importance if death results from deliberate withholding of food, especially from infants. In such cases, the task of the forensic pathologist and the medical examiner, respectively, is not only to clarify the cause of death but also to give an expert opinion on the degree and duration of starvation. Several classification systems have been developed to estimate protein-energy malnutrition (PEM) in third world countries (e.g., Waterlow classification, Gomez classification). More simple classifications (e.g., the Gomez classification of PEM) use the weight expected for the respective age group as standard. When applying this standard, small infants will always be light infants. Following the Waterlow classification, a stunted physical condition (referring to retardation in cases of chronic malnutrition) is calculated by using the ratio of the measured body height to the one expected for the actual age. Body weight can be used as a sign of acute malnutrition (“wasting”). However, body weight should be related to the expected weight for the actual height. Using such classification systems, a grading of stunting and wasting can be achieved that is of great value for the assessment of a given child’s nutritional status in legal cases. The application of the Waterlow classification to this author’s case material and cases published earlier in the literature is demonstrated. The Waterlow classification is not only of importance for grading the final stage in cases of fatal starvation, but also for the chronological development of the nutritional status, if anthropometrical data have been recorded repeatedly from the affected individual in vivo.

Key Words

Starvation autopsy findings protein-energy malnutrition (PEM) Waterlow classification stunting wasting emaciation undernutrition malnutrition malnourishment 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Adelson L. Homicide by starvation. The nutritional variant of the battered child. JAMA 1963;186:458–460.PubMedGoogle Scholar
  2. 2.
    Adelson L. Pathology of Homicide. Springfield, IL: Charles C. Thomas, 1974.Google Scholar
  3. 3.
    Campbell JAH. The morbid anatomy of infantile malnutrition in Cape Town. Arch Dis Child 1956;31:310–314.PubMedCrossRefGoogle Scholar
  4. 4.
    Davis JH, Rao VJ, Valdes-Dapena M. A forensic approach to a starved child. J Forensic Sci 1984;29: 663–669.PubMedGoogle Scholar
  5. 5.
    Ellerstein NS, Ostrov BE. Growth pattern in children hospitalized because of caloricdeprivation failure to thrive. Am J Dis Child 1985;139:164–166.PubMedGoogle Scholar
  6. 6.
    Fieguth A, Günther D, Kleemann WJ, Tröger HD. Lethal child neglect. Forensic Sci Int 2002;130:8–12.PubMedCrossRefGoogle Scholar
  7. 7.
    von Harnack GA, Heimann G. Kinderheilkunde, 8thed. Springer, Berlin, Heidelberg, New York, London, Paris, Tokyo, Hongkong, 1990.Google Scholar
  8. 8.
    Helfer RE, Kempe CH. The battered child. The University of Chicago Press, Chicago, London, 1968.Google Scholar
  9. 9.
    Hughes EA, Stevens LH, Wilkinson AW. Some aspects of starvation in the newborn baby. Arch Dis Child 1964;39:598–604.PubMedGoogle Scholar
  10. 10.
    Listernick R, Christoffel K, Pace J, Chiaramonte J. Severe primary malnutrition in US children. Am J Dis Child 1985;139:1157–1160.PubMedGoogle Scholar
  11. 11.
    Madea B, Henßge C, Berghaus G. Fahrlässige Tötung eines Säuglings durch Fehlernährung. Arch Kriminol 1992;189:33–38.PubMedGoogle Scholar
  12. 12.
    Madea B, Michalk DV, Lignitz E. Verhungern infolge Kindesvernachlässigung. Arch Kriminol 1994;194:29–38.PubMedGoogle Scholar
  13. 13.
    Meade JL, Brissie RM. Infanticide by starvation: calculation of caloric deficit to determine degree of deprivation. J Forensic Sci 1985;30:1263–1268.PubMedGoogle Scholar
  14. 14.
    Mimasaka S, Funayama M, Adachi N, Nata M, Morita M. A fatal case of infantile scurvy. Int J Legal Med 2000;114:122–124.PubMedCrossRefGoogle Scholar
  15. 15.
    Nishio H, Matusi K, Tsuji H, Tamura A, Suzuki K. Immunohistochemical study of tyrosine phosphorylation signalling in the involuted thymus. Forensic Sci Int 2000;110:189–198.PubMedCrossRefGoogle Scholar
  16. 16.
    Sarvesvaran E. Homicide by starvation. Am J Forens Med Pathol 1992;13:264–267.CrossRefGoogle Scholar
  17. 17.
    Schmidt P, Graß H, Madea B. Child homicide in Cologne (1985–94). Forensic Sci Int 1996; 79:131–144.PubMedCrossRefGoogle Scholar
  18. 18.
    Tanegashima A, Yamamoto H, Yada I, Fukunaga T. Estimation of stress in child neglect from thymic involution. Forensic Sci Int 1999;102:173–180.CrossRefGoogle Scholar
  19. 19.
    Wehner F, Schieffer MC, Wehner HD. Percentile charts to determine the duration of child abuse by chronic malnutrition. Forensic Sci Int 1999;102:173–180.PubMedCrossRefGoogle Scholar
  20. 20.
    Di Maio VJ, Di Maio DJ. Forensic Pathology. 2nd ed. CRC Press, Boca Raton, London, New York, 2001.Google Scholar
  21. 21.
    Gee D. Starvation and neglect. In Mant AK, ed. Taylor’s Principles and Practice of Medical Jurisprudence. Churchill Livingstone, Edinburgh, London, Melbourne, New York, 1984, pp. 276–279.Google Scholar
  22. 22.
    Giese W, Hörstebrock R. Allgemeine Pathologie des exogenen quantitativen Nahrungsmangels. In: Büchner F, Letterer E, Roulet F, eds. Handbuch der allgemeinen Pathologie, Vol. 11, Umwelt II, part I. Springer Verlag, Berlin, Göttingen, Heidelberg, 1962, pp. 446–591.Google Scholar
  23. 23.
    Madea B, Banaschak S. Verhungern. In: Brinkmann B, Madea B, eds. Handbuch Gerichtliche Medizin, Vol. 1. Springer Verlag, Berlin, Heidelberg, New York, 2004, pp. 905–919.Google Scholar
  24. 24.
    Mueller B. Schädigungen und Tod infolge Nahrungsmangel. In: Mueller B, ed. Gerichtliche Medizin, Vol. 1, 2nd ed. Springer Verlag, Berlin, Heidelberg, New York, 1975, pp. 497–500.Google Scholar
  25. 25.
    von Neureiter F, Pietrusky F, Schütt E. Tod und Gesundheitsbeschädigung durch Entzug der Nahrung. In: von Neureiter F, Pietrusky F, Schütt E, eds. Handwörterbuch der Gerichtlichen Medizin und Naturwissenschaftlichen Kriminalistik. Springer Verlag, Berlin, 1940, pp. 811,812.Google Scholar
  26. 26.
    Prokop O. Das Verhungern. In: Prokop O, ed. Forensische Medizin, VEB Verlag. Berlin, 1966, pp. 141–143.Google Scholar
  27. 27.
    Becker M. Chronische Gedeihstörungen im Säuglingsalter. In: Bachmann KD, Ewerbeck H, Kleihauer E, Rossi E, Stalder E, eds. Pädiatrie in Praxis und Klinik., Vol. 1, 2nd ed. Gustav Fischer Verlag, Stuttgart, New York, 1989, pp. 545–552.Google Scholar
  28. 28.
    Behrmann RE, Vaughan VC, Nelson WE. Nelson’s Textbook of Pediatrics, 13th ed. W.B. Saunders Company, Philadelphia, London, Toronto, Montreal, Sidney, Tokyo, 1987.Google Scholar
  29. 29.
    Bremer HJ. Protein-Energie-Malnutrition der Entwicklungsländer. In: Betke K, Künzer W, Schaub J, eds. Lehrbuch der Kinderheilkunde, 6th ed. Thieme Verlag, Stuttgart, New York, 1991, pp. 247–251.Google Scholar
  30. 30.
    World Health Organisation: Joint FAO/WHO Expert Committee on Nutrition, 8th report. Food fortification and protein-calorie-malnutrition. Tech Rep Ser Wld Hlth Org, No. 477 (WHO, Geneva, 1971).Google Scholar
  31. 31.
    Gomez F, Galvan RR, Cravioto J, Frenk S. Malnutrition in infancy and childhood with special reference to Kwashiokor. Adv Pediatr 1955;7:131–169.PubMedGoogle Scholar
  32. 32.
    Suskind RM. Primary protein-energy malnutrition: clinical, biochemical and metabolic changes. In: Suskind RM, ed., Textbook of Pediatric Nutrition. Raven Press, New York, 1981, pp. 189–307.Google Scholar
  33. 33.
    Suskind RM, Varma RN. Assessment of nutritional status of children. Pediatrics in Review 1984;5: 195–202.CrossRefGoogle Scholar
  34. 34.
    Waterlow JC. Classification and definition of protein-caloric malnutrition. Br Med J 1972;2: 566–569.Google Scholar
  35. 35.
    Waterlow JC. Note on the assessment and classification of protein-energy malnutrition in children. Lancet 1973;2:87–89.PubMedCrossRefGoogle Scholar
  36. 36.
    Waterlow JC, Buzina R, Keller W, Lane M, Nichaman MZ, Tanner JM. The presentation and use of height and weight data for comparing the nutritional status of groups of children under the age of 10 years. Bull World Health Organ 1977;55:489–498.PubMedGoogle Scholar
  37. 37.
    Beaton GH. Nutritional needs during the first year of life. Pediatr Clin North Am 1985;32: 275–288.PubMedGoogle Scholar
  38. 38.
    Bürger M, Grosse-Brockhoff F. Energiestoffwechsel. In: Grosse-Brockhoff F, ed. Pathologische Physiologie. Springer Verlag, Berlin, Heidelberg, New York, 1969, pp. 688–697.Google Scholar
  39. 39.
    Ulmer HV. Ernährung. In: Schmidt RF, Thews G, ed. Physiologie des Menschen, 22nd ed. Springer Verlag, Berlin, Heidelberg, New York, Tokyo, 1985, pp. 628–641.Google Scholar
  40. 40.
    Adelsberger L. Medical observations in Auschwitz concentration camp. Lancet 1946;2:317–319.CrossRefGoogle Scholar
  41. 41.
    Cahill GF. Starvation in man. New Engl J Med 1970;282:668–675.PubMedCrossRefGoogle Scholar
  42. 42.
    Chmelnizkij OK. Zur Rolle der Pathologen im belagerten Leningrad. Z allg Pathol pathol Anat 1987; 133:307–310.Google Scholar
  43. 43.
    Giese W. Die Pathologie des Hungers. Allg Pathologie 1953;71(Pt II):98–100.Google Scholar
  44. 44.
    Girgensohn H. Pathologische Anatomie der Gefangenschaftskrankheit mit Bemerkungen zu ihrer Klinik und zur Frage der Spät-und Dauerschäden. Die Medizinische 1959;16:761–769.Google Scholar
  45. 45.
    Holle G. Über plötzliche Todesfälle bei schwerer Inanition. Z Ges Inn Med 1948; 15/16:491–500.Google Scholar
  46. 46.
    Hottinger A, Gsell O, Uehlinger E, Salzmann C, Labhart A. Hungerkrankheit, Hungerödem, Hungertuberkulose. Benno Schwabe u. Co Verlag, Basel, 1948.Google Scholar
  47. 47.
    Leyton GB. Effects of slow starvation. Lancet 1946;2:73–79.CrossRefGoogle Scholar
  48. 48.
    Mollison PL. Observation of cases of starvation at Belsen. Br Med J 1946;1:4–8.PubMedGoogle Scholar
  49. 49.
    Selberg W. Pathologische Anatomie der Unterernährung. Synopsis. 1948;1:23–50.Google Scholar
  50. 50.
    Simpson K. Exposure to cold-starvation and neglect. In: Simpson K, ed. Modern Trends in Forensic Medicine. Butterworth, London, 1953, pp. 116–132.Google Scholar
  51. 51.
    Uehlinger E. Die pathologische Anatomie der Hungerkrankheit und des Hungerödems. Helv Med Acta 1947;415:584–601.Google Scholar
  52. 52.
    Wolff-Eisner A. Über Mangelerkrankungen auf Grund von Beobachtungen im Konzentrationslager Theresienstadt. Lothar Sauer-Morhard Verlag, Würzburg, 1947.Google Scholar
  53. 53.
    Isner JM, Roberts WC, Heymsfield SB, Yager J. Anorexia nervosa and sudden death. Ann Intern Med 1985; 102:49–52.PubMedGoogle Scholar
  54. 54.
    Missliwetz J, Mortinger H. Tod durch Hypoglykämie nach Hungerzustand—Pathophysiologie versus Morphologie. Beitr Gerichtl Med 1992;50:319–323.PubMedGoogle Scholar
  55. 55.
    Ratcliffe PJ, Bevan JS. Severe hypoglycaemia and sudden death in anorexia nervosa. Psychol Med 1985; 15:679–681.PubMedCrossRefGoogle Scholar
  56. 56.
    Rich LM, Caine MR, Findling JW, Shaker JL. Hypoglycaemic coma in anorexia nervosa. Arch Intern Med 1990;150:894,895.PubMedCrossRefGoogle Scholar
  57. 57.
    Smith J. Hypoglycaemic coma associated with anorexia nervosa. Aust NZ J Psychiatry 1988;22: 448–453.Google Scholar
  58. 58.
    Kanzow U. Beobachtung während einer 53-tägigen Hungerperiode an einem Hungerkünstler. Dt Arch Klin Med 1951;198:698–705.Google Scholar
  59. 59.
    Leiter LA, Marliss EB. Survival during fasting may depend on fat as well as protein stores. JAMA 1982; 248:2306,2307.PubMedCrossRefGoogle Scholar
  60. 60.
    Berwick DM. Nonorganic failure-to-thrive. Pediatrics in Review 1980;1:265–270.CrossRefGoogle Scholar
  61. 61.
    Holzel A. Sugar malabsorption due to deficiencies of disaccaridase activities and monosaccharide transport. Arch Dis Child 1967;42:341–352.PubMedGoogle Scholar
  62. 62.
    Pipes PL. Nutrition in infancy and childhood, 2nd ed. The C.V. Mosby Company, St. Louis, Toronto, London, 1981.Google Scholar
  63. 63.
    Janssen W. Forensische Histologie. Verlag Max Schmidt Römhild, Lübeck, 1977.Google Scholar
  64. 64.
    Schocken DD, Holloway JD, Powers PS. Weight loss and the heart. Arch Intern Med 1989;149: 877–881.PubMedCrossRefGoogle Scholar
  65. 65.
    Roessle R, Roulet F. Mass und Zahl in der Pathologie. Verlag von Julius Springer, Berlin, 1932.Google Scholar
  66. 66.
    Madea B, Banaschak S. Remarks on: “Percentile charts to determine the duration of child abuse by chronic malnutrition.” Forensic Sci Int 1999;105:191,192.PubMedCrossRefGoogle Scholar
  67. 67.
    Coe JI. Postmortem chemistries on human vitreous humor. Am J Clin Pathol 1969;51:741–750.PubMedGoogle Scholar
  68. 68.
    Coe JI. Some further thoughts and observations on postmortem chemistries. Forensic Sci Gazette 1973; 4:2–5.Google Scholar
  69. 69.
    Madea B. Zur Postmortalen Diagnostik von Störungen des Wasser-Elektrolyt-Haushaltes. Rechtsmedizin 1996;6:141–146.Google Scholar
  70. 70.
    Madea B. Zur Postmortalen Diagnostik der Hypertonen Dehydratation. Paper presented at the 16th Spring Meeting of the German Society of Forensic Medicine (Northern Group), Kiel, May 2003.Google Scholar
  71. 71.
    Madea B, Herrmann N. “Normal values” in vitreous humor and on dysregulations which can be diagnosed postmortem. In: Jacob B, Bonte W, ed. Advances in Forensic Sciences, Vol. 4., Forensic Criminalistics II. Verlag Dr. Köster, Düsseldorf, 1995, pp. 49–61.Google Scholar

Copyright information

© Humana Press Inc., Totowa, NJ 2005

Authors and Affiliations

  • Burkhard Madea
    • 1
  1. 1.Institute of Forensic MedicineRheinische Friedrich-Wilhelms-University BonnBonnGermany

Personalised recommendations