Xerophthalmie (xerophthalmia — the drying of the conjunctiva and cornea caused by vitamin A deficiency) was the principal object of the eye survey carried out by Dr. C. E. Gomperts in Groot-Atjeh during 1937, and — with its severe form keratomalacie — in his judgement the most frequent cause of blindness among the Acehnese young.
Frequency in Groot-Atjeh
Of 11,400 children examined, 459 cases were found — about 4 per cent. The overall figures were 206 cases among 3,025 boys aged 0–5 and 63 among 3,088 boys aged 6–14; among girls, 113 of 2,652 aged 0–5 and 34 of 2,481 aged 6–14.
Gomperts drew three conclusions from the table:
- that among both Atjehnese boys and girls xerophthalmia occurred markedly more frequently in the age group 0–5 than in the group 6–14;
- that it occurred far more among boys than among girls, in both age groups;
- that in the kuststreken (coastal districts) it occurred, especially in the 0–5 group, far less than in the valleistreken (valley districts).
Broken down more finely, the incidence was 6½ per cent in boys aged 0–1, 7½ per cent aged 1–2, and 7 per cent aged 2–5; among girls 6 per cent, 4 per cent and 4 per cent respectively — confirming, in agreement with Mulock Houwer’s findings, a greater frequency among kleuters (toddlers) than among infants.
The three questions
The findings raised three questions which Gomperts posed explicitly: why the coastal frequency was lower than the valley frequency; why the disease was concentrated in the 0–5 group; and why it struck boys far more than girls, “terwijl de levensomstandigheden van beide geslachten gelijk zijn” — while the living conditions of both sexes are the same.
To the first he answered candidly that an answer was not possible. To the second he pointed to the low vitamin A content of the milk of indigenous mothers established by Mevrouw Van Stockum, Dr. J. H. de Haas and Ir. Meulemans on Java; since Atjehnese nutrition was certainly poorer than Javanese, the milk of this population group was to be expected lower still, and the Atjehnese custom, as on Java, of geprotraheerde borstvoeding (protracted breast-feeding, 18 to 20 months) meant that the low vitamin A level sufficed only up to a certain point, after which growth, other developmental processes, infections and diminished internal secretion depressed it further into hypo- or avitaminosis, “die de deur opendoet voor de xerophthalmie” — which opens the door to xerophthalmia. To the third he offered the suggestion of some investigators that the subcutaneous fatty tissue is better developed in the female sex and forms a reserve depot of vitamin A.
Against a purely dietary explanation
Gomperts rejected the reduction of xerophthalmia to dietary vitamin A deficiency alone. He quoted Zeeman’s warning — “Nieuwe proeven houden ons af van een al te eenvoudige voorstelling” (new experiments hold us back from an all too simple representation) — and observed that since the basic food of the Atjehnese kampong population consisted of rice, supplemented only very sparsely with vegetables and meat, the population suffered a chronic vitamin A shortage, “of misschien beter gezegd, zich op een lager vitamine-A-gehalte van het bloed heeft ingesteld” — or perhaps better said, has adjusted itself to a lower vitamin A content of the blood. Were diet the sole cause, a far higher percentage than 4 per cent would have been expected.
He tested the proposition against the harvest data he had gathered. 1936 and 1937 were marked by long-continued drought, so that the paddi planting failed to take well except in VI Moekims Lhong and Moekim Lam-Teuba, where irrigation of the sawah fields was fed by mountain streams that carried enough water even in the dry season; in Lam-Teuba planting and harvest took place twice a year, in the rest of Groot-Atjeh only once. In V Moekims Montassie there was in addition a walangsangit plague, producing an almost complete crop failure in some moekims.
Set against the xerophthalmia figures, these data showed: that in the coastal moekims Lhong, where the rice supply left nothing to be desired, the influence of nutrition did not clearly express itself in the frequency; that in the valley moekim Lam-Teuba, with ample rice, the percentage was practically the same as in Indrapoeri, Seulimeum and Lam-Kabeuë where the harvest was less favourable; and that in Montassie, with a great crop failure, the frequency differed little from that of Baet with a much better harvest. “Met het bovenstaande meent verslaggever voldoende het bewijs te hebben geleverd, dat men alleen met den factor voeding het xerophthalmie-vraagstuk niet kan oplossen.”
Infectious disease
A table of infectious diseases among the xerophthalmia cases recorded, for boys and girls respectively: buikziekten (bowel complaints) 19 and 12 per cent; pyodermie 5 and 3 per cent; framboesia 8 and 3 per cent; and dikke buiken (distended bellies, strong and light) 26 and 18 per cent strong, 50 and 48 per cent in total. Gomperts concluded that “de invloed van infectieziekten en infecties op het ontstaan van xerophthalmie niet duidelijk tot uiting komt” — the influence of infectious diseases and infections on the origin of xerophthalmia does not clearly express itself. He noted that many Atjehnese children were admitted to the Militair Hospitaal in deplorable condition, bearing the traces of long illness with all manner of complications, yet showing no trace of xerophthalmia.
Comparison with Java
Oey Djoen Hoat, investigating the Regentschap Keboemen, found 88 cases among 4,532 boys and 20 among 3,595 girls — 2 per cent and ½ per cent respectively — figures which, Gomperts remarked, “steken zeer gunstig af bij onze statistiek” (compare very favourably with our statistics).
Local signs and Bitôt’s spots
On the vlekken van Bitôt Gomperts noted the work of Sie Boen Lian, who had shown that in adults these spots were not a conditio sine qua non for xerophthalmia. He regretted that Sie Boen Lian had not stated whether in such deviant cases the conjunctiva showed the other marks of xerophthalmia, namely the xerotic condition with the discolouration typical of the disease. In a seventeen-year-old youth complaining of hemeralopie (night blindness) Gomperts himself found Bitôt’s spots and xerotic conjunctival changes, and both subjective and objective signs disappeared promptly on a vitamin-A-rich diet and therapy, so that the diagnosis could be made with fair certainty without determining the blood vitamin A level.
Acehnese knowledge of the disease
In the moekims Lhong, Lho-Nga and Lam-Kabeuë the condition was known by the name penjikit sisë (Tijssen writes siseh), while in the rest of the surveyed area it was not known under that name. Elsewhere the word sisë was known, but in the sense of kulit ikan (the scales of a dead fish) and also as kaki ajam (chicken’s foot). The leucoma corneae left after keratomalacia or an eye inflammation was known everywhere in Groot-Atjeh as boh thenë.
Three indigenous remedies against xerophthalmia were recorded: the fluid obtained by placing a dried goat’s liver in a frying pan over a slow fire, an oily fluid being secreted and dripped into the patient’s eyes; the dewdrops collected from the leaves of a certain plant, the poepoon ritiëng; and the fluid of a certain kind of grass, obtained by hanging the grass in banana leaves over the steam of boiling rice for some time.
Significance
Gomperts’s conclusion was that xerophthalmia and keratomalacia were to be regarded as eye conditions with one common underlying cause — an a- or hypovitaminosis A — complicated by a coincidence, more drastic in keratomalacia than in xerophthalmia, an interpretation he took from Mevrouw Van Stockum rather than from Tijssen’s constitutional theory.
See Also
- Keratomalacie
- Vlekken van Bitôt
- Blindheid in Groot-Atjeh
- C. E. Gomperts
- Levertraan
- Boh thenë
- Mulock Houwer
- Sie Boen Lian
- 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.