CONJUNCTIVAL DIPHTHERIA Conjunctival diphtheria is a very rare disease, usually secondary to -a nasopharyngeal diphtheria advancing through the lachrymal canals. Occasionally it is primary and then it often sets up secondarily a diph theria of the nose and throat. Impetigo, eczema and cachexia increase the predisposition to it (Malian). According to the chief local symptoms, two main forms are recognized, the croupous and the diphtheritic. A sharp distinction is not possible, for the two forms merge into each other.
The disease always begins on the palpebral conjunctiva with red ness and swelling and in both forms it may spread to the bulbar con junctiva, and also in the severest forms to the cornea.
In croupous conjunctivitis, bluish or yellowish white deposits are found, sometimes thin, sometimes thick, rich in fibrin but containing few cells. When this is removed the underlying mucous membrane is seen to be red, roughened or velvet and bleeding easily. The secre tion is profuse and purulent and contains flocculi. The bulbar conjunc tiva is chemotic, often covered with hemorrhages in the form of dots or streaks, and at times it is partly covered with membrane. The -cornea is clear but may rarely show a superficial clouding with a bluish film. As a rule all these appearances develop in a few days. The de posits disappear in from three to ten days, leaving a catarrhal and purulent conjunctivitis which lasts for several weeks. The cornea remains intact, hardly ever becoming permanently cloudy.
In the diphtheritic form the lids are very red and swollen, often with a hoard-like infiltration. On attempting to separate them a scanty and later profuse secretion flows out, a dirty, turbid and blood-stained serum. In the average form the grayish yellow membranes, spotted with blood or brownish discoloration, are scattered over the palpebral conjunctiva to which they are firmly attached. In the severest confluent form the
conjunctiva from the edge of the lids to the palpebral folds is covered in its whole extent with a fat-like membrane, like yellowish gray rubber. Only a few of the deposits can be torn off and this causes decided ing with deep loss of tissue. The chemotic pale yellow bulbar cornea, at times shows diphtheritic infiltration and is raised around the cornea like a wall. The neighboring Iymph-nodes are swollen and hard. There are usually more or less general constitutional symptoms with fever. After three to five days, or in the confluent form eight days, the secretion becomes purulent, the so-called blennorrha4form stage. The swelling and board-like infiltration of the lids subside and granulation tissue appears, followed by healing with scarring. The fate of the cornea depends on how soon the blennorrha'iform stage develops. If it becomes affected before this stage, it may be destroyed in twenty-four hours, either by loss of epithelium at the centre with infiltration and a step like loss of substances, or by a shutting off of the corneal blood supply tbv pressure from the exudate) followed by a degeneration of the cor neal tissue from the edge. In all the severe cases the eye is greatly in jured, amounting to complete blindness in some cases as a result of scars, staphyloma or shrinking of the eyeball from a secondary suppurative In both of the forms general symptoms of toxaemia may supervene on the local changes. Postdiphtheritic paralyses are not rare after the diphtheritic form. In very weak children even conjunctival diphtheria alone may cause death by a general toxtrmia.