The clinical picture of malnutrition in the D.I. Jogjakarta

The significance of malnutrition as cause of death.

Malnutrition is evidently the most important cause of death for little children from 1 till 7 years old in Jogjakarta. This appeared from the data, mentioned in table VII-7. In the group of infants its contribution to the mortality amounted already to 9%, but in the second year of life the mortality caused by malnutrition increased to 36% of the total mortality in this age. After a rise to 40% in the third year of life the share of malnutrition as cause of death in the preschool age-group gradually declined to 19% in the 6th and 7th year of life. After the age of 7 we only sporadically saw children, suffering from malnutrition and dying of it. In addition to the significance, which malnutrition has as cause of death, it is of importance as a factor furthering the fatal issue of many other diseases by reducing the defensive forces of the body, and because of this, many diseases have a higher mortality than with well-fed children would be the case.
This fact was very obvious in small enteritis-patients. These patients, who have a more labile equilibrium of fluid and electrolytes owing to their malnutrition than well-fed children, soon get into a state of dehydration in case of an enteritis, owing to which the prognosis worsens considerably. How far malnutrition of the mother might be of influence for the high frequency of prematurity with its great mortality among the newborn infants, we discussed under the par. “Prematurity” (chapter VIII). The clinical picture of malnutrition, as we saw it in the region of the D.I. Jogjakarta, we would describe below:
We forego the use of the vague and indistinct name of “kwashiorkor”, borrowed from the language of the Ga-population in Ghana and introduced into literature by C.D.Williams as a name for this disease, in view of the many interpretations in circulation about the possible meaning of this name, to wit: The disease, the child gets when the next baby is born (C.D. Williams) or: Kwashi means first and orkor means second (Miss F.W.Grant 1953) or: Red boy. (Trowell and Muwasi 1945, citied by L.N.Went 1955). Or: Kwashi is the Ga name for a boy born on Sunday and Oko is unknown in the Ga language, but in the Fanti and Twi languages it means red or reddish. However in these languages the name for the disease is “Ason”, (J.A. Van Beukering 1954). We consider this name to be unsatisfactory, all the more so, as by continued research, the cause of the disease, namely a deficient diet in respect to proteins and calories, namely a deficient diet in respect to proteins and calories, has become more and more evident. The name Protein-calorie-malnutrition (Jeliffe 1959) seemed to us to deserve preference. The name “sakit abu”, which is mentioned by Trowell, Davies and Dean in their monography (1954) on page 283, as a name for this disease in use in Java, did not at ample investigation appear to be in use in the area of the D.I. Jogjakarta as an indication for a disease, The Javanese word; abuh means swollen or swelling, either by oedema,infiltrate, disfigurement, or indistinctly outlined tumour. It only indicates the symptom of swelling and therefore should not be considered as a Javanese synonym of the word: malnutrition.
From the voluminous literature concerning malnutrition it has been evident, that this syndrome is wide-spread in south-East Asia too. Publications and communications concerning the occurrence of malnutrition in the Indian Union (Gopalam 1955, 1957), Pakistan (Perabo 1960), ceylon (Jayasekera 1951), Afghanistan (Perabo 1959), burma (Perabo 1953), thailand (Netrasiri 1955, Stahlie 1959). Indochina (Bablet and Canet 1952). Philippines (Stransky 1950, 1958), Federation of Malaya (Williams 1940). Fiju (Manson-bahr 1952), China (Chen 1942), and Japan (Arakawa et al. 1951) demonstrate the spread of this disease over almost all regions of S.E.Asia.
The clinical picture of malnutrition has been known in Indonesia already for some decennia. The first description by M.Straub we found in his thesis of 1927. It concerned Javanese children, of whose parents one or both worked as labourers on the culture-estates (tobacco, rubber) on the east-coast of Sumatra.
He described as symptoms a too low body-weight, in addition to a strong atrophy, oedema appearing in the legs. Also the obvious apathy, the reduced level of the serum proteins, the severe fatty infiltration of the often enlarged liver, especially in the 2nd and 3rd year of life, and the occurrence at the same time of all kinds of inflammations (Cystitis, otitis, enteritis) in these patients, often a decay of the teeth and sometimes the presence of gangrene of the mouth-mucosa, were mentioned in his description.
In 1939 de Haas demonstrated some children with nutrition-oedema, while he noted that children suffering from this disease were regularly taken to the children’s ward of the Central hospital in Djakarta, In 1940 M.Ismangil published, in his study about “Nutritional oedema in Bodjonegoro”, also two pictures of malnutrition patients, whom he had come across during his research in East-Java. After the second world war it was especially Oomen, who published a number of studies on malnutrition in Indonesia in the years 1950-1955, while in 1956 Hoogenkamp wrote a thesis on malnutrition in the island of Kalimantan. In 1957 the thesis of Poey Seng Hin appeared on the clinical picture of malnutrition in Djakarta.
In our systematic investigation of all malnutrition patients, who were admitted into the children’s ward of the Bethesda hospital during the period July 1, 1954 till July 1, 1959, we followed the way of determining the seriousness of the patient’s condition, such as Oomen (1954) had proposed. Also in a great number of malnutrition-patients admitted into the University children’s ward, we traced the seriousness of their symptoms in this way. The method of examination described by Oomen is as follows: Of the 10 most important symptoms, often appearing in malnutrition-patients and almost all belonging to the most constant symptoms of the disease: malnutrition (Kwashiorkor) as it has been described in the extensive literature concerned (Brock and Autret 1952), in the examination is traced whether the deviations are absent, slight, moderate or very distinct, which was respectively indicated by the figures 0, 1, 2, or 3. After adding them up we find the malnutrition-index. The directives which we followed in judging the seriousness of the various symptoms, we will give here below in a survey, table X-1.

Table X – 1

Criteria used in the determination
This way of research is of course subject to the influence of a great subjective factor in judging about some symptoms. Especially the judment on the subcutis, the depigmentation, the xeratrophy of the skin and the muscle-atrophy will indeed vary somewhat with different examiners. However the value of this method of research is situated in the circumstance, that it compels to make a decision and to observe each case attentively. The value of the judgement in an individual case is from its very nature only for the judge himself, but in a long series by one and the same examinator it renders possible a mutual comparison in the series.

Weight:

We took the body-weight after the loss of possible oedema. The child was weighed daily on the gauged baby-balance of the children’s ward. As a norm for the body-weight at baby-age we used the curve of the average weights of Indonesian babies, at Djakarta in 1937 published by Liem Tjay Tie, Soeparno and de Haas and made up from the data of a number of welfare-centres in Djakarta in the period 1932-1935 for the greater part. It concerned babies of Indonesian officials. Only the weights of the babies, who got breast-feeding, were used for the growth-curve. The weights of babies of the poorest population-group are practically absent from these data. The curve was made up out of 3,134 observations and ranged from 3,800 grammes at the age of 4 weeks unto 7,800 grammes for boys at the end of the first year of life. Therefore the curve may be somewhat more favourable than reality justified in that period. As a norm for the body-weights in the pre-school age group we took the weight-curve, made up by Tan Eng Dhong, Soekonto and de Haas in 1938, from the data on the weights of 7,012 children, who, in the period 1932-1937 on account of light indispositions, visited the polyclinic of the General Central Hospital in Djakarta. It concerned small children from 1 till 6 years of age. It was obvious that the weights of the various groups of examined Indonesian children, to wit Javanese, Sumatran and Chinese pre-school children, did not vary worth mentioning at the corresponding ages. The curve found was the result of 3,894 weightings of boys and 3,118 weightings of girls. The weight curve went from 8.1 kg at 1 year to 15.8 kg at 6 years with boys and from 7.6 kg at 1 year to 16.2 kg at 6 years with girls.

Length:

The norm for body-length at infant and pro-school age we also derived from the above-mentioned investigations.

Depigmentation:

Discolouration of hair is not counted except when striking other qualities are present. (thinning out, atrophy, dryness). The de-pigmentation of hair and skin were judged together.

Crazy pavement dermatosis:

The fixing of 9% of the skin-surface, taken as the limit between a judgment 2 and 3, is so far arbitrary, that it has been taken from “the rule of nine”, suggested by Evans (1952) for measuring the affected skin-surface in burnings. It sounds: head and neck 9%, arm 9%, trunk-front 18%, trunk-back 18%, leg-front 9%, leg-back 9%, genitalia and perineum 1%.

Fig. 24.

Standard  weightcurve

Fig. 25.

Standard  lengthcurve of Indonesian toddlers. Djakarta (1932-1937)

Xerophthalmia:

In a large number of the little malnutrition-patients, who at the same time suffered from xerophthalmia, we had the possibility to consult an oculist (colleague Tjoa Siok Thjiang).

Size of the liver:

The distance 2 and 4 cm in determining the size of the liver was measured during inspiration along the line, starting from the spot, where the papillarline crossed the costal margin and going from there to the umbiculus. Because, as a routine, we also x-rayed the children suffering from malnutrition, we could diagnose that an enlargement of the liver upwards did not occur among our patients.
In the period July 1, 1954 until July 1, 1958 505 patients were admitted in the children’s ward of Bethesda hospital in Jogjakarta, because of malnutrition. It appeared, that 16% of all 3,148 patients younger than 7 years of age admitted in the ward in this period, were admitted because of serious malnutrition. Less serious cases were poly clinically treated, if possible.
In the period May 1, 1955 until July 1, 1958 552 malnutrition-patients were admitted in the University children’s ward. Here the malnutrition-patients. Made up 29% of all admitted patients, younger than 7 years of age, which amounted in total to 1,814 admissions. A grouping as to sex and age of the 1,057 malnutrition-patients admitted in the above mentioned Children’s wards has been given in table X-2.

Table X – 2.

Survey of the 1057 Malnutrition

The mortality-rates in the various year-groups have also been noted in this table. Boys appeared to suffer from malnutrition more frequently than girls and the largest number of malnutrition-patients per year-group appeared to occur in the second year of life, next in the 3rd year and then in the first year (see fig. 26, diagram).

fig. 26.

Age-distribution of 1057 malnutrition-patients,
This age-distribution is in agreement with the one given by Trowell, Davies and Dean (1954) and which was made up from the data regarding 1,141 child-patients, collected from the publications of various authors.
Also those of Oomen (1954) and Poey Seng Hin (1957) of respectively 124 and 138 malnutrition-patients at Djakarta give a practivally equal age-distribution. By other authors – a.o. Van der Sar (1951) and Netrasiri (1955) we find also this age-distribution stated regarding malnutrition-patients in Curacao and Bangkok. So it concerns especially the older infants and the young toddlers who run the greatest risk of falling victims to malnutrition. At increasing age, mortality evidently decline din this group of malnutrition-patients treated. In the first half year of life mortality among malnutrition-patients amounted to 38% and in the 7th year this mortality appeared to have declined to 16%. In this survey not included are the patients admitted to the hospital because of a serious state of illness brought about by another disease, in addition to which we perceived in the clinically observed malnutrition-patients, we have collected in the clinically observed malnutrition-patients, we have collected in the undermentioned survey.

Table X – 3.

Survey of the clinical manifestation in 454 malnutrition-patients

It regards 454 of the 505 malnutrition-patients admitted in the Bethesda hospital in the above mentioned period. A number of cases are left out of consideration, because the data were incomplete. The average malnutrition-index appeared to be 16. The most constant symptoms appeared to be : an important weight deficiency compared with the norm, atrophy of the muscles and xeratrophy of the skin. The last two symptoms were reckoned to be positive, only if in the determination of the malnutrition-index they were judged as 2. the liver, which may be palpable in healthy children too by physical examination to 2 cm (sometimes 3 cm) under the costal margin (Feer 1951). we consider as enlarged when palpable to 2 or more cm under the costal margin. It is possible that in a very few cases a normal, low-reaching liver was interpreted as pathologic, but we thought this possibility very slight, as in the course of 5 years we only sporadically observed a liver reaching to more than 2 cm below the costal margin in healthy or slightly sick, well-fed Javanese babies and pre-school children. Crazy pavement dermatosis, a typical symptom of malnutrition we saw in 12% of all these malnutrition-patients. The combination of protein calorie-malnutrition with vitamin A-deficiency was met with very frequently. Of the 454 malnutrition-patients 251, that is 55% suffered from xerophthalmia simultaneously. It is often a complaint about the eyes of the child that induces the mother to consult a doctor. A more of less atrophic child is a phenomenon occurring so often, that this hardly alarms the mothers; only when phenomena of photophobia appear, and the child keeps the eyes permanently closed, this is a reason for many mothers to have the child examined. In many cases indeed blindness may be prevented, but in 14% of these patients the xerophthamia led to complete destruction of the two corneae and to blindness. Xerophthalmia was often the indication for admission to the clinic, thus to reduce the risk of blindness for these children. Anemia appeared to occur in a great percentage of the malnutrition-patients. It was mostly a normocytic normochromic anemia. Ancylostomiasis is in the pathogenesis of anemia in these children of very little importance, as this worm-infection is very seldom found in children in this area.
Also 380 of the malnutrition-patients, admitted to the University children’s ward during the period May 1, 1955 till July 1, 1958 were examined in the way described above. The frequency of the symptoms in these malnutrition-patients was also collected in a survey, table X-4, however somewhat less extensively than in table Z-3. We see a very great conformity between the two groups malnutrition-patients in their symptomatology. In these patients too a xeratrophic skin and an atrophic musculature is a very frequent symptom. An experience, ever again made in the examination of these malnutrition-xerophthalmia-patients, was that the serious forms of xerophthalmia and keratomalacia in which the eye-sight has been lost by the destruction of great parts or of the whole of the cornea, are exclusively found in children, who at the same time suffer from a serious form of malnutrition.

Table X – 4.

Survey of the clinical manifestations in 380 malnutrition-patients.

In children in a state of good nutrition we did observe sometimes xerosis conjunctivae, but we did not come across the combination of a state of being well-fed with xerophthalmia leading to blindness, while we have been constantly on the alert for this phenomenon. This is also the experience of oculist Yap Kie Tiong, director of the Dr.Yap Eye-Hospital and of oculist Tjoa Siok Thjiang working at this hospital.
The constant meeting with xerophthalmia leading to blindness, combined with malnutrition seems to justify the conclusion that only little power of resistance there is in the corneae of the malnutrition-patients, at the moment when already ulcera corneae have appeared in the course of xerophthalmia, which is no longer able to check the progress of this illness and thus the corneae are easily destroyed. In a publication on “Protein-deficiency in keratomalcia” by Dr. Yap Kie Tiong (1956) a comparative investigation is described between 10 keratomalacia patients at ages from 1 – 3 years and 10 xerophthalmia patients at ages of 1 – 4 years, who were all in a bad nutritional condition. No important difference was found between the percentages of Vit. A in the blood of both groups of patients, though in the percentage of the serum-proteins a difference did exist. The group of keratomalacia patients had an average bloodserum-percentage of 4.3 gr/100 ml. (alb. 1.7; glob. 2.6), while in the group of xerophthalmia patients these figures were 6.2 gr/100ml. (alb. 3.0; glob. 3.2). The author concluded that “these findings suggest that, besides the lack of Vit. A, also protein deficiency plays an important role in the pathogenesis of keratomalacia”. A conclusion that to our thinking also seems of importance for the serious forms of xerophthalmia.
For the study of histopathology of the liver in malnutrition-patients we made a research, directed to this disease by means of liver-punctures after having acquired the disposal of a liver-biopsy-needle in May 1955. We however limited this to the malnutrition-patients, who came to die, in which case, at once after death we took away a piece of liver-tissue by means of puncture. The tissue was sent for examination to prof. Bambang Soetarso, professor of pathology at the Gadjah Mada University at Jogjakarta. The results of this investigation were as follows:

Data of 95 malnutrition-patients, to wit 55 boys and 40 girls who came to die from malnutrition in the children’s ward of the Bethesda hospital and whose liver-tissue was sent to the pathologist, have been put together, arranged according to the age of the patients at death in table X-5.

Table X – 5

Results of the histopathological examination

It appeared that in 83% of all these cases of malnutrition examined a slight to very sever fatty infiltration of the liver-tissue existed. In 58% of all the cases examined this fatty infiltration was heavy to very heavy. The criteria used in judging about the degree of fatty infiltration of this liver-tissue were as follows:

Slight: when less than 25% of all the cells contained fat-vacuoles. The fat-vacuoles in these cases are situated in the peripheral areas of the liver-lobules.

Moderate: when at a rough estimation 25% to 50% of all the cells of the liver, judged in a few microscopic fields of vision, contained fat-vacuoles.

Heavy: when more than half of all cells in the slide appeared to be turned into fat.

Very heavy: when only after a long search it was possible to find still normal liver-cells in the slide.

However it appeared not to be possible to keep consequently to this criterium solely, as a fatty infiltration of a great number of cells, which however contained a small fat-vacuole, would then be judged equally with a fatty infiltration of liver-tissue in which the liver cells all consisted of almost on big fat-vacuole. In judging account was kept with the number of fat-vacuolated liver-cells, but also with the size of the fat-vacuoles.
The “fibrosis” was formed by a condensation of the reticulin-tissue.
Increase of collagen-tissue in these preparations with “fibrosis” could not be proved. Necrosis of liver-cells, as described by some authors, in liver-preparations of malnutrition-patients was not found by the pathologist in any of the preparations.
Interrupted growth, without exception found in children suffering from malnutrition, is clearly evident from the weight curve of fig. 24 and from table X-6, in which the average weights of 737 patients, suffering from malnutrition, of the age of 0 to 8 years are mentioned.

Table X – 6.

Survey of the average bodyweight of 737 malnutrition-patients

We took the weights of malnutrition-patients, who were respectively 6 months (5 – 7 months), 12 months (11 – 13 months), 18 months (16 – 20 months), 2 years, 2½ year, 3 years, 4 years, 5 years, 6 years, 7 years and 8 years of age. The patients’ ages are estimated. The exact date of birth was known only in part of the cases. We took those cases in which the mother’s statement was identical with our own estimation. The weight curve of the patients has been drawn, together with the curve-line of the weights from the publications of Liem Tjay Tie (1937) and Tan Eng Dhong et al. (1938), which we used as a norm. A strong weight deficiency in these patients may be read from fig. 24. The weights of the malnutrition-patients regard the weights after contingent oedema had disappeared, so that patients, who died before the oedema had disappeared, have been excluded from this survey, as also the patients who did not belong to the various age-groups.

Diarrhoea. Watery stools was a frequently occurring symptom in malnutrition-patients. In a high percentage of the malnutrition-patients we found watery stools, changing with a frequency of 2 – 10 times a day, especially under the 5th year of life. Arranged according to the age of the malnutrition-patients in the age-groups, which norm we also followed in the paragraphs before, this gave, of 456 patients, all nursed in the children’s ward of Bethesda hospital, the following table X-7.

Table X – 7

Frequency of diarrhoea in 456 malnutrition-patients

Alterations in the skin observed with malnutrition, through disturbances in the process of cornification and in pigment-distribution, may be distinguished into some different types. Crazy pavement dermatosis, so typical for this disease, we saw in 12 – 13% of all the cases, mostly accompanied with oedema. In 72% of all patients with crazy pavement, oedema too was in evidence. Varying from many small, darkbrown, pointed, hyperkeratotic spots to confluent, dry, sharply outlined peeling plaques, especially localized on abdomen, buttocks, genital-region, and lower limbs (knee-hollow), crazy pavement occurs. After peeling off, the underlying skin is depigmented. Most frequently we saw xeratrophy, in which an atrophic, dry, wrinkled skin without pigmentation-deviations is found. The lines in the skin are here much more distinct than usual. Sometimes we saw xeratrophy in which a strong peeling of the entire skin appeared with very fine scales, localized mostly on the back. In order of frequency we saw the following skin-alterations in the malnutrition-patients:

  1. xeratrophy
  2. mosaic skin
  3. crazy pavement dermatosis
  4. superficial skin-erosions with little inflammatory-reaction

The mosaic skin (crackled skin), in which slight hyper pigmentation occurs in addition to peeling was seen especially on the front side of the lower legs, on the crown of the heads of children with very little hair. All these kin-alterations were cured or changed for the better during treatment in the ward. Normally the hair of Javanese children is black, shining and sleek. The hairs of malnutrition-patients, mostly short and scarce, are duller of gloss, dry, fine, and have sometimes a brown colour through a slight de-pigmentation. We also observed such a scarce hair-growth with very short hairs, that the head made the impression of baldness. With some pulling the hairs come off very easily, especially in the region of the temples.

The serum proteins: As hypoproteinemia as a symptom is described in almost every publication regarding malnutrition in Africa, Asia and Latin America, we also controlled the protein-spectrum in venous blood of 89 patients, taken in the first four days after their admission to the hospital. The determinations were made in the Central Laboratory of Public Health at Jogjakarta, by the ;method of Howe-Cullen-van Slijke. In the serum of these patients the following average values were found concerning:

  • Total protein : 5.01 grams per 100 cc serum.
  • Albumin : 2.67 grams per 100 cc serum.
  • Globulin : 2.34 grams per 100 cc serum.

In all these patients with malnutrition a distinct hypoproteinemia and hypalbuminemia was evident, when compared with the values given as normal, which are found in healthy children with the above mentioned method. Also Dr. Yap Kie Tiong – during an investigation in Jogjakarta in 1956/1957 – had diagnosed hypoproteinemia in malnutrition-patients. In two series of investigations he examined the protein-level of the serum in respectively 79 children of 6 – 18 years, taken from 3 different social milieus (to wit: doctors’famillies, children from an orphanage and children from the desa) and in 20 pre-school children of 1-4 years, suffering from malnutrition and keratomalacia resp. Xerophthalmia. The diet of these groups of children was also taken into the investigation. It appeared that per day with the diet was consumed:

  • by the 25 doctors’children : 2,218 cal., 63 gr.protein and 3,505 I.U. Vit.A.carotenoids
  • by the 25 doctors’children : 1,473 cal., 39 gr.protein and 4,159 I.U. Vit.A.carotenoids
  • by the 25 doctors’children : 1,271 cal., 28 gr.protein and 809 I.U. Vit.A.carotenoids

In the group of 20 patients, (pre=school-children, aged 1-4) – when compared with the 3 groups of children from various social milieus-, a strongly reduced protein-level in the bloodserum was found. The albumin-level was always reduced, while the globulin-level might rather be called somewhat increased. The results of Yap Kie Tiong’s research, together with those of other authors, who made researches in this field in other S.E.Asian countries, have been placed together in table X-8.

Table X – 8.

Result of the investigation concerning serum-protein

The findings have been reached with various methods of research, so that this reservation concerning the comparability must be made.
A connection between the level of protein or albumin in the serum of malnutrition-patients, who showed oedema and of those who had no oedema, we could not prove, though this connection was demonstrated in 1954 by Gomez et al.

Anemia: A percentage of hemoglobin lower than 10 grammes per 100 cc of blood, measured according to the method of Sahli, we found in 68% of the 447 malnutrition-patients, in whom we examined this. The anemia was in the majority of the cases normochromic and normocytic, while in a small number of cases also other types of anemia were found, viz. Hypo- and hyperchromic anemias. So little frequently ancylostomias is infection was found in children, that this worm-infection cannot be of importance in the genesis of these anemias.

Mental changes: If left alone, the patients are somewhat sleepy, apathetic, uninterested in their surroundings and they hang motionless in the “slendang” (sling to carry children) carried by the mother, or are lying quietly in bed in the ward, when they have been admitted there. Because of the large degree of muscle-atrophy they mostly are not able to sit, to stand or to walk any more. Xerophthalmia-patients keep their eyes closed and turned away from the light. At examination the patients offer a faint resistance to the actions of the physician. They cry and kick a little until arms and legs are held. This irritation and peevishness quickly changes again to apathy after the examination is over. In addition to this “peevish mental apathy”, which is a very constant symptom of malnutrition, we also very frequently find a diminished appetite. During many weeks of the treatment the patients remain apathetic and chagrined and not until the nutritional condition has distinctly improved after a prolonged treatment do the children smile for the first time. Complication of malnutrition with noma we only saw sporadically. In the period of this 4 years’ research we saw 5 cases of malnutrition with noma admitted into the Bethesda hospital, while in the University children’s ward 2 cases were observed. The noma was localized at the gingiva of the upper jaw in the non-serious cases, but in the greater part of the patients, tissue of cheek and upper jaw had been destroyed by this inflammatory process, so that in 4 of the 5 patients after recovery ugly disfigurements stayed behind.
The type of malnutrition-patients, who in literature bears the name of “sugar baby”, we only seldom saw. These patients make an impression of plumpness. Their paleness is to be ascribed rather to a thick skin than to anemia. In the fat pasty legs no oedema is demonstrable. Weight is less subnormal than in atrophic malnutrition-patients, but during their stay and treatment in the clinic their weight first goes down before rising as a favourable reaction to the treatment.

Therapy: As there is a great unanimity in the literature on this disease, concerning the most important factor in the pathology, herewith the most important directive is also given for the therapy. At once after admission we gave only liquid food namely a 600 cc skim-milk solution of 6%, supplemented with 10% rice-water to 1,000 cc. If necessary this food was brought into the stomach by means of a nasal tube. It often occurs that feeding per nasal tube has to be continued during 4 weeks in heavily anorexic patients. When it is evident that the patient can endure this food, in the first week of admission the skim-milk solution is increased from 6% to 12%. In the course of 1-4 months, dependent on the patients’ appetite, the consistency of the stools, the diet is extended, from “fluid” to “semi-solid” and “solid”. In addition to the milk we first give banana, further porridge of skim-milk consisting of rice-flour, sugar and skim-milk. When this porridge is well endured, other porridge is given besides, to which are added vegetables, carrots, chopped meat, liver, egg and fruits. For the children who have no teeth yet, this porridge is first sieved. The following and last extension is the diet, with which the child is sent home. It consists of rice, to which is added protein-rich food made with soyabean (tahu, tempe) , vegetables and one egg per day, with this order of diet the patients receive 3 – 4 gr. Animal-protein per kg. Bodyweight and sufficient calories and fluid. Besides a diet rich in protein and poor in fat we also gave a treatment of repeated little blood transfusions. Only to the 500 malnutrition-patients, who were concerned in this research and who were admitted to Bethesda hospital, were administered more than 400 small blood transfusions of 50 – 70 cc during this period of 4 years. We gave those blood transfusions after the loss of much oedema, which takes place mostly in the first 10 days after admission. These patients very easily fall into a state of dehydration after loss of oedema. In this critical period, living on the border of circulatory-failure, they get blood transfusions during 3 – 4 successive days. Atrophic patients, who even after some weeks of treatment do not yet increase in weight, are treated with a small series of blood transfusions, the same as anemia patients. Also malnutrition -patients, who suffered from diarrhoea and in whom an insufficient resorption as well as the danger for dehydration were presents, were treated in this way. In this way parenteral-proteins were administered for the very first recovery of the deficiencies. Of these repeated little blood transfusions we saw a good influence on the recovery of the malnutrition-patients. There always was a slight risk of transfusion-malaria, but it is our impression that the risk of transfusion-malaria does not counterbalance the advantages of these blood transfusion for the patients. Intercurrent infections found in these patients, in addition to malnutrition, are naturally attended to at the same time. This concerns mostly enteritis, bronchitis, otitis media, ascariasis and cystitis. The patients were sent home, when they had a good appetite and increased in weight.
When surveying this description we are of the opinion, on the score of the great conformity between the clinical picture as described in many places in literature and the picture we so frequently observed in Jogjakarta, that we have rightly dianosed: protein-calorie-malnutrition.
In the monography by Brock and Autret (W.H.O. 1952) they describe the following criteria for the diagnosis protein-calorie-malnutrition:

1. Retardation of growth at the late breast-feeding, weaning and post weaning ages.
2. Dyspigmentation of the hair and to a lesser extent of the skin
3. Oedema usually associated with hypo-albuminemia.
4. Pathological changes in the liver which include one or more of the following:
fatty infiltration, fibrosis and necrosis.
5. A heavy mortality if the syndrome is untreated or incorrectly treated.
(6). Dermatosis, occurs in a variety of patterns but may be absent.
(7). Gastro-intestinal disorders (anorexia, diarrhoea, mild steatorrhoea.
(8). Peevishness and mental apathy.
(9). Mild normocytic or slightly macrocytic anemia.
(10). Atrophy of the acine of the pancreas, resulting in decline of the enzymatic
activity of the duodenal contents.

The first 5 symptoms form the fundamental phenomena of the clinical pattern of protein-calorie-malnutrition. Only the last-mentioned symptom (10) we could not verify. Obductions are always refused by the parents, while examination of the lipasis – and amylasis-contents in the duodenum-fluid, was technically impossible for use.
Comparison with the descriptions from other parts of the world, viz. Africa, Central America and southeast Asian countries, proves that the coincidence of malnutrition with Vit. A deficiency as in Java, is seen very frequently. Also in malnutrition-patients in Djakarta (Poey 1957), Bangkok (Netrasiri 1955) and Coonoor (Gopalan 1956) the often occurring coincidence of malnutrition and xerophthalmia is described, while in Africa and Central America it is not the case.
The clear dyspigmentation of the hair, described in African children by Brock and Autret ( 1952 ) is much less clear in the Javanese malnutrition-patients. Also in the publications on malnutrition in India, Fiji, Curacao, Ceylon, Burma, Thailand and Djakarta only a slight change in colour of the hear-hair is described. We have the impression, in view of the small numbers of patients described in many publications, that in Java the frequency of malnutrition is very high.

The domicile: of the malnutrition-patients has been indicated in the subjoined diagram fig. 27 in which each point represents a malnutrition-patient admitted into one of the two children’s wards during the period July 1, 1954 till July 1, 1958. The town in this diagram has been indicated in black. Totally 422 malnutrition-patients, coming from the town of Jogjakarta, were admitted into the two children’s wards. By far the greater part of our malnutrition-patients proved to be coming from the town of Jogjakarta, the kabupaten of Sleman and the kabupaten of Bantul. From the two other kabupatens, Gunung Kidul and Kulon Progo only a small number of malnutrition-patients came for admission, however from these two latter kabupatens usually few patients come for admission to the hospitals in the town of Jogjakarta. The distribution of these patients in fig. 27, is very probably due to the varying distances between the place of residence and the children’s ward.

Fig. 27.

The place of residence of 1057 malnutrition-patients

From other sources it is known, that in Kulon Progo and Gunung Kidul too protein-calorie-malnutrition occurs among the pre-school-children. In the entire area of the D.I. Jogjakarta we suppose that this disease is very frequent among the infants and toddlers of the Javanese population of this region. In the area of Sleman, Bantul and the town of Jogjakarta the principal food of the population is rice, in contrast with the kabupaten of Gunung Kidul, where gaplek (dried cassave) is the staple-food. In the dabupaten of Kulon Progo the staple-food of the population in the southern part is rice, while in the northern mountainous part in addition to rice also gaplek is eaten by the population. The patients with malnutrition, whom we set eyes upon, are for the far greater part from this rice-area, because Bethesda hospital and the University clinic are situated in the town of Jogjakarta, in the centre of this area.

Intercurrent diseases.

In the anamnesis of many malnutrition-patients, whom we decided to admit into the clinic and whose anamesis was recorded more accurately than this would be possible at the polyclinic, we found the following: for a long time the child enjoyed a reasonable health, at least according to the mother’s statement. After the occurrence of an infectious illness (for the greater number of cases concerning an enteritis) the child began to be ailing of a bad appetite, became drooping and never quite recovered. The child gradually grew thinner and was taken to the polyclinic for examination, where the diagnosis: malnutrition was made. These pre-school children, who had been on an insufficient diet for a long time already and who could be kept in a labile balance on this diet, appeared not to be able to hold on any more because of the infection. The bad appetite found in many malnutrition-patients often dates from the first appearance of a disease and renders the malnutrition quickly progressive.

Fig. 28.

Age-distribution of 2056 xerophthalmia patients