Also after infancy enteritis appeared to be a frequently observed disease in this region. Especially during the period of 6 months till 2 years many children suffer from enteritis. After the second year of life this disease becomes less frequent. In the group of patients admitted because of enteritis in the two children’s wards at Jogjakarta during the period July 1, 1954 – July 1, 1958 778 out of 920,i.e. 84% were younger than two years. The mortality among these patients ranged between 26 – 45%. The data concerning these patients are collected in table IX-1.
Amebiasis.
In this group of enteritis patients a number of clinically and etiologically differing diseases can be distinguished. In microscopical examination the causative agent of enteritis in amebiasis, i.e. Endamoeba histolytica can be identified. The number of patients suffering from amebic dysentery was rather small compared with the number of patients suffering from non-amebic dysentery in this group.
Table IX – 1.
Survey of patients, Suffering from enteritis in two children’s wards at Jogjakarta in the period July 1, 1954 till July 1, 1958.
In the two children’s wards 37 patients with amebic dysentery were admitted in this four year-period. It appeared that amebic dysentery was a rare disease in the first three years of life. Eighty per cent of the patients observed were aged 3 and above. In this group three patients died, aged 3, 4 and 5 respectively. The patients who died were in an unsatisfactory or bad nutritional condition. In two of them post mortem liver puncture was done. The pathologist (Prof. B. Soetarso) observed severe fatty infiltration of the liver in the slides prepared of the liver tissue obtained in this way.
The stools of every patient suffering from diarrhoea were examined microscopically several times during the first days after admission. The clinical picture differs in most cases from that of shigellosis. Fever is mostly absent. The mother complains that the stools are mixed with blood and this occurs very rarely in shigellosis. The diagnosis was based on the demonstration of Endamoeba hystolytica in the stools. All the 34 patients who recovered from this disease were ordered to stay in bedrest and given Emetine hydrochloride in a total dosage of 8 milligram per kilogram bodyweight administered intramuscularly in the course of 12 dayss, while after the first week of treatment also yeatreen (chiniofon) is given in a dosage of 500 mg. Daily for 14 days. The patients suffering from amebic dysentery had their residence in the town (12 cases), Sleman (18 cases) and Bantul.
Table IX – 2.
Age distribution of 37 patients suffering from amebiasis (intestinal form). Who were admitted in two children’s wards at Jogjakarta (July 1, 1954 till July 1, 1958).
Shigellosis.
The most important cause of enteritis is very probable the group of pathogenic Shigella strains. An attempt to confirm in a great number of cases the clinical diagnosis bacillary dysentery by the result of bacteriological examination, demonstrated that this was impractible in Jogjakarta. In 1939 Lammerts van Bueren described in his thesis an extensive inquiry into the occurrence of pathogenic shigella strains in Djakarta in Indonesian children suffering from diarrhoea. The results of this inquiry proved the great importance of Shigella strains as a cause of enteritis in infancy and childhood. In older toddlers and schoolchildren bacillary dysentery was less frequent than in the age-group ½-2 year.
The occurrence of pathogenic Shigella strains in Java was first demonstrated by Lim in Semarang in 1908. Grijns did so in Djakarta in 1908. In the period 1908-1942 a number of publications demonstrated the occurrence of these strains in many regions of Indonesia. (Magelang, Deli, Sumba, Dairilanden).
In the period 1925-1926 many labourers from Central-Java went to Deli in sumatera to work on the plantations in that region. It appeared that one of the causes of the occurrence of these pathogenic strains there was the import of these strains by the labourers coming from Central-Java. (Banjumas, Kedu, and Semarang). Wolff succeed in isolating Shigella flexneri and Sh. Sonnei from the dysentery patients in Deli.
The great importance of shigellosis in Indonesia for infant- and child-mortality was emphasized by Straub (1927). de Haas (1932) and lammerts van Bueren (1939).
Because it appeared impossible to confirm the clinical diagnosis of bacillary dysentery with a bacteriological examination this diagnosis was based on the clinical picture and the microscopical examination of the stools. The clinical picture of this disease in early childhood is rather variable. Lammerts van Bueren described a great number of types of clinical pictures of this disease, and according to out experiences also, it is useful to distinguish a number of clinical types.
In Jogjakarta we observed the following types:
- Only little fever
- Only slight diarrhoea.
- Severe diarrhoea.
- Febris continua after abrupt onset which terminates often by crisis
- A course leading to dehydration.
- Slight diarrhoea with clear cerebral symptoms and mostly leading to death.
- Course with an intestinal bleeding.
- Chronic course.
The most constant symptoms are fever and mucus in the stools. Only in rare cases the stools are mixed with blood. In the mucus many leucocytes can be observed when microscopically examined. The great importance of the microscopical examination for the diagnosis bacillary dysentery was for the first time stressed in 1918-1923 by Willmore and Shearman, English physicians working in tropical regions. Later on the importance was stressed again by de Haas and Lammerts van Bueren. In 1937 the former author wrote: “In typical cases of bacillary dysentery the diagnosis can be made with the data of the anamnesis. The macroscopical aspects of the evil-smelling and muco-purulent stools is mostly sufficient to make the probable diagnosis: bacillary dysentery. This probability becomes certainty when the preparation of the stools, (prepared at the same time with water or lugoland thin eosine-solution), shows 5 to ten, sometimes dozens of leucocytes per field of microscopical vision, as an expression of the purulent feature of the stolls. The signification of the microscopical examination of the stools to make the diagnosis: bacillary dysentery, can hardly be over estimated.
Lammerts van Bueren wrote in his thesis about: Bacillary Dysentery in children at Djakarta (1939) that the microscopical examination of the stools was the most important criterion for the diagnosis of bacillary dysentery.
He wrote: “The great confidence in the microscopical examination of the stools for the recognition of bacillary dysentery has in the last years been highly strenghened by the experiences with several thousands of preparations of stools”.
This experience of Lammerts van Bueren is of such great importance because in his investigations he was able to confirm the clinical diagnosis in 74% of the 408 cases.
Our diagnosis in the case of the children in Jogjakarta suffering from bacillary dysentery was based on anamnesis, clinical picture and microscopical examination of the stools. In the first six months of life only in 50% of the patients suffering from enteritis the diagnosis bacillary dysentery could be made, while in the second half year of life till the ninth year of life in 90% of the patients suffering from enteritis the mucopurulent stools were observed.
Especially in the age-group ½ – 2 years of age we observed a great number of patients. Of the patients, who were admitted because of Shigellosis in the University children’s ward 80% was aged less than 2, while in Bethesda children’s ward 82% of them were aged less than 2. In his thesis Lammerts van Bueren mentioned that 74% of the 408 patients suffering from bacillary dysentery in Djakarta in the period 1935-1937 was aged less than 2.
From the University- and Bethesda children’s ward were sent to the Central laboratory at Jogjakarta 41 and 63 specimen of stools respectively for bacteriological examination in the course of the period July 1, 1954 – July 1, 1958. Though the stools spectimens were chosen of patients with a clear clinical picture and mucopurulent stools and sent to the laboratory just after passing, only in 10 cases a Shigella strain was isolated from the stools.
Table IX – 3.
Survey of the 10 patients suffering from bacillary dysentery, whose diagnosis could be confirmed by bacteriological examination (Jogjakarta).
It appeared that also in the first three months of life Shigellosis occurred, however it is in this period of life a rare disease, according to the findings of Lammerts van Bueren and de Haas (1938). They observed among 400 cases in Djakarta only eleven patients aged less than 3 months. The authors mentioned that in young infants the macroscopical aspect of the stools is not so clear as in older children, but the microscopical examination is the same. Besides the results of the bacteriological examination of the specimen of stools we sent to the laboratory also the results of the bacteriological examination of stools of children aged less than 10 sent in by other colleagues in Jogjakarta to the laboratory were kindly put to our disposal by the chief of the central laboratory. These data concern the period 1955-1958 and are collected in Table IX-4. These patients lived in the city of Jogjakarta, the kabupatens Sleman and Bantul. The Shigella strains which were most frequently found appeared to be Shigella flexneri and Sh. Sonnei.
First among the circumstances which led to the death of these enterit is patients was in the greater part the condition of dehydration. This was the case in 68% of all the enteritis patients aged 1 up to and inclusive 9 who died of this disease.
Bacillary dysentery with cerebral symptoms leading to death occurred in 19% of the toddlers and young schoolchildren who died of this disease. The cerebral symptoms were unconsciousness, spasm in the extremities, high fever up to 42ºC, convulsions, twitches in the muscles of arm and leg, and a strange look in the eyes. Only one toddler of 15 months of age was cured from this type of bacillary dysentery. In many cases the bad nutritional condition favoured the lethal course of the disease. Among the toddlers who died by bacillary dysentery and who were mentioned in table VII-7 in the section: intestinal disturbances, where 63 children who besides from dysentery also suffered from malnutrition, viz. 41 children aged 1, eight children aged 2, six children aged 3, seven children aged 4 and also one child who was 5 years of age. In these cases the malnutrition was rather severe and the prognosis must have been influenced by the coincidence of these two diseases.
Children suffering from malnutrition have the quality that their equilibrium of fluid and electrolytes is easily disturbed by enteritis so that dehydration can appear very rapidly after the onset of diarrhoea.
Table IX – 4.
Shigella strains, isolated from the stools of patients suffering from enteritis, by the Central Laboratory of
Jogjakarta in the period 1955 – 1958.
This factor must be of importance for the explanation of the high frequency of dehydration in young toddlers in this region. Both diseases occur so often that a coincidence of these two diseases is far from rare.
The dysentery patients who died with cerebral symptoms when the course of the disease was very rapid were all taken home just after death. Postmortem examination was never possible. The cerebrospinal fluid was examined in all these cases and appeared to be normal.(Nonne- and Pandy-test, cellcount, glucose, protein). In his publication of 1941 Verhaart described this type of encephalopathy in consequence of bacillary dysentery in 180 patients. Out of these patients 143 died, while in 16 cases postmortem examination was possible. This type of encephalopathy was after encephalopathy of unknown origin the next frequent cerebral disease in infants and children in Djakarta.
Epidemiology of bacillary dysentery.
The most recent and detailed investigation concerning epidemiology of bacillary dysentery in Java was done in the Tanah Tinggi district of Djakarta in the period 1937-1939, and published by Dinger, Tesch, Marseille and Gispen. Because we suppose that the epidemiology of dysentery in the D.I. Jogjakarta corresponds very much with that in Djakarta we like to mention some data which were obtained by means of the investigations in Djakarta.
The number of inhabitants of the test-district in Djakarta was 26,104 of whom 22,026 were Indonesians and 2,664 Indonesian of Chinese descendent. In this investigation was included:
- Tracing of persons who excreted Shigellas among a number of unselected persons.
- Investigation of persons who were suspected to suffer from dysentery.
- Postmortem bacteriological examination of the stools of persons who died in the
test-district. - Tracing of persons who excreted Shigellas among a number of persons who had
been in contact with dysentery patients or Shigella-carriers.
This investigation lead to the following results:
ad 1 : Among 1888 unselected persons only 13 i.e. 0.7% appeared to have Shigellas in
their stools. The isolated strains were Sh.Flexneri 10 times, Sh.sonnei 2 times
and once a mixed infection.
ad 2 : In the period 1937-1939, 609 inhabitants of the testdistrict suffered from
diarrhoea and their stools were examined. In 466 cases there was only a changed
consistency of the stools and in these patients only 22 times, i.e. 4.7% a Shigella
strain could be isolated from the stools. In 143 cases the stools contained blood,
mucus or pus. In these patients 27 times i.e. 18.9% a Shigella strain was isolated.
In these 49 cases with positive result the isolated organisms were Sh.Flexneri 34
times, Sh.sonnei 14 times ans Sh.Smitz.Most cases in which a Shigella was found
in the stools concerned toddlers. Out of this group of 609 persons suffering from
diarrhoea 561 were aged 0-4. The percentages of positive results for the infants
and for the toddlers differed in this respect that among the infants a great
number of diarrhoea cases were found whose diarrhoea was not caused by a
Shigella, while among toddlers the greater part of the enteritides was due to
Shigellas. This experience agrees very much with the clinical findings in
Jogjakarta, where bacillary dysentery also occurred especially in the age-group
½ -4 years.
ad 3 : In the stools taken 2 – 20 hours after death in 443 persons in 58 cases a Shigella
strain could be isolated from the stools. Also of this group the greater part
appeared to be toddlers age 1 – 4 . In the analysis of all the data which could be
obtained through this investigation at Djakarta it became very probably that the
morbidity and mortality of bacillary dysentery was in the age-group 0 – 4 years
30-40 times greater than in the age groups 5 – 14 years and 14 years and over.
ad 4 : The fourth part of the investigation of Dinger and co-workers concerned the
occurrence of Shigella strains in the stools of persons who had had contact with
persons whose stool-culture was positive. A number of 528 selected persons was
examined.
These persons had had contact with 103 persons, suffering from Shigellosis or Shigella-carriers. In 25 cases a Shigella strain could be isolated from the stools of these persons and nearly always the same type of Shigella as in the patients or Shigella carrier who was supposed to be the source of it. In 4.7% of these 528 selected persons a Shigella strain could be isolated from the stools. This percentage is higher than in the group of unselected persons (ad 1). In this group the percentage was 0.7% it seems probable that in the neighbourhood of dysentery patients and Shigella carriers the Shigella strains circulate in greater numbers than in surroundings without patients or carriers. Contact infection within the family seems of importance for the spread of this disease.
Some results of this important investigation are mentioned in the table IX-5.
The Shigella strains which were isolated during this investigation were Sh.Flexneri in 75%, Sh.sonnei in 20% and other strains in 5% of the cases.
This result is very simular to that of Lammerts van Bueren in Djakarta (1939).
In epidemiology this disease is described as an endemic disease which is maintained by contact infections, a disease which has its victims especially in the younger age groups and to a less extent in the older age groups. The causative agent is in 90% of the causes Sh.Flexneri and Sh.sonnei. All the date about bacillary dysentery which we collected about the bacillary dysentery in the D.I. Jogjakarta fit very well into this picture of the epidemiology described by Dinger and co-workers for Djakarta.
Table IX – 5.
Survey of the results of the investigation into the occurrence of Shigellosis among the population of the Hygienic Study Ward of Djakarta, 1939 (Dinger and co-workers).
