330 BACTERIOLOGY OF THE EYE 



do not disappear so rapidly. This agrees with the statements first made 

 by Coppez, and so often repeated in the literature, that the curative 

 action in corneal complications is very uncertain. Even in spite of 

 the healing of the conjunctival lesions, the cornea can go steadily on 

 to destruction ; this is due to the fact that the inflammation and 

 ulceration are not due to the diphtheria bacilli, but to secondary 

 infections with pyogenic organisms. These are not directly overcome 

 by the action of the serum, but only indirectly influenced by it to this 

 extent, that the subsidence of the conjunctival diphtheria favourably 

 influences the nutrition of the cornea, and the neutralizing of the 

 toxin in the conjunctival sac prevents a further toxic action on the 

 corneal tissues. 



In general it cannot be stated that destruction of the cornea occurs from the 

 action of the diphtheria bacillus. Certainly by experiment on animals we may 

 succeed in producing a severe keratitis by the introduction of a large number of 

 very virulent bacilli into a central pocket in the cornea. No condition similar to 

 this has ever been observed clinically in diphtheria in man. Coppez' experiments, 

 which were confirmed by Morax and Elmassian, showed that repeated instillations 

 of diphtheria toxin into the conjunctival sac, without any action of the pyogenic 

 organisms, can in the end cause a necrosis of the cornea, especially when there is 

 a defect of the epithelium ; these results, however, cannot be applied to man. It 

 has recently been disputed by Dugast 1 that this is even the case in animals ; it is 

 doubtful if he is right, as it is very possible that Coppez may have worked with 

 a more potent toxin than Dugast, who gives no details on this point. Coppez' 

 results are confirmed by Romer,- who injected minute quantities of diphtheria 

 toxin into the tissues of the cornea, and thus obtained necrosis in non-immunized 

 animals, while immunized ones suffered no damage. 



For these reasons we may, when suppuration has already com- 

 menced, give a streptococcal serum, such as the polyvalent serum of 

 Menzer (Merck 3 ), as well as the diphtheria antitoxin. But even when 

 the infection of the cornea is due to the Streptococcus, it is questionable 

 whether such a procedure can save the cornea. In conjunctival 

 streptococcal diphtheria I have succeeded in curing the conjunctiva 

 and improving the general condition, and still the cornea went on to 

 destruction. Only an early exhibition of the streptococcal serum will 

 benefit, and even then not with the certainty of the antitoxic action 

 of the diphtheria serum against the infection with the diphtheria 



1 These de Paris, 1905. 2 A. f. 0., 1901, liv., p. 164. 



3 This is obtained from as many fresh strains as possible of the organism obtained from 

 man. The Marmorek serum, which is so much used in eye diseases in France, and is 

 specially recommended by Boucheron, is made from cultures which are kept up to their 

 virulence by passage through animals. The antistreptococcal sera of Hochst, of Moser, 

 and of Ahronson, combine these two methods in varying degrees. Tavel's serum is a 

 polyvalent horse serum, containing many strains which are pathogenic for man (from T. D. 

 Kredel, Berlin, Gerichtstrasse 12, 13). All these sera are accompanied by exact directions 

 as to their manner of use. 



