SPECIAL FORMS OF CONJUNCTIVAL INFECTION 161 



infiltrations, and emphasized the important clinical fact that the original con- 

 junctival inflammation was often but slight and easily overlooked, but that the 

 corneal condition also healed rapidly with zinc. Hoffmann, Zur Nedden, McKee, 

 and Pfliiger corroborate this fully. The latter always found a mixed infection with 

 Pneumococci when an ulcus serpens occurred in a diplobacillary conjunctivitis. 



This, however, is not always corroborated. Gifford described a severe ulcerative 

 keratitis, and Uhthoff and Axenfeld found the Diplobacilli in a hypopyon-keratitis 

 which greatly resembled an ulcus serpens. Further cases are described by Paul, 

 Erdmann, Stoewer, Schmidt, McKee, and Doetsch. When we include the Petit 

 type of the Diplobacillus and that can be done with slight reserve the number 

 of such cases is not small. In the course of years I have seen more than twenty 

 cases of hypopyon-keratitis with Diplobacilli both of the Petit and the Morax- 

 Axenfeld type. The latter form is capable of causing a hypopyon-keratitis 

 (cf. papers by Paul, McKee, and Erdmann). It is important to note that this 

 severe form also can be cured by the use of zinc sulphate. Further particulars are 

 given in the chapter on ' Corneal Bacteriology.' The conjunctival signs in such 

 cases may be quite obscured. 



The clinical appearance of a blepharo-conjunctivitis should immediately arouse 

 suspicion that the Diplobacillus is present. 



It would be going too far, however, to give a positive diagnosis off-hand, for in 

 such cases other findings occur or the examination may be quite negative. Examina- 

 tion of a slide or a culture alone will give a certain diagnosis. This marked affection 

 of the angles may be absent in a case of diplobacillary conjunctivitis ; and acute 

 catarrhal cases from this cause have been described by Axenfeld, Hoffmann, Zur 

 Nedden, Pfliiger, Pollock, Usher, Fraser, and Brown-Pusey. Not infrequently the 

 objective signs of inflammation are so slight that they may readily be overlooked, 

 and patients, on account of a burning sensation in their eyes by artificial light, may 

 be treated for asthenopia by means of glasses, etc., without result, although a course 

 of zinc would rapidly remove all their trouble. The slightest secretion at the angles 

 should be examined. In the very slightest ' almost normal ' cases the bacilli are 

 often very numerous. Lundsgaard states that occasionally only slight lacrymation 

 may occur. 



After a severe catarrh has occurred for a long time, ectropion districhiasis and 

 eczema of the lids may result. Such cases are often wrongly considered as the 

 ordinary blepharitis. 



In all cases, therefore, of blepharitis the secretion should be examined for Diplo- 

 bacillii as their demonstration is an indication for the usual routine zinc treatment. 

 MacNab has very rightly emphasized this recently. Follicles are occasionally 

 observed in the conjunctiva. When they are very plentiful and resist treatment, 

 they are usually not due to the diplobacillary infection, but to a combination such 

 as is not uncommon in the case of true trachoma. 



The affection when untreated lasts, with occasional exacerbations, for a long 

 time. It is not known whether the rarer acute cases resolve more rapidly, as all the 

 cases observed so far have been cut short by treatment. We have no definite 

 records of cases healing spontaneously. What the patients call healing is often only 

 a transient improvement. 



The conjunctivitis is sometimes accompanied by a nasal catarrh. In a family 

 which suffered from a very free conjunctival discharge I found at the nasal orifice 

 reddened and macerated areas, on which Diplobacilli occurred ; in another patient 

 the same condition occurred at the angles of the mouth (Lobanow). Whether, in 

 such cases, we should speak of a diplobacillary rhinitis or stomatitis is still open to 

 question. Meyerhof states that catarrh of the upper air passages often occurs 

 in people who have diplobacillary conjunctivitis. I have not found it so myself. 



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