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THE UNIVERSITY
OF CALIFORNIA

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TROPICAL OPHTHALMOLOGY



BY THE SAME AUTHOR

SCLERO-CORNEAL TREPHINING IN THE OPERATIVE
TREATMENT OF GLAUCOMA, 1913. Second Edition,
1914. George Pulman & Sons Ltd., London.

GLAUCOMA: DIGEST OF THE YEAR'S LITERATURE.
The Ophthalmic Year-Book, 1913-1916. Herrick Book and
Stationery Company, Denver, Colorado, U.S.A.

GLAUCOMA: A HANDBOOK FOR THE GENERAL
PRACTITIONER. H. K. Lewis & Co. Ltd., London, 1917.

GLAUCOMA: A TEXTBOOK FOR THE STUDENT OF
OPHTHALMOLOGY. H. K. Lewis & Co. Ltd., London,
1918.

THE INDIAN OPERATION OF COUCHING FOR
CATARACT, incorporating the Hunterian Lectures, delivered
before the Royal College of Surgeons of England, on February
19 and 21, 1917. H. K. Lewis & Co. Ltd., London, 1917.




BY

ROBERT HENRY ELLIOT

M.D., B.S.(Lond.), Sc.D.(Edin.), F.R.C.S.(Eng.)

LIEUTENANT-COLONEL I.M.S. (RETIRED)
LATE SUPERINTENDENT OF THE GOVERNMENT OPHTHALMIC HOSPITAL, MADRAS

AND PROFESSOR OF OPHTHALMOLOGY, MEDICAL COLLEGE, MADRAS
HONORARY FELLOW AND GOLD MEDALLIST OF THE AMERICAN ACADEMY OF

OPHTHALMOLOGY AND OTOLARYNGOLOGY

LECTURER IN OPHTHALMOLOGY, LONDON SCHOOL OF TROPICAL MEDICINE

OPHTHALMIC SURGEON TO THE SEAMEN'S HOSPITAL SOCIETY, AND TO THE

HOSPITAL FOR TROPICAL DISEASES, ENDSLEIGH GARDENS, LONDON



WITH 7 PLATES AND 117 ILLUSTRATIONS



LONDON
HENRY FROWDE HODDER & STOUGHTON

OXFORD UNIVERSITY PRESS WARWICK SQUARE, E.G.

1920



PUBLISHED BY THE JOINT COMMITTEE OF

HENRY FROWDE, HODDER & STOUGHTON

17 WARWICK SQUARE, LONDON, E.G. 4



TO

THE STUDENTS OF THE LONDON SCHOOL
OF TROPICAL MEDICINE

PAST, PRESENT, AND FUTURE

THIS BOOK IS DEDICATED

With an expression of the hope that they will appreciate
the very considerable labour that has been entailed in
writing it for their assistance, and that they will make a
return, not only by increased energy in the study of the
many little-understood tropical conditions which affect
the eye, but also (i) by offering advice, criticism, and
information on those subjects dealt with in the book, of
which they have first-hand and accurate knowledge ; and
(2) by sending material of all kinds, pathological, zoological,
and botanical, to the author for transmission to experts.



TO

E. C. I. E.

BUT FOR WHOSE UNWEARYING

HELP, THE BOOK WOULD NEVER

HAVE BEEN WRITTEN



PREFACE

So far as I am aware, no one has ever yet written a mono-
graph on Tropical Ophthalmology. Such a task requires
the best part of a lifetime of experience, and the majority
of those, who have thus qualified themselves, have returned
to Europe too climate-wearied to undertake a work of this
magnitude. The consequence has been that each fresh
student of the subject has had to start almost from the
commencement. Such a state of affairs is truly lament-
able. It means a waste of time, energy, power, and ability.
So impressed have I been with the need to supply this
deficiency, that I have for many years been gathering
data for the purpose of writing a book, which might be of
service to the surgeon in the Tropics, and especially to the
beginner there. These lands furnish an immense field for
original research ; opportunities are waiting on every
hand ; clinical material is abundant, and painstaking
observation, aided by the compilation of careful records,
cannot fail to add to the stock, not merely of knowledge
which will be scientifically interesting, but also of that
which will prove of value from a clinical point of view.
Indeed, the worker in the Tropics has an almost virgin field
for labour ; the opportunity is given to him of serving
humanity in a material and practical way, and incidentally
of writing his name indelibly on the records of medicine.



viii PREFACE

If this book has one paramount object, it is to stimulate
the young worker to play a man's part in the far-off lands,
to which ppportunity has led, or necessity has driven him.
With this end in view, every page of it has been written.
No attempt has been made to produce a comprehensive
textbook of ophthalmology. Such would have been a
mere work of supererogation. From first to last I have
striven to set forth such knowledge as has been gained by
past workers in tropical lands, to make the literature of
each subject readily accessible, and to indicate the lines
along which it seems likely that advances may be made.

It has been no part of my intention to give a full
record of the literature of each and every subject ; that
would be impossible, within the limits of any reasonable
textbook. What I have tried to do, has been to select with
great care those references, which seem most likely to
be helpful, and especially those which lead up to a larger
bibliography. In this way it is hoped that my work will
prove an opening door to those who desire to go, as it is
my earnest hope many will do, far beyond it.

I have had another and a very strong motive. The
Great War has broken down our so-called " splendid
isolation," and to-day tropical disease in many forms has
come to make its abode, for a long time at least, throughout
the length and breadth of our islands. Its study is no longer
of merely academic interest to the general practitioner in
Great Britain ; it has become an extremely practical matter,
entering frequently and intimately into the business of his
everyday life. Never has there been more need to repeat
the call, first uttered by our present King " Wake up,
England ! " If this book can do something, however little,



PREFACE



IX



to assist that awakening, it will, by that alone, have repaid
all the toil with which it has been written.

If, to the critical eye, the work seems full of weaknesses
and of omissions, I will hasten to admit to my prospective
mentors, that probably not one of them realises its defici-
encies so fully and clearly as I do myself. In extenuation,
I would plead that the task has been a pioneer one, replete
with all the difficulties that surround such work.

My friends have been most generous in advice, help,
and assistance, and the list of services that I have to
acknowledge is so great that I shall not overburden the
preface with it, but shall devote a separate chapter to this
topic alone.

In conclusion, if I am able to serve others by the many
years of work that I have given to this book, I would ask
them to be so kind as to help me in return, by sending me
specimens, items of information, or criticisms, as oppor-
tunity arises. I would point out to them that no man
can write a complete work on tropical ophthalmology alone,
and that items of everyday knowledge to those working in
distant parts of the Empire will prove of the greatest value
and interest to me in the preparation of a second edition
of this work, should one be called for, as I hope it may be.
I can assure them that all such assistance will be grate-
fully acknowledged, and that the fullest publicity will be
given as to the source of any information supplied me.

ROBERT HENRY ELLIOT.

54 WELBECK STREET, LONDON, W. 1,
July 1920.



PRINTED IN GREAT BRITAIN BY
MORRISON & GIBB LTD., EDINBURGH



ACKNOWLEDGMENTS

MY grateful acknowledgments are due to those who have
so kindly assisted me in various ways :

Mr. E. Treacher Collins most generously placed at my
disposal the valuable notes, on which his lectures to the
students of the London School of Tropical Medicine were
founded. I have not hesitated to draw freely on this
material.

Lieut. -Colonel H. Herbert has helped me most materi-
ally by personal communications, and by contributing
a number of photographs and illustrations, which have
added much to the interest and completeness of at least
one section of the book.

Major Walter Kiep, R.A.M.C., has very kindly supplied
me with illustrations of dysenteric iritis, and with much
valuable information on the eye complications of dysentery,
a subject to which he and his collaborator, Miss Euphan
Maxwell, to whom also my acknowledgments are due,
have made most important contributions.

Lieut. -Colonel H. Kirkpatrick has most kindly contri-
buted chapters on the Madras Operation for Cataract, and
on the Ophthalmoscopic Appearances found in Natives of
India. He has also assisted me most liberally by means of
personal communications, and by his advice on a number
of difficult points. Last, but not least, he has furnished



xii ACKNOWLEDGMENTS

me with a number of drawings and paintings which only
require to be seen to be appreciated.

Dr. Manson-Bahr has relieved me of a considerable
responsibility by so kindly writing the article on Filaria
bancrofti. He has also helped me with his advice on
several other subjects, and has been most generous in allow-
ing me to use a number of illustrations from Hanson's
Tropical Diseases, a work which he is now engaged in re-
editing, and which may be looked forward to as a most
authoritative exposition of the subject.

Professor Miyashita has generously helped me with the
chapter on Beriberi, a disease with whose phenomena he
is most intimately acquainted.

Dr. Louis Sambon has very kindly written for me the
article on Yaws, and has generously helped me with
illustrations from the albums of his beautiful collection of
photographs of morbid, tropical conditions.

The Editorial Committee of the British Journal of
Ophthalmology have very generously allowed me to re-
produce a number of illustrations from the pages of The
Ophthalmoscope and of the British Journal of Ophthal-
mology.

Messrs. J. Weiss & Son have most kindly furnished
me with blocks illustrating a number of the instruments
described in the book.

R. H. ELLIOT.



CONTENTS

SECTION I
INTRODUCTORY

CHAP. PAGK

I. EYE DISEASES IN TROPICAL COUNTRIES . . .3

The Centres for the Distribution of Ophthalmic Relief . 4

Railway Facilities ...... 5

The Poverty of the People . . 6

The Mental Attitude of the People . . 9
Suspicion of Foreign Agencies . . . .12

The Influence of Unqualified Native Practitioners . 14

The Prevalence of Eye Disease . 14

Diet .... ... 18

II. DOMESTIC REMEDIES AND UNQUALIFIED NATIVE PRACTITIONERS 19
III. A DANGEROUS FORM OF EXPLOSIVE . . . .29

SECTION II

THE EFFECTS OF EXPOSURE OF THE EYES TO
STRONG LIGHT IN TROPICAL COUNTRIES

I. THE PHYSICAL PROPERTIES OF BRIGHT LIGHT . . 35

II. GLARE ASTHENOPIA . . . . . ' . 38

III. GLARE CONJUNCTIVITIS . . . . .49
IV. INJURIES OF THE EYES BY LIGHTNING . . .52

V. ECLIPSE BLINDNESS ... 62

VI. NIGHT-BLINDNESS ... 75

VII. ERYTHROPSIA AND CYANOPSIA . 87



xiv CONTENTS

SECTION III

THE EFFECTS OF EXPOSURE OF THE EYES TO
WIND AND DUST IN TROPICAL COUNTRIES

CHAP. PAGE

I. INTRODUCTORY . . .. . . .95

II PlNGDECULA AND PTERYGIUM . . . . .99

III. THE CAUSATION OF EPIDEMICS OP OPHTHALMIA IN THE EAST 108

SECTION IV

INJURIES INFLICTED ON THE EYE BY
ANIMALS IN THE TROPICS

PART I. GENERAL CONSIDERATIONS
PART II. INJURIES BY FLYING INSECTS

INTRODUCTORY . . . . . . 121

I. MECHANICAL INJURIES ...... 122

II. CHEMICAL INJURIES . . . . . 124
III. SEPTIC INFECTION ...... 129

PART III. CHEMICAL INJURIES BY OTHER
ANIMALS

I. ASCARIS POISONING . . . - ... . 131

II. EEL'S BLOOD CONJUNCTIVITIS ..... 132

PART IV. INJURIES BY STINGS AND BITES
I. WASP AND BEE STINGS . . . .133

II. MOSQUITO BITES . . . . . 136

III. ANT BITES . . . . . , 137

IV. TICK BITES ... ... 138

V. INJURIES BY OTHER POISONOUS ARTHROPODS 139



CONTENTS xv

CHAT. PAOE

VI. LEECH BITES . . . . . . .140

VII. MISCELLANEOUS (CHICKEN PECKS, RAT BITES, ATTACKS BY

SNAKES, ETC.) ...... 142

PART V.-THE INVASION OF THE LIDS AND EYES

BY SMALL ARTHROPODS . . 145

SECTION V
PARASITIC DISEASE OF THE EYE

INTRODUCTORY . . . . . . .149

PART I. PLATYHELMINTHES
I. TREMATODES . . . . . . .152

II. CESTODES ....... 153

PART II. NEMATHELMINTHES
I. FILARIA BANCROFTI . . . . . .158

II. LOA LOA . . . . . . .161

III. FILARIA INERMIS . . .' . . . 171

IV. FILARIA Ocun HUMANI ..... 173
V. ONCHOCERCIASIS . . . . . .178

VI. THELAZIASIS ....... 180

VII. ANKYLOSTOMIASIS . .... -183

PART III. ARTHROPODA

I. INTRODUCTORY ... . . 187

II. OCULAR MYIASIS . . . . . .191

PART IV. MISCELLANEOUS

I. RHINOSPORIDIUM KINEALYI . . . . . 200

II. MYCETOMA ....... 207

III. ASPERGILLOSIS ....... 208

IV. MURMEKIASMOSIS AMPHILAPHES . 210



xvi CONTENTS

SECTION VI

THE INDIAN OPERATION OF COUCHING FOR
CATARACT

CUAP. PAGE

I. HISTORICAL . . . . . . .215

II. THE TECHNIQUE OP COUCHING .... 218

III. THE INDIAN COUCHER AND HIS HABITS . . . 222

IV. STATISTICS . . . . . . .226

V. PATHOLOGY . . . . . . .229

VI. DIAGNOSIS . ..... 233

VII. CLINICAL . 239

SECTION VII

CATARACT EXTRACTION

INTRODUCTORY ....... 245

I. SELECTION OF CASES FOR OPERATION . . . 246

II. THE PREPARATION OF THE PATIENT FOR OPERATION . 251

III. ASEPSIS, ANTISEPSIS, AND GENERAL ARRANGEMENTS . 254

IV. METHODS OF OPERATING FOR CATARACT . . . 263

V. THE MADRAS CATARACT OPERATION. By Lieut.-Col.

H. KIRKPATRICK . ... 265

VI. WARNINGS AND RULES . . . . 276

VII. THE AFTER-TREATMENT OF EXTRACTION CASES . . 280

VIII. THE FREQUENCY OF CATARACT IN TROPICAL COUNTRIES . 285

SECTION VIII

DISEASES OF THE CONJUNCTIVA, THE CORNEA,
THE LIDS, AND THE LACHRYMAL PASSAGES

INTRODUCTORY . . . . . . .291

PART I. DISEASES OF THE CONJUNCTIVA . 293

I. PHLYCTENULAR CONJUNCTIVITIS .... 293

II. TRACHOMA 295



CONTENTS xvii

'HAP. PAOK

III. SOME COMPLICATIONS AND KESULTS OF TRACHOMA . . 302

IV. SOME RESULTS OF VARIOUS FORMS OF CHRONIC CON-

JUNCTIVITIS ...... 307

V. PARINAUD'S CONJUNCTIVITIS ..... 312

VI. SAMOAN CONJUNCTIVITIS . . . . .314

VII. SPRING CATARRH . . . . . .316

VIII. FILARIAL CONJUNCTIVITIS . . . . . 321

IX. A DISTINCTIVE CONJUNCTIVAL PAPULE . . 322

X. MISCELLANEOUS . . . . . . 324

PART II. DISEASES OF THE CORNEA . . 325

I. SUPERFICIAL PUNCTATE KERATITIS . . . 325

II. FILAMENTARY KERATITIS ..... 331

III. HERBERT'S CORNEAL PLAQUES . . . 333

IV. LEAD INCRUSTATION OF THE,-CORNEA . . . 336
V. SEPTIC ULCERATION OF THE CORNEA . . . 337

PART III. DISEASES OF THE LIDS . . 341

I. A RARE FORM OF SUBCONJUNCTIVAL GRANULOMA MET

WITH IN CENTRAL CHINA .... 341

II. OTHER UNUSUAL THICKENED CONDITIONS OF THE LIDS . 346

PART IV. LACHRYMAL OBSTRUCTION . 348

SECTION IX
MISCELLANEOUS

I. ANATOMICAL PECULIARITIES OF DARK-SKINNED RACES . 365

II. GLAUCOMA ....... 367

III. NEW GROWTHS OF THE EYEBALL AND ITS ADNEXA . 377

IV. THE CORRECTION OF ERRORS OF REFRACTION . . 383

V. OPHTHALMOSCOPIC APPEARANCES IN THE TROPICS. By

Lieut.-Col. H. KIRKPATRICK, I. M.S. . . . 387

VI. HOSPITAL MANAGEMENT ..... 395
b



xviii CONTENTS

SECTION X

GENERAL DISEASES

CHAP. PAOB

I. BERIBERI . . . . . . . 405

Epidemic Dropsy . . . .414

II. CHOLERA ....... 416

III. DYSENTERY . . . . . . 419

IV. LEPROSY . . . . .429
V. MALARIA . . . . . : . 445

VI. QUININE POISONING ...... 461

VII. PELLAGRA ....... 473

VIII. PLAGUE .476

IX. SMALLPOX ....... 481

X. TRYPANOSOMIASIS ...... 485

XI. TYPHUS ..... . . 492

XII. YAWS . . 497

XIII. VARIOUS GENERAL DISEASES ..... 500

Black-water Fever ..... 500

Dengue ....... 501

Diabetes ....... 502

Enteric Fever . . . . . .503

Heat-stroke . . . . .503

Sand-fly Fever ...... 505

The Tropical Relapsing Fevers .... 505

Undulant Fever . . . . . .506

Yellow Fever . . ... . .506

INDEX . 509



LIST OF COLOURED PLATES

PLATE FACING PAGE

I. CATARACT AND SYMBLEPHARON . . . .20

II. PTERYGIUM ... ... 102

III. PTERYGIA OF BOTH EYES ..... 104

IV. LARGE CYST IN CONNECTION WITH A PTERYGIUM . . 104

V. MlCROFILARLE OF THE BLOOD . . . . 158

VI. El'ITHELIOMA OF CONJUNCTIVA .... 378

VII. DERMOID CYST OF LIHBUS . 380



LIST OF ILLUSTRATIONS



F1O. PACK

1. The Manufacture of a Medicinal Preparation . . 21

2. Three blinded Children . . . . . .22

3. Corneal Opacities due to abuse of Drugs . . 24

4. Anterior Staphyloma . . . . . .25

5. Section of Eye to show Staphyloma . . . .26

6. Scotoma from Sun-blinding . . . . .63

7. Eclipse Scotomata (after Ask) . . . .66

8. Double Pterygium ...... 101

9. Pterygia of both Eyes ...... 102

10. McReynolds' Operation, Early Stage . . . 105

11. Application of Sutures . . 106

12. Operation for Double Pterygium .... 107

13. Spargamim mansoni . . . . . .155

14. Chrysops dimidiata ...... 162

15. Chrysops silacea . . . . . . .163

16. Loa loa, natural size ... . . . .164

17. female . . . . . .164

18. male . . . . . . .165

19. posterior extremity of male . .. . . 165

20. female . . .165

21. Filarin palpebralis, male ..... 181

22. Head of Filaria palpebralis . . . . .181

23. Filaria palpebralis, natural size . . . .181

24. tail of female . 181

25. embryos of .... 181

26. Ankylostomum duodeiutle, natural size . . . .183

27. female . . .184

28. male . . . .184

29. Necator americanus, male . . . . .185

30. female . . . ' .185

31. Dermatobia hominis ...... 189

32. maggot . 189

33. Rhinosporidium kincalyi ...... 201

34. microscopic section . . . 203



xxii LIST OF ILLUSTRATIONS

FIO. FACE

35. Rhinosporidium kinealyi, microscopic section . . . 203

36. 203

37. ,, . 203

38. Rhinosporidium of Lachrymal Sac, microscopic section . 205

39. Murmekiasmosis . . . . . . .210

40. Multiple Cutaneous Warts . . . . .211

41. Depression of Cataract . . . . . .216

42. Reclination of Cataract . . . . . .216

43. Couching, the Anterior Operation . . . .218

44. Couching, the Posterior Operation . . . .218

45. The Operation of Couching ..... 219

46. The Instruments used in Couching .... 220

47. Forward Dislocation of Couched Cataract . . . 229

48. Lens couched through Pectinate Ligament . . . 229

49. Couched Morgagnian Cataract in Vitreous . . . 231

50. Couched Lens bound down by Exudate . . . 231

51. Couched Eye in Process of Shrinking . . . 231

52. Couched Lens in Front of Vitreous Body . . . 231

53. The Iris Shadow . . . . . .247

54. Author's Cruet for sterilising Drops .... 255

55. Author's Tea-pot Irrigator ..... 256

56. Author's Tray for Irrigation ..... 256

57. McKeown's Irrigator, during Sterilisation . . . 257

58. ,, ready for use .... 257

59. Alcohol Steriliser for Cataract Instruments . . . 258

60. The Madras Cataract Bandage . . . . .260

61. The Madras Cataract Operation

Laceration of Capsule . . . . . 266

62. The Section . . . . . .268

63. The Iridectomy . . .""".. . .269

64. Delivery of Lens . . . . .271

65. Irrigation . . . . . . .273

66. Smith's Lid Control in Cataract Extraction . . . 274

67. Kirkpatrick's Cataract Goggles . . . . .281

68. Ziegler's Knife . . . . . . .283

69. Cataract Belt . . . . . .284

70. Sequela) of Trachoma .... .296

71. . . . .... 297

72. Snellen's Eyelid Clamp . . . . .298

73. Operation for Entropion ..... 299

74. parts shown in section . . 300

75. Pannus carnosus ....... 303

76. The Sinuous Lid Border . ... 305

77. Conjunctival Bridge, in section .... 308



LIST OF ILLUSTRATIONS xxiii

FIG. PAO

78. Conjunctival Bridge, shown by everting Lid . . . 308

79. Spring Catarrh, palpebral ..... 317

80. Trachoma . . . . . . .318

81. Spring Catarrh, bulbar ...... 319

82. Superficial Punctate Keratitis, Kirkpatrick's Disease . 328

83. The Three Main Forms of Kirkpatrick's Disease . . 329

84. Herbert's Corneal Plaques . . . 334

85. Author's Evisceration Spoon ..... 340
86 Subconjunctival Granuloma ..... 343

87. . 343

88. ,, . . 343

89. ... 344

90. . . 344

91. . 344

92. . 344

93. Lachrymal Obstruction . . . . . . 351

94. Position of Table, etc , in Extirpation of Lachrymal Sac . 354

95. Miiller's Retractor . . ... . . 355

96. Author's Dissector ...... 355

97. Spindle-shaped Cautery for Nasal Duct . . . 356

98. Ball-shaped Cautery for Dome of Wound . . . 356

99. Author's Optico-ciliary Neurectomy Hook . . . 374

100. Teratoma of Orbit . . . . .. .378

101. Mickulicz's Disease, front view ..... 379

102. side view . . . . . 379

103. showing enlarged accessory lobe . 379

104. Malignant Tumour of Lachrymal Gland . . .381

105. 381

106. Paraplegic Beriberi ...... 408

107. Dropsical Beriberi ...... 408

108. Pestle-shaped Scotoma of Beriberi .... 409

109. Perimetric Field of Beriberi . . . . . 409

110. . 409

111. .Results of Bilateral Dysenteric Iritis .... 423

112. Progress of Dysenteric Iritis ..... 423

113. Advanced Nodular Leprosy . . . . 432

114. . 433

115. Anaesthetic Leprosy ...... 434

116. Simulium niyroyilvum, imago ..... 474

117. Yaws 498



SECTION I

INTRODUCTORY

CHAPTER I. EYE DISEASES IN TROPICAL COUNTRIES.

The centres for the distribution of ophthalmic
relief.

Railway facilities.

The poverty of the people.

The mental attitude of the people.

Suspicion of foreign agencies.

The influence of unqualified native prac-
titioners.

The prevalence of eye disease.

Diet.

,, II. DOMESTIC REMEDIES AND UNQUALIFIED NATIVE
PRACTITIONERS.

III. A DANGEROUS FORM OF EXPLOSIVE.



CHAPTER I
EYE DISEASES IN TROPICAL COUNTRIES

THE surgeon who has become accustomed to the nature of
his surroundings in a tropical country learns to accept, as
matters of his everyday life, things which arrest the atten
tion of visitors from more civilised parts of the world. He
is awakened to the privileges of his position by the ex-
traordinary interest such travellers take in what to him
have become the routine happenings of an exiled existence.
He has forgotten what Kipling, the Poet of Empire, has
sung that

" The strangest things of Kew, are the facts of Khatmandhu,
And the crimes of Clapham chaste in Martaban."

It cannot fail to be of assistance to the young student
of ophthalmology in the Tropics, that at the very outset,
he should gain a clear comprehension of the influences,
which are at work to make his experience different from
that of his brother who practises in the West. To most
of us, such knowledge has only come as the result of years
of slow- won and often painful experience. The object of
this chapter is to enable the beginner to start where
many of us have left off. He will have to learn much
for himself, but he will short-cut many a difficult, devious
and dangerous road, if he will be content to learn from
those who have passed on before him. For the sake
of simplicity, we shall endeavour to tabulate some of
the principal influences which are at work in tropical
countries to stamp ophthalmic practice there with peculiar
characteristics.



4 TROPICAL OPHTHALMOLOGY

THE CENTEES FOR THE DISTRIBUTION OF
OPHTHALMIC RELIEF

In backward countries these are few and scattered. It
is difficult for an English student to realise the condition
of affairs in a land, where there is only one well-equipped
eye hospital for forty million or more inhabitants, and yet,
until quite recently, that was the state of affairs in different
parts of our Indian Empire. No one, who has not spent
years of his life at work in a tropical country, can form any
real conception of the enormous amount of preventable
and curable blindness, that lays its sombre shadow over
the health, the happiness, and the usefulness of millions of
our fellow-subjects ; yet, and one is bound to say it, those
in authority have done but a bare fraction of their duty
in the matter. The present method of selection of the
men who hold the highest administrative posts, in India
at least, is inimical to the choice of the class of ruler needed
in backward countries. To stand well with the " powers
that be " is far more important than to take wide and
long views of life ; to have the reputation of cutting down
expenses is more favourable to a man's promotion, than the
power to depart from precedent and to think for himself.
The consequence is that too many of those, who rise to the
top of the tree, are quite unfitted to wield the great power
which comes into their hands ; they would be far better
employed in saving rupees in some comparatively subordi-
nate post. With painfully few exceptions they lack vision,
imagination, and independence of thought, and are incap-
able of inaugurating large schemes, or of departing from the
beaten track. Another feature which, in India at least,
has disfigured the administration, has been a jealousy on
the part of the Civilian Executive of the medical officers.
It is to be feared that such conditions are not confined to
India, and are common to many of the tropical and sub-
tropical lands we rule. One thing is certain, and that is,
that there is a strong need for the awakening of a sense of
our medical responsibility as an Empire to the nations we
govern, and this, not merely for moral reasons, but for the