SPECIAL FORMS OF CONJUNCTIVAL INFECTION 259 



generally is derived from the patients themselves ; it is not contagious 

 from without. As virulent aureus is relatively very rare in the skin, 

 the question as to whether the ordinary skin cocci, by some variation, 

 have increased in virulence must be considered. Such a change would 

 require an antecedent and preparatory change in the skin. 



The cocci which occur in eczema of the skin have an influence on 

 the course of the disease, and generally are more virulent in their 

 characteristics, when contrasted with the common skin saprophytes. 

 This is obvious from the fact that they can form hsemolysin and 

 agglutinate the pyogenic forms. In the scrofulous inflammations of 

 the lids, which are only in part eczematous or impetiginous, and are 

 much more nearly allied to acne, the Stapkylococcus pyogenes aureus 

 commonly occurs (Gifford, Straub, Deyl, Stephenson, Meijers, van 

 Haaften). To ascribe on this account the clinical picture which we 

 know as kerato-conjunctivitis phlyctenulosa, and still more the indi- 

 vidual phlyctenules, to this organism is going much too far. 



Though the study of eczema is of importance, it should for the 

 present be provisionally kept distinct from that of the phlyctenular 

 inflammations, as this appearance does not occur in every case of 

 eczema affecting the region of the eye, but only in young scrofular 

 patients, or those who have been affected with scrofula from their 

 youth ; and, on the other hand, the corneal eruption has not been 

 proved anatomically to agree exactly with eczema of the skin (cf. here 

 the records of Klingmiiller). In particular, the formation of a true 

 vesicle, which has been once recorded by J. von Michel, appears to be 

 a rare exception in the records available ; phlyctenules are rather 

 subepithelial nodules, and even so they are not quite identical with 

 eczematous papules. The whole clinical course of the corneal con- 

 dition is not a characteristic of eczema in general, but rather of 

 scrofula. 



It should here be noted that Nias and Paton found that the opsonic 

 index of the blood-serum of patients with phlyctenules was lowered for 

 tubercle. The index rose as the lesion improved. They conclude 

 that the phlyctenules are caused by attenuated or dead tubercle 

 bacilli, especially as they found that, under treatment with tuberculin, 

 phlyctenules occasionally occurred. The pathogenesis is by no means 

 proved by this. If phlyctenular kerato-conjunctivitis should be proved 

 to be a staphylococcal disease, the vaccine treatment of Wright with 

 Staphylococci should be tried (further, see p. 355). 



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