A simultaneous appearance of protein-calorie-malnutrition and Vit. A. deficiency is very frequent among the patients examined by us, viz. it occurs in more than half of all these cases. Among the patients admitted in the children’s wards especially many serious cases of xerophthalmia occurred. Light cases (xerosis conjunctivae, xerosis corneae) were treated polyclinically. However the number of cases of xerophthalmia in babies and toddlers, who visited our polyclinic, was not as great of course as the number taken to the polyclinic of the eye-hospital, “Dr. Yap”, which has been established in the town of Jogjakarta since the year 1923 already. From the director of this hospital, Dr. Yap Kie Tiong, we obtained permission to trace the histories of all the patients with xerophthalmia, who visited the polyclinic in the years 1952 – 1953 and 1955 – 1958 inclusive. The case-histories of the year 1954 in this hospital were missing from the records. The diagnosis in these cases has been made up by the ophthalmologist. We traced the places of origin of the 2917 xerophthalmia patients, who had been treated in the eye-hospital during these 6 years. We grouped the patients resident in the D.I.Jogjakarta according to the kabupatens of origin. This survey has been placed in table x-23.
Table X – 23.
The xerophthalmia-patients made up ± 4% of all the patients, in this eye-hospital examined during this period. 71% of the examined xerophthalmia patients and keratomalacia patients proved to be living in the D.I. Jogjakarta, viz. 2,056 patients. At a further classification of these patients according to the kabupaten where they lived, 29% proved to come from the town of Jogjakarta, 41% from sleman and 21% from Bantul. Practically all patients came from the district, where rice is the staple food. From Gunung Kidul, where gaplek (dried cassave) is the chief food, there were in all 14 patients in this period of 6 years. The low frequency of the number of patients from gunung Kidul does not rest on a coincidence. During the diet-inquiry and the inquiry into the state of health of the population which took place in Gunung kidul in the period 1938/1939, it was found, that among 1259 examined children there were only 3 cases of xerosis conjunctivae.
The experiences of colleague H.J. Nielen, kabupaten-physician of Gunung Kidul in 1958 and 1959 and of K.V. Bailey, nutritionist at the Institute of Nutrition at wonosari in gunung Kidul in 1958 and 1959 were, with respect to the frequency of xerophthalmia among children, also in accordance with the inquiry of 1938. both at the polyclinics, and at the examination of a great number of schoolchildren in this kabupaten, only very exceptionally a sporadic case of xerosis conjunctivae was observed. The very small number of patients form gunung Kidul coming to the polyclinic of the eye-hospital for examination thus finds its explanation in the really low frequency of this disease among the population of the kabupaten of gunung Kidul. When in the table we compare the figures in the column of the town of Jogjakarta with those of Sleman, we see that the number of xerophthalmia patients coming to the polyclinic of the eye-hospital for examination form the kabupaten of Sleman in the year 1952 amounted to 28% of all xerophthalmia patients living in the D.I. Jogjakarta while in the years ’53, ’55, ’56, ’57, and ’58 this amounted to resp. 36%, 42%, 46%, 45% and 47%. so here is a distinct increase to be noticed. Notwithstanding the distance from the eye-hospital the percentage increases. For patients from the town of Jogjakarta these percentage are resp.: 40%, 36%, 28%, 25%, 23% and 26%.
Here we see a distinct decrease of the percentage, despite of the short distance. This changing difference between the proportions of these percentages formed by the patients from Sleman and from the town of Jogjakarta in the course of this period, to our thinking should be ascribed to the unfolding of the activities of the welfare centres of the “Mother-and-Child Health” who have had the opportunity, in the course of the period 1951 till 1958, in all 13 kemantrens of the town to controll the food- and health-situation of babies and toddlers, through which many thousands of children have had a chance of receiving Vit. A. drops regularly at a symbolic price. For a long time already the occurrence of xerophthalmia in south Central Java had been known. In 1929 a publication a appeared on: “Avitaminosis’A in native babies”, by Sie Boen Lian of the eye-hospital “Dr.Yap” in Jogjakarta, in which he wrote that xerophthalmia affected mostly toddlers at the age of 2 and 3 years. Of the more than 200 patients, who were observed there during 1928 and the first months of 1929, only 4 were younger than 1 year, to wit 3 of the age of two months and 1 of the age of 4 months. Three of these children were still nurslings.
In the period 1925-1935, according to the concerning annual reports of Bethesda hospital, 218 cases of xerophthalmia were admitted for treatment (136 male patients and 82 female patients), of whom 32 died to wit 15 male and 17 female. By far the greater part of them were children. A more precise indication was not given. From other parts of Java too occurrence of hypovitaminosis A. was reported, viz. a.o.
- Djakarta (de Haas 1940).
- Kebumen (Oey Djoen Hoat, 1936).
- Patjet (West-Java between bogor and Bandung).
- Pulosari (Central – Java) south of Pemalang. Van Veen and Lanzing 1940.
- Gresik (East-Java) North of Surabaja.
- Segalaherang (West-Java) East of Djakarta.
- Tjiandjur (West-Java) W.F. Donalth, F.J. Gorter.
- Rengasdengklok (West-Java).
Of the 2056 patients with xerophthalmia who were examined, diagnosed and treated at the eye-hospital “Dr.Yap” and who lived in the D.I. Jogjakarta we traced age and sex. The results were as follows….table X-24 and…..diagram fig. 28. (see page. 333)
The greatest number of xerophthalmia patients per year-group appeared in the age-group of 3 years. Thus the greatest frequency is somewhat later than in the patients with malnutrition. Where it falls in the second year. Xerophthalmia is mostly a disease occurring in pro-school children and much less in young schoolchildren.
- 68% of all the cases were in the age-group of 1-4 years old and
- 12.7% of all the cases were in the age-group of 5-9 years old.
The infants formed only 5% of all the patients. Also in the grouping according to the age of the patients of the six separate calendar-years this showed the same proportions, viz. That in the third and fourth years of life were the greatest number of xerophthalmia patients. In all year- and age-groups an obvious preference for the male sex may be noted.
Table X – 24.
By means of the many inquiries into the pathogenesis of xerophthalmia a lack of vit. A. has been determined as the cause of it. The great frequency of this pattern therefore first draws our attention to the child’s nutrition, as this was also the case in the great frequency of protein-calorie-malnutrition in the years of childhood. In the area of the D.I. Jogjakarta, in consequence of the circumstance that there are two kinds of staple food, a contrast may be observed in the frequency of xerophthalmia in the various parts of the region. Xerophthalmia in the kabupaten of Gunung Kidul was explained by the extensive diet-investigation of 1938/1939. Because of the bad qualities of the principal article of food in this region, viz. Gaplek (dried cassave-roots), which besides is not at the disposal of the population in sufficient quantities all the year round the people have begun to eat young cassave-leaves as a vegetable. These leaves, which are properly speaking a worthless by-product, as this crops is grown only for the sake of the roots, proved to be rich in carotenoid.
The inquiries of Van Veen in 1938 brought to light that young cassave-leaves when cooked contain per 100 gr. Fresh product 16,000 I. Units Vit.A. And those almost entirely in the shape of β-carotenoid. When steamed the content was 15,000 I.U. Vit.A., calculated at 100 gr. Fresh product. In addition young cassave-leaves after cooking contain 50 I.U. Vit. B. and 24-36 mg. Vit. C. or amply 100 I.U. Vit. b. and 52-75 mg. Vit.C., when the leaves were steamed, everything calculated at 100 gr. Fresh product. The fact that these leaves are eaten very frequently by the people in Gunung Kidul is the explanation that usually in the diet sufficient Vit. A. is found (as β-carotenoid) and so the occurrence of xerophthlmia will be scarce. In the rice areas: sleman, Bantul, the town of Jogjakarta and south-Kulon Progo, xerophthalmia is anything but rare. The people’s diet in these areas differs considerably from the daily food in Gunung Kidul. Rice is the staple food here. As concerning the diet in the kabupatens of Sleman, Bantul and Kulon Progo we disposed of few detailed data, we would derive some data from inquiries, made by the Institute for Nutrition, which in our opinion are of great importance for food-conditions in the D.I. Jogjakarta.
Investigation at Segalaherang.
During the pre-war years some diet-inquiries have been made in Java in the region where the staple food was rice and where xerophthalmia was rife among the children. The inquiry was made in Segalaherang. It took place during a period of 4 months, viz. From September till December 1937 included. It was one of the series of investigations made by the “Institute for Popular Nutrition” with the intention, in a short period to gather basic material on the nutrition of the Indonesian population. This series of investigations should be helpful in a rapid orientation in other regions with about the same type of diet. Segalaherang is situated a little south of the line between the places Purwakarta and Subang and north of the town of Bandung in the Province of West-Java. It is a thriving area, where in 1935 many cases of xerophthalmia were observed among the children. At the beginning of the diet-survey the lurah desa was asked to give a statement of the number of xerophthalmia patients in the desas concerned. These patients were examined on xerophthalmia by the oculist Sie Boen Lian in those billages whenre, according to the statement of the lurah, must be the largest number of cases. These desas were situated in the ketjamatans Sehalaherang, Wanajasa and Tjisalok. In this way 143 patients were examined of whom 124 were small children. In 93 persons unmistakable or very probable symptoms of Vit. A.-deficiency were found. 60 boys and 31 girls were concerned of the age-group of 2-8 years and 2 adults. They were mostly emaciated and weak children with a serious lack of appetite. Only a single child with xerophthalmia made a healthy impression. As the diet investigation, embracing 100 families, implicated also 60 children with xerophthalmia into the examination, it was found that in the course of the survey 24 of these children happened to die. The survey concerned 60 families, in which at least one of the members (mostly one of the children) had xerophthalmia and 40 other families with as much as possible the same family-composition as the above mentioned 60 families, who were rich in children. The level of prosperity of these 40 families was chosen in agreement with the average level of prosperity in the desa where they lived. In this area, with a moderate density of population in 1937, viz. Amply 200 inhabitants/square kilometre, sawah-cultivation is possible because of the presence of a number of rivers. The sawahs are planted once a year, while most of the fields remain fallow after the harvest. On 10% of the sawahs maize, sweet potatoes, peanuts and other pulse were planted after the rice-harvest. In the compunds, in addition to sweet potatoes and cassave, many sorts of vegetables were cultivated, while the families also possessed fruit-trees. The area provided its own rice, buffalo-meat, cocoanuts, many sorts of vegetables and pulse, sweet potatoes and cassave, many sorts of vegetables were cultivated, while the families also possessed fruit-trees. The area provided its own rice, buffalo-meat, cocoanuts, many sorts of vegetables and pulse, sweet potatoes, fruits, aren-sugar, etc., while various products also were exported to Bandung and other large towns in the neighbourhood. In the area of Segalherang the work on tea- and rubberplantations was of great importance for the people’s economy, in additions to popular agriculture, By these estates 300,000 Dutch guilders in wages were put into circulation among the people, which amounted to 6 times the total landrent-assessment of this area. The diet of this region with rice as its main foodstuff was strongly marked by this fact. The rice furnished in the diet:
- 90 – 94 % of the calories;
- 73 – 89 % of the protein;
- 62 – 77 % of the fats;
- 92 – 96 % of the carbo-hydrates;
- 89 – 95 % of the Vit. B.
The most important difference between the diets of the 5 various resorts of investigation appeared to be the differences in the quantities of rice per day/person. On an average this quantity was 400 gr. Per head/per day, but it varied from 330 – 550 gr. Per head/per day. The more wealthy families had per head/per day 100 gr. Rice more in their diet. The consumption of nutritious elements was practically directly proportional to the rice consumption, as the consumption of subordinate food was very small. The quantity of rice consumed per head/per day was clearly proportional to the level of the family’s prosperity.
The principal subordinate foods were the cassave-roots and sweet potatoes in the shape of sweets: kinds of flour and sugars a.o. in the shape of krupuk and kripik, green vegetables, cucumber and aubergin (eggplant), fungus-peanut-product ontjom, leguminous-seed pété and djengkol. Animal food was taken in a very modest quantity, to wit as dried, salt fish, but did not amount to more than 3.7 gr. Per head/per day. Only in one place, where the people had a regular money-income because of their being employed on estates as tea-pickers and rubber-tapsters, more animal food was eaten: viz. 6.7 gr. Per head/per day. The calories got out of the food varied from 1,230-1,900 cal. Per head/per day. (the slametans included). The protein supply varied from 30-49 gr. Per person/per day. This concerned mostly biologically high-value proteins.
- Rice provided : 73 – 89 % of the protein:
- Animal food provided : 5 – 17½ % of the protein:
- Pulse : 2 – 8 % of the protein; (mostly ontjom and tempè).
In one region part of the protein was still provided by vegetables (viz. 4.3%). In the diet appeared to be sufficient Vit.B. And little fat (to wit 4 – 6 gr. Per head/per day). The normal fat-providing by foodstuffs, cocoanut and cocoanut-oil, were infrequently consumed in this area. In this region the population has only very few cocoanut-trees. The (pro-) Vit. A.-consumption which was the principal object of research in connection with the occurrence of cases of xerophthalmia, produced the following data: The average consumption of (pro-) Vit. a. in those areas, where xerophthalmia appeared, amounted to 400 – 600 I.U. Per day/ person, (which is, starting from the normal requirement of 800 I.U. Per day/person, too low) so that the existence of xerophthalmia need not be wondered at. However there was one area, whenre xerophthalmia occurred and where 1,560 I.U. Vit. A. per day/person were consumed; the highest Vit. A. consumption observed in the 5 test-areas. This observation led to a further investigation, namely into the distribution of the food within the family. That is to say the quantities of rice, vegetables and other foodstuffs eaten by the various members of the family. This produced important data, which gave a more profound insight into the pathogenesis of xerophthalmia at pre-school age. It was proved that the distribution of the food within the family was very uneven. Those, who could entirely satisfy their requirement of calories and protein, were the adult, male members of the family. The group of toddlers was worst off in all respects, concerning the supply of calories, as well as protein and Vit. A., so that the occurrence of xerophthalmia in this age-group was explained. Some data derived from this inquiry are included in the subjoined table X-25.
Table X – 25.
It concerns the results of an examination of 5 families, in whom a number of children had xerophthalmia.
As for the supply of Vit. A. there was a great difference between the boys and the girls, to the boys’ disadvantage. The subordinate food containing protein, which was eaten with the rice, was mostly taken by the adult persons, in consequence of which the toddlers had hardly anything else but rice for the supply of their relatively high protein requirement. With such a distribution of the food within the family it is possible, that the average Vit. A . supply is sufficient per person and yet the toddlers have xerophthalmia. As many mothers had out-door jobs and consequently were absent from home during part of the day and had to leave the care of the toddlers to their only little older children, a lack of supervision of the meals is also an important factor. Evidently there was a sufficiency of Vit. A. -holding foodstuffs, but wrong habits of alimentation led to xerophthalmia. The principal sources for Vit. A. were:
- coloured, yellow and red batatas;
- vegetables, viz. The sawah-vegetables gendjer, swamp cabbage, salada aer, and the vegetables growing in the compound and in the woods;
- young pulses and
- fruits containing coloured juice.
These supplied resp. 44%, 41%, 4% and 5% of the Vit. A. in the diet of the families, with whom table X – 25 is concerned.
Half a year after the diet-inquiry, a medical examination was made in the same area. It was found that the population as a whole was in a satisfactory nutritional condition. Among 1,150 children, who were examined, 12 proved to be suffering from xerosis conjunctivae (amply 1%, 10 boys and 2 girls in the age of 3-14 years), while 9 of these children were in a serious state of under nutrition. Among the children in the examined families 9% – (8 out of 92 children, of whom 7 boys and 1 girl) – suffered from xerophthalmia. As those families had been purposely selected on the occurrence of xerophthalmia among the children, this high percentage is understandable. Among the 1,295 adults, who were examined, only one man proved to have a slight xerosis conjunctivae (0.1%). The Vit.A. Values in the blood were of an average lower in the children than in the adults. As an explanation of the large number of xerophthalmia cases in 1935 and 1937 it was supposed that an enteritis epidemic had probably contributed to the raised frequency of xerophthalmia, because of a heightened Vit. A. want through the infection and the decreased resorption of Vit. A. from the food.
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Investigation of Rengasdengklok.
Another inquiry into the genesis of xerophthalmia in Java is the investigation of Rengasdengklok. Some data of this investigation are also of importance for the D.I. Jogjakarta.
In December 1938 the hospital attendant for ophthalmic care in the kabupaten of Rengasdengklok reported that in the kelurahan of Pataruman, situated 50 km east of Djakarta in the province of West-Java, a large number of cases of xerophthalmia was found among the small children. This was affirmed by the residence physician. On account of this a diet survey was made in this district at a short term, following the system of test-families, which might be a good complement to the diet survey in Segalaherang. In the month of March 1939 a medical examination was executed, and in the period of April-June 1939 the diet survey was made. Rengasdegklok was a typical rice-area in the low-lying plain along the northcoast of West-Java, which is a prosperous region. The food supply of the population left nothing to be desired. In the desa Paturuman, where xerophthalmia was first ascertained, 145 children younger than 5 years were examined in March 1939. Of them 5 ( = 3.5%) had xerophthalmia. Of 342 children older than 5 years xerophthalmia was found in 11 cases ( = 3.2%). In the desa with the identical name of the kabupaten, viz. Rengasdengklok, another number of children were examined on xerophthalmia by the Residence physician. Here it appeared that of 232 children younger than 5 years 1 (=0.4%) and of 215 children older than 5 years 4 (=1.8%) suffered from xerophthalmia. The children with this disease made a healthy and well-fed impression. At further investigation it was clear that those xerophthalmia patients did belong to the labourers rather than to the farmer population in the neighbourhood. The diet-inquiry was made in the desa Pataruman, where 10 families were found with children suffering from xerophthalmia and 10 families without xerophthalmia patients.
To get a more complete picture of the nutritional situation in this area, 20 other families living in 3 neighbouring villages were drawn into the diet survey, who were as much as possible in agreement with the average village-level. At a closer investigation these families proved to be a little above the economic level of their desa, as the landed property of the people examined was somewhat larger than the average. The results of the diet-survey were as follows: Rice took a dominant place, exactly like this was the case in Segalaherang. The average consumption per head/per day was ± 600 gr. Of rice. Only in poorer labourers’ families, exactly where the children with xerophthalmia were found, an average consumption per head/per day was measured of 400 gr. Of rice. Which is , for that matter, still an amply sufficient quantity, the more so as precisely in these families many small children were found. Viz. 40% of the total number of members of the families, who have a small basal-metabolism, and who were all the same counted for full consumers. Because of this fact the average figures of consumption have turned out to be much lower. Though in all families a sufficient quantity of food was consumed up to satiety, there were still important quantity of food was consumed up to satiety, there were still important qualitative variations. As for the subordinate food there appeared to exist a difference between thrifty families and poorer families whose children suffered from xerophthalmia. In the families first mentioned more animal food and more green vegetables and young pulses were eaten, while the consumption of peanuts and beans did not differ so much. The consumption in the families with children suffering from xerophthalmia was very low, viz. 8 gr. Per head/per day. In the other families this quantity was indeed higher, viz. 13 – 33 gr. Per head/per day, but this is still a rather low consumption, especially as the distribution within the family left much to desired, as is seen in segalaherang.
The nutritional value of the diet of the working class families with children suffering from xerophthalmia and of the diet in the other families has been put together in the subjoined table X-26.
Table X – 26.
The test-families without sick children thus ate plentifully. Also the poorest population group disposed of a quantitatively sufficient amount of foodstuffs. The protein supply in the survey-families without sick children proved to be 59 gr. per head/per day, which may be called very good for a Javanese diet. In the families with sick children the protein-supply is less favourable, viz. 38 gr. As these families had a great number of small children with a high want of protein, in connection with their growth, the protein requirement in these families is much greater. As the people take no account of the special want of protein of the children, this means to say that there is little reserve in the protein supply of the children.
The proteins in the food are provided by:
- rice 75 – 86%,
- animal food 8 – 18% and
- kinds of pulses 4 – 6%,
so that the proteins in these combinations are biologically of high value. The Vit.A. supply proved not to be dependent on the prosperity, but on the age of the members of the family. In this region, where the differences in prosperity were not very great, this proved also to be the case with the rice. The quantities of rice consumed were dependent on the feeling of satiety and the basal metabolism and thus on the age. The quantity of subordinate foodstuffs appeared to be in a fixed proportion to the quantity of rice consumed, though the composition of the subordinate foodstuffs varied with the prosperity. Especially animal food was more often consumed in proportion to an increasing economical condition. Individual factors, such as taste, proved to have a great influence on the quantity of vegetables consumed and also on the average Vit. A. supply. A very great spreading in Vit. A. supply from family to family appeared to occur.
In one family this supply may amount to tenfold that in the other. The cultivation of vegetables for their own consumption was considered by the people as merely accidental. The population’s attitude to green vegetables was entirely one of indifference and they did not consider them as real food, because they did not know their real value. Thus the “cultivation” of vegetables on compound or sawah was left for the greater part to chance. Because during the rainy season the compounds were often flooded and the surface of the sawah-dikes, where also vegetables are grown, was small, the quantity of available grounds was limited. Precisely the families possessing only small compounds or sawahs or none at all, and who thus could not dispose of vegetables, appeared to be most struck by xerophthalmia. As these families being able to supply their own rice and other foodstuffs only in a limited measure, had to buy there vegetables, their possibility of selecting it is greater, and therefore personal taste becomes a very important factor in the composition of the diet.
It was evident from this inquiry that a too low (pro-) Vit. A. consumption was the direct cause of the occurrence of xerophthalmia.
The two surveys made in Segalaherang and Rengasdengklok in Java about the xerophthalmia supplied data, which are still of great interest in connection with the endemic occurrence of xerophthalmia in the area of the D.I. Jogjakarta, where likewise rice is the staple-food. It gives an explanation of:
- the occurrence of xerophthalmia among the young age-groups, especially toddlers;
- the more frequent occurrence of xerophthalmia in boys than in girls;
- the occurrence of xerophthalmia precisely in children form the poorer classes of Javanese society, who as a rule have not the disposal of any ground or only of small plots, and who thus have few means of self supply with food;
- the difference in frequency of xerophthalmia among children in Gunung Kidul (cassave-area) and the kabupatens of Sleman, Bantul and the town (rice area);
- the coincidence of an insufficient protein- and Vit. A. supply in these children’s diet, who subsist on a rice-nutrition, as we also found it among the xerophthalmia patients coming from the D.I. Jogjakarta.