Extracted from the 
TRANSACTIONS OF THE COLLEGE OF PHYSICIANS OF 
PHILADELPHIA. 
THIRD SERIES, VOLUME V. CASES OF STARVATION FEVER. 
By 
J. M. DA COSTA, M.D., 
PROFESSOR OF THE PRACTICE OF MEDICINE IN THE JEFFERSON MEDICAL 
COLLEGE, PHYSICIAN TO THE PENNSYLVANIA HOSPITAL, ETC. 
[Read April 7, 1880.] 
I desire to lay before the College a remarkable 
group of cases, which happened in the practice of Dr. 
Julius Schrotz; and it was with him that I had an 
opportunity, in two of them, of witnessing the strange 
phenomena. 
Case I. A little girl, three years of age, for some time 
pale, weakly, and irritable, was seized on the night of Jan- 
uary 1, with vomiting. It became so frequent that Dr. 
Schrotz was sent for; and he found her very feeble, unable 
to sit up in bed, and complaining of giddiness. The next 
day the same symptoms persisted, and the pulse was small 
and very rapid. Subsequently a marked fever was observed, 
and the vomiting lessened ; indeed, under quinine, beef-tea, 
brandy, and milk, the gastric symptoms disappeared. The 
fever was unattended with sore throat, eruption, or diarrhoea, 
was not of long duration, and by the ninth day from the 
beginning of the attack, the little patient, in good spirits, 
with appetite fully returned, was sitting up in bed playing, 
seemingly quite convalescent. On the evening of the 10th 
of January, vomiting returned ; henceforth nothing was re- 
tained on the stomach ; the child complained of not being 
able to see, became weaker and weaker, and expired ex- 
hausted on the evening of the 13th. 58 
DA COSTA, 
All autopsy was made the next day. In the thorax, yel- 
lowish serous effusion was found in both pleural sacs. There 
was no evidence of lymphy exudation on the pleura; the 
amount of fluid was sufficient to have compressed the lower 
lobes of both lungs, which were carnified over a limited 
extent; the upper lobes were healthy. The heart presented 
nothing abnormal, except that it was flabby. The stomach 
was empty, its mucous membrane dryish and very pale; the 
intestines exhibited no swelling of any of the glands, either 
in the small or large bowel; the walls w7ere thin; the large 
intestine contained a small amount of hard dry feces. The 
spleen was slightly enlarged ; the liver had a nutmeg appear- 
ance ; the kidneys were normal. On opening the skull, the 
dura mater was found to be somewhat congested, but free 
from adhesions ; the pia mater was opaque; the cortical por- 
tions of the brain were cedematous; the convolutions were 
deep. A section of the upper part of the brain showed punc- 
tiform injection; the lateral ventricles were dry; but there 
was some effusion in the fourth ventricle. 
Case 11. A brother, four months of age, also a pallid, ill- 
nourished child, was seized with convulsions on the 10th of 
January. There was no retraction of the head, the urine was 
passed, and was not albuminous. He had had a convulsive 
seizure two months previously, leaving apparently no trace. 
The convulsions of the 10th of January lasted until nearly 
evening, and some hours afterwards death took place. In 
the afternoon a few dark spots, like very small petechiae, 
were noticed on the neck, and shortly before death similar 
spots were detected in the hypogastric region. 
The autopsy gave results very similar to those in the first 
case. In all the thoracic and abdominal organs, evidences of 
profound anaemia; some serous effusion in the pleural sacs; 
stomach pale, containing a small plug of casein ; absence of 
signs of glandular enlargement in the pale intestines, and 
a rather fluid blood, were the points specially noticed. Per- 
mission to examine the head was not obtained. STARVATION FEVER. 
59 
Case 111. A little girl a year and a half old was now the 
patient, and this case I watched with Dr. Schrotz. She, too, 
appeared ill nourished, and was far from a vigorous child. 
She was on the eighth of January attacked with fever, which 
was soon found to be associated with an acute bronchitis, 
and subsequently with a circumscribed broncho-pneumonia. 
There was no sore throat, no eruption, no albuminous urine. 
The child was well sustained, and under quinine and stimu- 
lating expectorants she slowly recovered in two weeks, 
having been very ill. 
What are we to call these strange cases? What 
explanation can be given of them? That they were 
not cases of scarlet fever, or diphtheria, or typhoid 
fever, was self-evident, though it was equally evident 
that in some general cause producing profound altera- 
tion of nutrition, or in some blood poison, was to be 
sought the explanation. The convulsions, the erup- 
tion, the speedy termination in the second case, sug- 
gested cerebro-spinal fever; but spinal symptoms 
were wanting, and the phenomena in the other cases 
were not at all those of this disease. The question 
of poisoning from bad drainage was carefully con- 
sidered; the drains were all thoroughly examined; 
they were everywhere in good order, and there was 
no water-closet or stationary wash-stand near the 
rooms in which the children played and slept. The 
supply of water in the house was good, and none of the 
adults suffered in the least from its free use. Atten- 
tion was then directed to the food of the children, and 
here a clue was obtained, which led to an unexpected 
discovery. The children lived almost entirely on 
cow’s milk; the two youngest, exclusively; the 
eldest, almost exclusively. They had been always well 
cared for by their parents, although, perhaps, not made 60 
DA COSTA, 
to pass as much time in the fresh air as would have been 
good for them ; yet, though taking large quantities of 
nourishment, they did not thrive. While the cases 
just described were in progress, at all events before 
the first and the last had terminated, the milk which 
served as their food was analyzed by Prof. Maisch, 
and another specimen was procured, as it came di- 
rectly from the milkman, but without its having 
passed first through the kitchen. This is the report 
of the distinguished chemist on milk sent him Jan. 13. 
Dr. Schrotz, 
Dear Sir: The result of the milk analysis is as follows: 
No. 1. Milk from pot.—10 grammes left 1.498 grm. dry 
residue, containing 0.486 butter. 
No, 2. Milk from nursing bottle.—lo grammes left 0.42 
grm. dry residue, containing 0.021 butter. 
The percentage of fat in No. 1 is 4.36. 
“ “ “ “ 2 “ 0.21. 
It is evident, therefore, that skimmed milk, or partly 
skimmed milk, was diluted with one and a half parts of 
water. 
This is further proven by the amount of cream separated 
from both milks on standing. 
No. 1 has separated a thick layer of cream. 
No. 2 “ u a mere film of cream. 
Both milks are free from metallic poisons. 
Very respectfully, 
JOHN M. MAISCH. 
Here, then, was the food on which these children 
had been nourished almost from their birth; here the 
cause of their lax tissues, their want of resistance. 
And while they had been growing wanner and paler, 
a stout maid servant in the kitchen had been orowino- STARVATION FEVER. 
61 
fatter and more ruddy. She had been, day in and 
day out, drinking the milk intended for the children, 
and diluting the miserable remnant on which they 
lived. When the doctor’s suspicion had been aroused 
some months before, at casual visits, and he had asked 
on two occasions to see the milk, she had taken good 
care to send up to him the milk as it came, fairly 
good, into the house; and, finally, when the true state 
of things was detected, confessed to her love of milk 
and. her iniquities. 
The cases are now clear enough. In the anomalous 
fever, the local congestions, the vomiting, the stains 
on the skin, the convulsions, the ready collapse; in 
the collection of fluids within the serous sacs, the 
thinness and pallor of the mucous membranes, we 
have the phenomena of inanition or starvation, as 
they have been experimentally demonstrated. To 
call these cases “ Starvation Fever,” would, I think, 
be fully justified. Yet the question remains, whether 
some cause, in itself of little importance, did not 
act as an exciting cause to bring about the crash; 
some cause like a passing influenza, which, throwing 
the least weight on functions and organs incapable 
of resistance, broke them down at once. The fact of 
all the cases happening about the same time, and the 
catarrhal symptoms in Case 111., favor this view. 
In concluding this paper, it seems incumbent to 
dwell on the source of danger to little children it lays 
bare, and this in a class of society where want does not 
exist, and where starvation with its fatal consequences 
would not be looked for. But no words can enforce 
it better than the histories read before you to-night; 
the facts themselves speak far more eloquently than 
I can.