SPECIAL FOEMS OF CONJUNCTIVAL INFECTION 203 



and often also in the pericardium. The spleen is usually unchanged ; 

 the kidneys often show parenchymatous haemorrhages. The upper 

 part of the stomach is reddened. Injection into the peritoneum pro- 

 duces a hgemorrhagic peritonitis. The bacilli multiply especially in 

 the site of puncture, but can also pass into the blood. 



If we cannot inoculate from the original tube, then a pure culture 

 must first be made, and from this we can inoculate. 



In cases which clinically are slight or moderate in severity we can 

 await the result of this examination, which takes a few days, and in 

 the meantime we can treat locally and take precautions against con- 

 tagion. In the severe cases, whenever the smear shows bacilli of the 

 diphtheria group, Behring's serum should always be injected. "When 

 bacteriological examinations are not made, then every case of pseudo- 

 membranous conjunctivitis must be treated with the serum. 



Along with the diphtheria bacilli pus-formers are often present 

 (Staphylococci, Streptococci, Pneumococci, Plate I., Fig. VI.}. The 

 mixture of Streptococci with diphtheria bacilli produces an especially 

 severe clinical lesion of the conjunctiva. 



The experiments of Coppez, confirmed by Dugast, show that the 

 participation of the cornea in a conjunctival diphtheria is due to the 

 toxin, which loosens the epithelium and penetrates into the paren- 

 chyma. Such a complication only shows after twenty-four to forty- 

 eight hours, when the toxins begin to diffuse. The cornea then 

 becomes cloudy. When a very powerful toxin acts for a long 

 enough time, a partial necrosis of the cornea may occur (Coppez). 

 Diphtheria in man never reaches this stage by the action of its toxin 

 alone, though the way is thus prepared for a secondary infection. 

 The actual suppuration of the cornea is caused, as a rule, by 

 secondary infection with pyogenic organisms. For this reason a 

 suppuration, when it has already begun, is not influenced by the 

 serum treatment in other respects GO generally efficacious. 1 



Uhthoff has shown by experiment on rabbits that occasionally a 

 severe purulent corneal infiltration can be caused by the diphtheria 

 bacillus alone. 



Morax and Elmassian found the same incubation time for the con- 

 junctiva which Coppez had obtained for the cornea. Twenty-four 

 to forty-eight hours after the instillation of diphtheria toxin into the 



1 In considering the action of serum used locally (Coppez), or better subcutaneously 

 injected (Dugast), we must note that even without it many of these cases heal rapidly ; the 

 beneficial effect on the severe cases is the best proof of its value (Saemisch, c/1 Axenfeld, 

 ' Serumtherapie infektioser Augenerkrankungeu,' Freiburg, 1905). Schmidt-Rimpler and 

 Aubineau have used the serum in cases of post-diphtheritic paralysis of accommodation. 



