The blame, “neglect of the young child by the mother”, which seems to be obvious as a factor of importance in the genesis of malnutrition proves, at closer consideration, to be not quite justified. When under neglect we understand a conscious withholding of good care from the young child, which is necessary for its welfare, then the factor of neglect in the genesis of this disease is not great. The Javanese mother indeed does give her special care to the new-born child, just like other mothers do. Already before the child’s birth this care begins. In the 7th month of pregnancy as a rule an extensive slametan (meal of welfare) is held, to which many guests from the village are invited. A date in which the number 7 occurs sometimes has preference for this slametan, called “tingkep”. The intention is to dispose the higher powers of life favourable towards the welfare of this still unborn child and towards its community, into which it will be born. The importance, which the parents attach to this slametan, is great and sometimes a mother, who has not got the necessary means, is tempted to steal, in order to have this slametan by all means take place. During pregnancy, to the opinion of a number of 20 mothers (coming from outside the town of Jogjakarta), who were questioned about this subject and whose child had been admitted to the children’s ward, there are no special foodstuffs that are “tabu”, not allowed, according to the local customs. Some mothers told us that the consumption of many vegetables would be favourable to the child, of which she was pregnant. Nothing is changed in the food of the Javanese woman during her pregnant. Nothing is changed in the food of the Javanese woman during her pregnancy. The normal diet predominantly consisting of carbo-hydrates is left unchanged also in this period. Precepts which should be observed by the pregnant woman and the prospective father for the well-being of the unborn baby, are the abstention of killing any animal: hen, goat, dog or cow. Also the precept for the woman to be neatly dressed was mentioned by a few mothers.
After the child’s birth watch is kept in the house every evening by a man (father, neighbour, fellow-villager), while often songs are sung during the night, until the point of time when the umbilicus has dropped off. Departing from that moment the risk from malevolent spirits importuning the child is no longer so impending. For the commemoration of that fact another welfare meal (slametan) is held to which the neighbours, the benevolent watchers, the head of the dukuh and others are invited. At this occasion the child is also given a name. Much care is given to this name-giving, as the choice should be in conformity with the social status, the month of birth and other factors. Sometimes an ugly name is chosen on purpose, if some older children of these parents have died, like Buang (thrown away), Si Uwuh (waste) and others, in the hope that now this child will be left in peace by the spirits. When the mother dies during the confinement, instantly the child is given a name. Should it be “proved” later on, that the name is wrongly chosen, e.g. When the child is frequently ill, a new name is chosen and given to the child.
A child, who was cured of a pneumococdenmeningitis, received another name after its dismissal from hospital. In Java 2 sorts of weeks are distinguished, the seven-days’ week and the five-days’ week. A day is indicated with the double name, e.g. Monday-kliwon. In this way 35 combinations are possible. When 35 days after the birth – that is a period with the name lapan – the same combination recurs as in the day of birth, then again a ;slametan is celebrated, called Njelapani, and generally of a more modest plan than the slametan held at the dropping off of the umbilicus. By the well-to-do people in the area of the D.I. Jogjakarta, and especially by those connected with the old dynasties, also the first “contact” with the earth is celebrated. In the village this has almost wholly fallen into disuse. An other way to further the child’s welfare, in the parents’ opinion, is to shave off the hair on its head, while at the front side a small forelock is left, called kuntjung, or only a tuft of hair on the back of the head, called gombak. Certainly, also the Javanese mother is ready for many cares for the well-being of her child. The way in which her care finds expression has found a form originating form the Javanese religious thought-world which is magical of character and in which all attention is directed towards preserving an equilibrium with the higher powers of life and if possible towards winning their favour.
An other important factor is the mother’s attitude towards her child. When the child refuses food, for instance because of lack of appetite or a special preference for other food, the child’s wish is law for the mother. This law is the shortest formulated law existing, it sounds in Javanese: “emoh”, in Indonesian: “tidak mau” which means: I will not, and with that the matter is almost always finished. This circumstance leads a.o. to the long continuation of giving exclusively breast-feeding, as the mother did not succeed in accustoming the child to other food. Sometimes this has been the indication for us, when the mother’s milk was scarce, to take a child into the children’s ward to be weaned and turned over to a fit diet, based on many experiences of this kind, because we were convinced that often the mother was not able to realize the perseverance necessary at the changing over to another diet. This attitude of the mother, in which food is only given of the kind the child likes to take and is accustomed to, has a hampering effect upon the extension of the baby’s diet in the first years of life, and it serves the easy-going way in which many mothers pass off the matter of the care for their baby’s diets. An advice offered, may it be ever so simple and ever so vital for the child, concerning a change in the nutrition, often finds in this attitude an early ending.
During the nursing-period the Javanese mother observes some precepts of diet. In the first 35 days (lapan) preference is given to a diet, in which roasted soyabean-cake, maize and pulse occur, which have not been prepared with oil; and further bajem (Ind.Amaranth) and cooked papaja leaves. These last ones are never taken as food and are only eaten by the nursing mother in these 35 days.
In the fist months of the period of nursing various foodstuffs are avoided, such as red peppers, pepper (maritja) used in seasoning food, cocoanut milk and some fruits that are very juicy and are taken as vegetables: aubergin(eggplant), breadfruits, calabash and pumpkin. The red pepper is avoided to prevent the baby from suffering of diarrhoea. Also fish is avoided, lest the mother’s milk should smell of it. The data about the dietary customs of pregnant and nursing women in Java have been borrowed from the inquiry made systematically by the nurse Sumarni in the children’s ward of Betnesda hospital, in the year 1958-1959, and which consisted of an extensive interview with 20 mothers, a.o. about the two above mentioned dietary customs. For this inquiry, which took up much time, and which was executed in the Javanese language and which – for several reasons – could not be entrusted to a foreigner, we received her cooperation. These 20 mothers were asked to give her judgment about the value for toddlers of a number of foodstuffs, as these were current in their own surroundings. They were living in the country, in 10 various ketjamatans of the kabupaten of Sleman and in 6 different ketjamatans of the kabupaten of Bantul. They were mothers, of whom a child had been nursed for some time already in the children’s ward, so that the mothers had become familiar with the nurse. As the number of articles of food remain limited, a number of 10 were the object of the inquiry, as being of importance for the children as sources of protein and Vit.A. (carotenoid), viz. Mother’s milk, cow’s milk, meat, eggs, tahu, tempe (product of soyabeans), vegetables, fruits and sweet potatoes. The mothers, who were interrogated, were of the opinion that for infants and young children only mother’s milk, cow’s milk, rice, bananas and cassave sidered until the age of 1½ year (according to 4 mothers ) or better still 2 – 3 years (according to 16 mothers). In case of lack of mother’s milk and as a substitute for it, tea or the cooking-water of mung beans (a kind of pulse), possibly the cooking-water of “red” rice (air tadjin) are given to the young baby. Only once in a while also other substitutes for mother’s milk are used, viz. Water of the young cocoanut or a very thin maizena solution. Through these nutrition-customs the protein-providing foodstuffs (eggs, meat, and the soya products) remain out of reach of the young child: and even if it receives the soyabeans-products (tahu and tempe) the animal foods remain for the greater part out of reach, for these have a reputation to be causes of disease, especially meat. All 20 mothers were unanimously of opinion that worm-diseases (ascariasis in particular) were the consequence of the consumption of meat. Also fish, especially fresh fish, has a bad reputation as a cause of illness: the consumption of fresh fish by toddlers may lead to disease of the eyes and to blindness. In the judgment of some mothers there is a connection between the scales (sesik) of the fishes’ skin and the spots of bitôt (sisik), in which the fishes’ scales are found back, according to a number of ten mothers. Eating fish may also lead to get worm-diseases, (5 mothers) as also the eating of meat may do. The same objection a number of ten mother appeared to have to giving eggs to their toddlers: the relatively small risk the toddlers run by an infection with ascariasis has got a very large place in the world of prejudices round the feeding of babies and young toddlers, which the mothers have inherited from former generations and have further kept up. This prejudice concerning the connection between animal food and ascariasis cannot be but harmful to the extension of the diet of the babies from breast-feeding to normal diet. As meat and fish are financially out of reach of the desa population and are offered for sale only in limited quantities, the bias concerning eggs seems to us of greater importance. Hens walk about freely in the desa and scratch together their own food without the owner’s interfering with it. Eggs are within reach of quite a number of families for their food. If eggs are not sold in the pasar (market), with the gained money to provide for other wants, they do not appear, also through this prejudice, into the toddler’s diet, who wants them badly. Against the articles of food supplying vegetable protein there were few prejudices, as also against vegetables and a number of fruits, except that these were also to be fit only for the 2 – 3 years age-group, so that precisely these available articles of food were seldom given in the period of the second year of life, with its scarce quantity of mother’s milk and these children’s great want of protein. A few times soyabeans-cake was mentioned as a food, that might cause eye-diseases and blindness, but the risk that this might happen through fresh fish was considered much greater by 12 mothers.
Against cow’s milk (from Unicef-milkpowder) no tabu exists. It is a food that is readily accepted, judging from the great popularity of the M.C.H.-centres. Some mothers assured, that their children got diarrhoea from it and that therefore they had discontinued the use of it. Some fruits too had a reputation to cause disease: Kedondong, mango, pine-apple and sapodilla sometimes caused coughing and diarrhoea in young toddlers. Of these fruits, which are cheap in their season, only the mango is an important Vit.A. Source (carotenoid), which is withheld from the children through this bias. However there are sufficient other fruits and vegetables, providers of Vit.A., so this prejudice need not bring great difficulties for the toddlers’ nutrition. In addition to special foodstuffs as causes of disease, there are in the popular conception of child-medicine concerning the aetiology of some special children’s diseases very important causes of a quite other sort. These are the malevolent spirits, who trouble the young children and make them ill. They are the spirits of dead people, called lelembut who prove themselves now malevolent. These spirits are very sensitive to expressions of awe and cause diseases when they think, that they are not sufficiently honored. When children are made ill, it is mostly by an attack of fever and/or convulsions. However, not only the spirits of dead fellow-villagers are the originators of diseases, also some of the countless nature-ghosts many have that function. These ghosts of nature live in the invisible world surrounding the people and their village, according to the popular conception found in Java. Little children too are sometimes threatened in their health by a nature-ghost. Among the more than 90 nature-ghosts known by name there are some, who especially aim at little children. They are Sawan Klebu and Sarap. These two invisible tormentors may easily penetrate into the body. Sawan Klebu is often the cause of convulsions in small children, but he sometimes also is the author of eruptions of the skin. Sarap preferably causes skin-diseases, but sometimes also convulsions in children. All the mothers, who were interrogated, declared that in their desa the children were often tormented by these ghosts. All cases of convulsions and fever in little children were ascribed to these tormenters. Occasions en tailing special risk for the child to be surprised by those teasers are the celebration of a marriage-ceremony, or the slametan at the death of a fellow-villager. Therefore little children are kept away from these celebrations as far as possible. Thus it is understandable that in case of these diseases the dukun (native healer) is at once called for.
The dukun pronounces the incantation significant for this occasion and often also rubs the child’s skin with a mixture of leaves from different plants. Sometimes also a slametan is celebrated for the well-being of the sick child. This slametan is dedicated to the two tutelary spirits of children, to wit Kaki among and Nini Among, to whom also the slametans at the birth of the child and at the dropping off of the umbiculous cord were consecrated. These two tutelary spirits protect the child up from his birth till his marriage. Only when the dukun is evidently powerless to cast out these tormenters, sometimes the doctor is called in for help as a last resort. A large number of children, especially those coming from the country, had already been extensively treated by the dukun before they came under our eyes. In this image-world also the symptoms of the pattern of illness “malnutrition” find their place. The symptom oedema(oboeh), which is often an inducement for the mother to take the child to the polyclinic to have it treated, was ascribed by 6 out of 20 mothers to influences of the malevolent nature-ghost, called Wangking.
However 9 mothers gave as their opinion that the oedemas were caused by the consumption of fresh fish, balsampear (papaja) or pumpkin. The phenomenon of “leanness” was ascribed by most of the mothers to the fact that in these cases the mother’s milk was imperfect. This led to the weaning of the child with changing over to a diet of thin rice-porridge (rice cooked in water). Diarrhoea was supposed to be caused mostly by incorrect feeding; either the child had received baked food or “forbidden” fruits, such as manggo or pine-apple or may be the mother’s milk was also unsound in this case. As a second cause of diarrhoea 8 mothers mentioned the progress in the motory development of the child. When the child had learned to crawl, to stand or to walk this was often accompanied with diarrhoea. Only one mother gave as a cause for the diarrhoea the tormenting of the lelembut.
When we survey these existing “tabus”, we do not think that they play an important roll in the pathogenesis of malnutrition. As it is especially the animal foodstuffs, that fall under the tabus, and it is exactly those, that are unobtainable to the greater part of the people, we have the impression, that the grapes are called sour because they are hanging too high.
In giving to the mothers of the toddlers an advice concerning the feeding we limited ourselves to advising to add the two soyabean-products (tahu and tempe), mungbeans (pulse rich in protein), the kinds of vegetables containing Vit.A. and an egg to the rice diet. In many cases even these cheapest of all protein-holding foodstuffs, not falling under the tabu and sufficient to render possible a good bodily development of the toddlers, were still beyond the financial reach of many parents.
Social and economic factors.
Almost all children suffering from malnutrition came out of the social class with a low or very low income, to which by far the greater part of the population should be counted. We only sporadically saw cases of children of well-to-do parents, who suffered from malnutrition. In these cases the malnutrition must be wholly attributed to ignorance of the mother about feeding of babies and toddlers. If once the child’s health had improved by the treatment, then it had in these cases a good prognosis, as the mother generally followed the advice, as she disposed of the financial means to give her young child a good diet. However in addition to the ignorance of the parents, it was their poverty, that was the dominant factor in the pathogenesis of malnutrition. Here giving an advice without disturbing the family-budget was possible only to a limited extent. Of 675 couples, parents of malnutrition-patients, we traced the social circumstances. Most of the fathers were casual labourers, who had not always regular work and so they had also an irregular money-income. Of the 282 fathers, who were casual labourers, in 42 cases also the wife worked more or less regularly. The income was as a rule too low, irregular and insufficient to satisfy the modest requirements of the family. The next group of fathers, 159 in number, were peasants with a very small plot of ground, the produce of which was, according to their own statement, insufficient to feed the family the whole year round. In 26 cases the wife also worked outside the house. The agricultural labourers, the job of 61 of the fathers, worked with a farmer, who wanted a labourer only temporarily. For them too employment is scarce and often limited to the season. Their income is very small and their poverty clearly visible. The other fathers were:
- lower officials, 42 in number, with a salary, on which it was hardly possible to keep a family;
- small dealers, 38 in number;
- betjakdrivers, 31 in number;
- workless, a long time already, 26 in number;
- in the army, 14 in number;
- prepares of Javanese sugar or cocoanut-oil etc., 13 in number;
- employed in the kraton(palace), 3 in number;
- other occupations, 4 in number;
- beggar, 2 in number.
The conditions under which many families live and are housed, make it necessary for many married women to look for work as a fellow-rice-winner outside her (small) house. The income which the husband earns is mostly too scarce to keep and to feed the family (and the additional partakers of the food). In a number of cases the husband does not work at all, so that the entire sustenance of the family has to be provided for by the wife. This causes family life to be very loose, so that it is often impossible for the mother to have sufficient time, money, social security and accommodation to raise her young children in health and well-being within the circle of her family. She carries on trade in the market, works as a house-maid, helps on the sawah during planting-and harvest-time, is sometimes employed in a batik-shop. In such cases it is the grandmother or one of the older girls who takes care of the children. The social circumstances in which the population in the region of D.I. Jogjakarta lives, we should like to call distressing the peasants have on the average a small piece of ground, on which subsistence is partly very modest and for another part harldly possible. Landless people in the country have only little opportunities of employment, unless at low wages and at irregular times. As most Javanese families have many children and the food is almost the only item on the family-budget, on which can be economized, similar social circumstances are very favourable to give rise to many cases of malnutrition among the toddlers. Truly rice in the staple food, but a number of parents bought also cassave, which is cheaper, as a substitute for the more expensive rice. The number of meals taken by the parents is mostly 2 per day. An inquiry made by colleague Muljotaruna in the kabupaten of Kulon Progo, concerning the nutrition of schoolchildren, showed that going to school without a breakfast was with them a very frequent event. This poverty also has its influence upon the calling in of a doctor’s help. However cheaply and with how much accommodating spirit it may be given, as a rule it still takes some money-expenses. These money-expenses sometimes refrain the parents from having their child taken into the hospital, even if they are told, that the costs are a minimum.
The older children too if possible help by the peddling of sweets and smoking-materials to make the family’s living possible. To give an impression of the low standard of life and the difficulties existing in this area to keep up the struggle for life, the following calculation may serve.
An official in government service, belonging to the privileged class, because he has a position with a regular fixed income, when married and father of three children and if he has been in government service for five years, receives the following salary per month:
Group lower official (A2)
Pasis salary Rp. 170.– = Rp. 330.–
Medium official (C2 – 1)
Basis salary Rp. 330.– = Rp. 631.50
Higher official (E2 – 1)
Basis salary Rp. 705.– = Rp. 1,223.–
According to the salary-scale valid on January 1, 1960.
At that date in the town of Djogjakarta a diet of the following composition:
Rp. 2.55 - 4 ounces of rice (home pounded)
Rp. 0.60 - 2 slices of soyabeancurd = 100 gr.
Rp. 0.50 - 2 slices of soyabeancake = 50 gr.
Rp. 0.50 - some vegetables
which all together contains cal. 1,600 and vegetable protein 47 gr., cost Rp. 4.15.
This means that the unkeep of an adult person, who is entirely included in the money-economy and has no ground to provide for his own food-necessaries of life, on January 1, 1960. cost Rp. 125.– per month. Thus a family of 5 persons, as mentioned above, wants about Rp.500.– to provide for their very first requirements. As there are naturally still other requirements (rent, fuel for cooking, clothes, light, water and transport, and others) it is clear that even this “privileged” group lives on the border of the minimum of existence. The struggle for life is made difficult because in the course of these last years the rice-price has strongly risen through the ever in creasing devaluation of the Indonesian money. The price of 1 kg. of rice has been multiplied by six in the period of 10 years, from 1950 till 1960, notwithstanding all the measures of the government to stabilize the rice-price. At the end of 1959 the price had advanced to Rp. 7.–, whereas there are no signs indication, that a balance between supply and demand has been reached in this matter.
Table X – 27
A great number of the parents, who are no government-official and who live in the desa, can partly provide for their own food by means of tilling their own ground, but for the ever increasing number of people, who have got no ground any more and who are compelled to change over from a goods-economy on the a money-economy, subsistence is very difficult. The minimum wages paid to casual labourers in non-government service amounted per day in table X-28.
On this level of wages only a sub-minimal living is possible and this only holds good for those labourers, who still have found employment. So, for those who are unemployed subsistence is still more difficult, while social security is as scarce and insufficient as is the case in the region of the D.I. Jogjakarta. There is therefore no reason to wonder about the high frequency of the disease of protein-calorie malnutrition among the population in the D.I. Jogjakarta. Ever proceeding poverty and ever proceeding economizing on the item “food” in the family-budget make an important contribution to the explanation of this phenomenon.
Late consequences of malnutrition.
While pro-school age the greatest number of victims fall in consequence of malnutrition and in consequence of the decreased general resistance, through which a number of infectious diseases make more victims than would have been most probably the case if the children had been better fed, also after childhood the influence of the qualitatively and sometimes also quantitatively insufficient nourishment asserts itself on mortality-figures. In the period of pre-school age indeed many victims fall of malnutrition, but the number of toddlers that, as mild cases of malnutrition because of the consumption for years of insufficient food, though damaged, still survived, is in our estimation many times as large. A great many toddlers and school-children have an insufficient bodily development because of a one sided diet scarce in protein. From the inquiry by Klerks (1956) concerning the nutritional condition of Indonesian schoolchildren in the age-group of 8-12 years in Kebajoran (Djakarta)
in Tjikini (Djakarta)
in Bandung
in Gunung Kidul
in Patjet (West Java), it was evident that the nutritional condition of the schoolchildren in the rural districts (Patjet and Gunung Kidul) is inferior. Also in the prosperous rice district of Patjet this was the case. The schoolchildren showed a staying-behind in growth and a less satisfactory nutritional condition. This was also the case with the adult people. The average weight of an adult Javanese man is ± 50 kg. and of an adult Javanese woman ± 43-45 kg., which may be called low. Especially the practically vegetarian diet, which 1) is mostly insufficient in calories, 2) consists principally of carbo-hydrates and 3) is poor in proteins that are almost entirely vegetable of origin, is responsible for this hampered bodily development.
This insufficient food is very probably also significant as a factor in the pathogenesis of liver-cirrhosis. Though the pathogenesis of liver-cirrhosis is still unsolved, the frequency of this illness in districts, where also malnutrition is frequently observed, is a strong indication that the deficient food may be of significance. (Patwardhan, 1955; Blankhart, 1951; Brock and Autret, 1952). what significance a deficient nourishment has in the pathogenesis of liver-cirrhosis, in addition to the possible factors, known (hepatitis, and harmful agentia) and as yet unknown, can not be judged about, because of a lack of insight into the etiology of cirrhosis of the liver. Liver-cirrhosis however does not appear to be a direct consequence of the fat-infiltration into the liver caused by malnutrition. (Suckling and Campbell 1957; Waterlow and Bras 1957. cited by Jeliffe 1955). Also the fact, stated by Waterlow and Bras, that liver-cirrhosis does not occur frequently in Brazil, while there indeed many cases of malnutrition are observed, indicates that the connection between malnutrition and liver-cirrhosis is still indistinct. In the district of Jogjakarta we find, in addition to the very frequent cases of malnutrition, also may cases of liver-cirrhosis at an older age. A coincidence of these two patterns of disease in the same area is found to be the rule, to which in Brazil an exception seemed to exist (Snijders and Straub 1922; Brock and Autret 1952). In the period of 1925 till 1935 to Bethesda hospital, which then had an equal capacity to what it has now, 322 cases of liver-cirrhosis were admitted (267 men and 54 women), of whom 80 died (67 men and 13 women).
So in this decade more than 30 cases of liver-cirrhosis were annually observed. We also traced that in the same period, over which our survey on malnutrition extends. In this period from July 1, 1954 till July 1, 1958 in Bethesda hospital in Jogjakarta 365 patients were admitted, for whom in the ward for internal diseases the diagnosis liver-cirrhosis was made. In this period 90 cases of liver cirrhosis were annually observed. Of all the patients admitted to this hospital in this period of 4 years, in 1.2% of the cases this diagnosis was made. Among those 365 patients with liver-cirrhosis there were 296 living in the D.I. Jogjakarta. The remaining 69 patients came from the province of Central-Java (Klaten, Kebumen, Purworedjo, Magelang). The liver-cirrhosis-patients came from 57 different ketjamatans of the totally 60 ketjamatans existing in the D.I. Jogjakarta. Only from the three ketjamatans in the mountainous district of Gunung Kidul (Senin, Ronkop, Ngawen), which are situated at the greatest distance from the town, no liver-cirrhosis-patients were admitted to Bethesda hospital, 73 patients were resident in the town of Jogjakarta. From the kabupatens of sleman and Bantul, situated close to the town, resp. 86 and 83 patients came, while from the kabupatens Gunung Kidul and Kulon Progo, situated at a father distance, resp. 31 and 23 liver-cirrhosis-patients were admitted. At a classification according to sex and age a preference for the male sex is evident. This disease most frequently appears after the 30th year of life. The youngest patients were 11 and 12 years old, table X-29.
Table X – 29.
Distribution of 365 patients, suffering from livercirrhosis, according to age and sex. These patients were admitted in Bethesda-hospital at Jogjakarta in the period July 1, 1954 till July 1, 1958.
They are mostly patients from the poor population-group, who are admitted with a liver-cirrhosis in a bad general condition. In 75% of the cases there is oedema on both the legs, often accompanied by ascites. In 13% of the cases haematemesis and/or melaena is the reason of admission. In the remaining cases there are other complaints (enlarged, senditive liver, enlarged spleen, icterus, meteorism or complaints about being quickly fatigued), which lead to admission.
Mortality among liver-cirrhosis-patients during their stay in the hospital amounted to 13%. a liver-cirrhosis is rare in children. In his thesis Blankhart (1951) described a high frequency of liver-cirrhosis among the population of Sangihe island (Indonesia). In 4 years’ time, in this small island with 84,000 inhabitants, 296 patients with liver-cirrhosis were observed in the only hospital there. Of those, 48% were younger than 15 years. In the course of the years. 1945-1949 the frequency of liver-cirrhosis among the admitted patients receded from 5% of all admissions to 1½of all admissions. The juvenile liver-cirrhosis concerned children from 5 – 15 years old. As a factor in the pathogenesis of this high frequency Blankhart showed to be likely the rather sudden worsening of the nutrition of the island-population, because the Japanese occupator prohibited – in 1942 – their fishing and very strongly impeded the import of rice.
In the same period (1942 – 1945 ) a malaria- and dysentery -epidemic occurred. The diet, already poor in protein, became by this circumstance still more deficient in proteins and calories.
In the region of the D.I. Jogjakarta a liver-cirrhosis under the age of 10 is very seldom seen. The case-history of the only patient suffering from liver-cirrhosis in pre-school age, which we observed, we should like to describe here below.
A liver-cirrhosis at the age of 2 years we did not yet find described in medical literature concerning Indonesia.
Case-history
On Nov. 23. 1959, so after the termination of this investigation, we admitted a boy of the age of 2 years, Sudira, who since a long time already had suffered from a “hard abdomen”, which was growing in size. At birth he had been a normal, lively baby. He had not passed through a period of icterus in the period from birth until one month before being admitted. The nourishment consisted of breastfeeding till he was one year old, from the sixth month on he got a small quantity of rice-porridge and 2 bananas. After weaning, his food consisted of 2 bananas, tea and also 2 times a week some skimmilk (60 cc, 10%), which the mother received from schoolchildren in the neighbourhood, who got the skimmilk at school, but could not appreciate it. At examination we found an underfed little boy with a weight of 7.7 kg. and a length of 75 cm. There was a distinct icterus, which according to the mother, had existed for only two weeks. The liver was distinctly enlarged, felt firm, had a blunt rim and reached to 4 cm. Under the costal margin in the right nipple-line. The spleen was just palpable. On the legs oedema was demonstrable. The eyes showed a xerosis conjunctiva with Bitôt-spots. Originally we diagnosed malnutrition and hepatitis. In the laboratory it was proved that:
- the Wassermann reaction was negative;
- Hemoglobin level 41%, Sedimentation rate of erythrocytes 85/113, Hymans v.d. Berg test directly positive, Bilirubin content 2.4 Units. H.v.d.Berg; mancke sommer test is positive to 30 mg. %.
The general condition of the child, who died 20 days after admission, gradually worsened.
The icterus increased, the oedema on the legs increased and ascites appeared. The slight appetite, present at the admission, disappeared almost entirely. This development, which we never observed in malnutrition, made us consider the possibility of a liver-cirrhosis. If we left the age out of consideration, the clinical pattern entirely suggested a liver-cirrhosis in the last stage. After death on Dec.22 1959 we made a liver-punction. Out of the abdominal cavity much yellow ascites fluid flowed off. At the punction the liver proved to have a stiff consistention. Prof.B.soetarso, pathologist, judged the slides of the liver-tissue as follows:
“There is a very sever fibrosis to be seen, both inter- and intralobular, which is irregular so that the structure of the liver-lobe is entirely gone. In the new connective tissue we observed many bilecanals. No fattening of the liver-tissue existed. In some places we d=found small necrosis-foci, sometimes accompanied with infiltration of lymphocytes. With the van Giesen colouring collagen is demonstrable in the fibrosis-parts.
Diagnosis: Liver-cirrhosis. (postnecrotic?)
Also liver-tumours (primary liver-carcinoma) are relatively frequent in this area. Between liver-cirrhosis and primary liver-carcinoma a connection has often been supposed in literature, viz. That these tumours come into existence more frequently in a cirrhotic than in a healthy liver. (Snijders and Straub 1922 and Patwardhan a.o. 1955). Snijder and Straub found in 1922 in Deli (Sumatera) that the frequency of primary liver-carcinoma in Javanese and Chinese was 35 – 30 times as high as it is in Europe. This high frequency was accompanied with a high frequency of the number of cases of liver-cirrhosis in that district.
Malignant liver-tumours are less frequently seen than liver-cirrhosis. In Bethesda hospital in the period July 1, 1954 till July 1, 1958, a total of 98 patients with primary liver-tumour was admitted. The classification according to age and sex is laid down in table X-30.
The preferential age is in agreement with the age in which mostly also liver-cirrhosis becomes manifest. In primary liver-tumours, the same as in liver-cirrhosis, a preference for the male sex is evident.
Table X - 30.
Distribution of 98 patients suffering from malignant liver-tumour according to age and sex, who were admitted in Bethesda – hospital in the period July 1, 1954 – July 1, 1958.
Diseases caused by deficiency of food at older age.
The hunger disease, recurring every year in the kabupaten of Gunung Kidul at the fixed time (patjeklik) and which then makes many victims and to which we will come back more extensively in Ch.XI “Food problems in gunung Kidul”, is neither a rare thing in other parts of the D.I. Jogjakarta. When during some months the available quantity of food is so scarce, that the population can not even provide for the necessary calories, hunger-disease sets in. it is the period in which that year’s harvest is not yet ripe and last year’s harvest has been consumed already. This seasonal famine principally appears in the kabupaten of Gunung Kidul and does not particularly affect pre-school agers, as was evidently the case with protein-calorie-malnutrition, but older people.
Resides in the kabupaten of Gunung Kidul, to which we will devote the next chapter, this famine-period also recurs in the ketjamatans of Sentolo and Nanggulan (Kulon Progo) and Pedes and Padjangan (Bantul). These four ketjamatans, abutting on each other, on both sides of river Progo, are poor in good arable grounds. In this area are also situated the heavily eroded hills of Sentolo, in which the possibilities for agriculture fall back annually by increasing erosion.
The food problems in this district are so much related to those concerning Gunung Kidul, that we refer to that chapter. Also in the ketjamatan of Imogiri, which administratively belongs to the kabupaten of Bantul and borders on the kabupaten of Gunung Kidul the problem of the “seasonal hunger-disease” is the same as in Gunung Kidul. In the years 1956 and 1957 some thousands of patients with hunger-disease were reported in these 5 ketjamatans in the statements of their local administration.