The methode-Tijssen — the working method of Dr. J. Tijssen, who from 1929 sought out the blind in the Acehnese kampongs and operated on them there at his own expense — was subjected in 1940 to a detailed statistical criticism by Dr. C. E. Gomperts in his report on the eye survey of Groot-Atjeh. Gomperts adopted the method’s central idea — going out to the population — but rejected its central practice, operating in the villages, and concluded that it was “zelfs ongewenscht” (even undesirable) for Groot-Atjeh.
What Gomperts kept
Gomperts’s own survey followed “een gewijzigde werkwijze van Tijssen” — a modified working method of Tijssen — and he was explicit in his praise of its principle: “Het idee van Tijssen om de bevolking in de kampongs op te zoeken en onderzoek in hun milieu te verrichten, is zeer toe te juichen. Hierdoor wordt het contact met de bevolking vergroot, hetgeen het vertrouwen in de Westersche geneeskunde ten goede komt.” — The idea of Tijssen to seek out the population in the kampongs and to conduct the examination in their own milieu is greatly to be applauded. Thereby contact with the population is increased, which benefits confidence in Western medicine. It also secured that a great part of serious eye diseases, not yet having destroyed the sight, could still be taken in hand in time.
What Gomperts rejected
The objection was to operating in the villages: “Door de operaties in de kampongs te verrichten, vervreemden we de bevolking nog meer van de ziekenhuizen, en hierdoor wordt in betrekkelijk korten tijd te niet gedaan, hetgeen we door langen en moeizamen arbeid hebben verkregen” — by performing the operations in the kampongs we estrange the population still further from the hospitals, and thereby what we have obtained by long and laborious labour is undone in a relatively short time. Gomperts accordingly sent patients requiring surgery to the Militair Hospitaal te Koetaradja with an opnamebriefje (admission note).
Tijssen’s apparent fear that the population could not be moved to be admitted to existing hospitals was, Gomperts held, groundless, and he adduced as proof the graph of Atjehnese out-patients and admissions at the eye-ear-nose-throat department of the Militair Hospitaal from 1934 to 1937.
The comparison of surgical results
Gomperts compared the outcomes of cataract operations performed by Tijssen under primitive circumstances with those performed by the Officieren van gezondheid eye specialists under better hygienic conditions. He noted that of the sixteen patients operated on by the military eye specialists, at least fourteen were treated by operators with shorter practical experience than Tijssen — so the comparison did not favour the military side by seniority.
Visual acuity in both groups was reached after correction with spherical positive glasses of 10 to 14 dioptres without cylinder combination. Vision was determined by having the patients count fingers, since they were illiterate and by reason of their slight education were equally unsuited to testing with simple optotypes.
Of the 17 eyes operated on by Tijssen: 4 eyes lost; 3 results moderate; 2 very moderate; 2 bad; 6 good — that is, good results in rather more than 35 per cent.
Of the 22 eyes operated on by the military eye specialists: 2 eyes lost of 22, or 9 per cent; results good in 91 per cent.
Gomperts noted individual complicating circumstances on the military side — one patient very restless during the operation, resulting in vitreous loss; another with glaucoma absolutum and a luxated cataractous lens in one eye and glaucoma signs in the operated eye before surgery; one patient operated on ten years earlier who had seen well with both eyes for five years afterwards, and whose later blindness was probably due to glaucoma with corneal degeneration, so that “dit geval is dus goed beschouwd niet als een slecht operatief resultaat op te vatten.”
The three conclusions
Though the statistical material was not large, Gomperts found sufficient ground for three conclusions:
- that Tijssen’s operative results were such that his working method did not come into consideration for imitation in Groot-Atjeh or in districts where communications by motor or other traffic were good;
- that Tijssen’s idea of having general medical practitioners perform eye operations by his method after a short training “mag volgens verslaggever geen ingang vinden” — should in the reporter’s view find no acceptance, since “we bereiken hiermee slechts, dat het gewonnen vertrouwen in de Westersche geneeskunde grootendeels weer verloren gaat”;
- that since operative success depended for the greatest part on pre-examination and after-treatment, and these did not come into their own under Tijssen’s method, there lay in this a further reason not to recommend it.
The clinical disputes
Gomperts also set out, in two parallel columns, Tijssen’s propositions on keratomalacia and xerophthalmia against his own findings. Against Tijssen’s view that keratomalacie was confined to infants up to two years, he held that it occurred certainly among toddlers as well; against Tijssen’s assertion of no sex preference, that his own statistics showed a higher frequency among girls; against Tijssen’s claim that ascariasis played no role, that “deze bewering is volgens schrijver wel wat te apodictisch.”
On xerophthalmie he disputed Tijssen’s figure that in Atjeh 240 per 100,000 children went through the disease and 60 per 100,000 were blinded by it: “wanneer met Atjeh Groot-Atjeh wordt bedoeld, dan klopt dit niet met schrijver’s statistiek,” since Gomperts found 459 cases among 11,400 children. Against Tijssen’s proposition that the disease occurred especially in areas of food abundance, “rijstovervloed in Atjeh,” he set the case of Moekim Lam-Teuba, where there was a rice surplus and yet only 4 cases among 290 children examined — 1½ per cent.
Above all he rejected Tijssen’s tenth proposition, that xerophthalmia was a constitutie-ziekte (constitutional disease): against this pleaded the fact that xerophthalmia among European children occurred only in the poor population group; and the fact that keratomalacia was always preceded by xerophthalmic changes gave no support to Tijssen’s view that the two conditions were essentially different, “immers wanneer deze beide oogaandoeningen in wezen verschillend waren, dan mocht men verwachten, dat ze zich ook niet steeds samen zouden manifesteeren.”
On two points Gomperts agreed with Tijssen without reservation: that the sufferers were badly fed or sick individuals, and that the therapy was a general treatment of mother and child; and on the therapy of xerophthalmia, “levertraan” — cod-liver oil.
Significance
The exchange is a compact record of a professional controversy in late-colonial Netherlands-Indies medicine: whether the proper answer to mass eye disease in an under-served population was itinerant village surgery by generalists, or village diagnosis feeding a hospital system. Gomperts’s answer — take the examination to the kampong, but bring the operation to the hospital — was argued from outcome statistics rather than from principle.
See Also
- J. Tijssen
- C. E. Gomperts
- Militair Hospitaal te Koetaradja
- Kampong medicine in Atjeh
- Xerophthalmie
- Keratomalacie
- Oriënteerend oogheelkundig onderzoek bij de Atjehsche bevolking van Groot-Atjeh gedurende 1937
Source
Oriënteerend oogheelkundig onderzoek bij de Atjehsche bevolking van Groot-Atjeh gedurende 1937 (“Orienting Ophthalmological Survey among the Atjehnese Population of Groot-Atjeh during 1937”), by Dr. C. E. Gomperts, offprint from the Geneeskundig Tijdschrift voor Nederlandsch-Indië, Afl. 19, Deel 80 (1940), pp. 1191-1238 (Batavia-Centrum: G. Kolff & Co.). Received by the editors 25 October 1939. Offprint DLP-157, Bibliotheek KITLV.