Diseases Of The Lachrymal Apparatus | Operating Microscopes

Diseases Of The Lachrymal Apparatus.
By SAMUEL THEOBALD, M.D.,
OF BALTIMORE

In treating of diseases of the lachrymal apparatus it is convenient to consider, first, those affections which have to do with the lachrymal gland and its ducts, and, second, those of the drainage apparatus, including the puncta, the canaliculi, the lachrymal sac, and the nasal duct. The lachrymal gland, probably owing to its protected position and its multiple ducts, is, comparatively speaking, rarely the seat of disease, while, on the other hand, disease of the drainage apparatus, doubtless because of its intimate anatomical and pathological relationship to the nasal passages, is of very frequent occurrence.

DISEASES OR THE LACHRYMAL GLAND.

Dacryoadenitis, or inflammation of the lachrymal gland, occurs as an acute and as a chronic affection. Both varieties are rare, though it seems not improbable that acute inflammation of the gland is sometimes mistaken for cellulitis of the orbit, from which it is not always easy to differentiate it.

Etiology. It occurs more frequently in children than in adults, and oftener in women than in men. It has been known to assume an epidemic character, and Galezowski reports having met with an unusual number of cases during an epidemic of mumps. Other causes to which it has been ascribed are traumatism, “cold," rheumatism, gout, stroma, syphilis, septic absorption, and the extension of inflammation from the conjunctiva and cornea. It is usually unilateral, but not infrequently both glands are involved.

Symptoms. Acute dacryoadenitis gives rise to severe pain, which may be accompanied by elevation of temperature, cerebral excitement, sleeplessness, and delirium. The lids, especially the upper lid, are greatly swollen, and there is marked chemosis of the conjunctiva. The eyeball may be displaced and its movements restricted and rendered painful through the enlargement, of the gland. Palpation of the exquisitely sensitive gland is difficult because of the edema of the lids, and eversion of the lid, to permit of its inspection, is out of the question. The general appearance of the eye is not unlike that which characterizes purulent conjunctivitis (S. C. Ayres). Suppuration may supervene within a few days, the pus making its way through the integument of the lid or into the conjunctival cul de sac, or the inflammation may subside without the formation of pus.

In chronic dacryoadenitis the characteristic enlargement of the gland may be recognized by palpation, and sometimes by simple inspection. By everting the upper lid the swollen gland may be brought into view as a red, tongue shaped, nodular mass (Hirschberg). The gland is usually sensitive to pressure, but the pain, swelling of the lids, and conjunctival chemosis are much less pronounced than in the acute variety of the disease. As in the latter, there may be marked displacement of the eyeball, usually downward and inward and this may give rise to diplopia. In rare instances non suppurative dacryoadenitis (mumps of the lachrymal gland, Hirschberg) is bilateral.

Treatment. The treatment of acute dacryoadenitis, if the case is seen at the outset of the attack, should consist in leeching, the application to the lid and brow of an ointment of mercury with opium or belladonna (ext. opii vel ext. belladonna 3j ; ung. hydrarg. 3J), and the administration of an energetic mercurial purgative, to be followed by liberal doses of quinin, sodium salicylate, or sodium pyrophosphate (the last named drug in twenty grain doses every two hours) ; or, instead, small and frequently repeated doses of calomel may be administered. Should these measures fail to cut short the attack, warm fomentations, containing opium or belladonna, should be employed, and as soon as the presence of pus can be detected it should be evacuated by an incision either through the integument of the lid or through the conjunctival cul de sac as may seem to be indicated.

chronic inflammation of the gland the local application of mercurial or compound iodin ointment, and the administration of alternatives and tonics, are indicated. Extirpation of the gland (see page 596) may be necessary should it become so enlarged as to endanger the integrity of' the eyeball.

Fistula of the Lachrymal Gland. This troublesome variety of lachrymal fistula may be a consequence of dacryoadenitis or may be of traumatic origin. Cases of congenital fistula of the lachrymal gland have also been observed.

The fistulous opening is usually at some point in the upper lid, and the constant flow of tears, which prevents its closure, gives rise to much annoyance.

It is not easy to bring about a healing of the fistula, and if this is accomplished, it is at the risk of precipitating a fresh attack of inflammation of the gland. The operative procedure which has proved most effectual is that proposed by Sir William Bowman (see page 596).

Dacryops, or cyst of the lachrymal gland, is a rare condition due to occlusion of one or more of the efferent ducts of the gland. It has also been met with as a congenital affection.

Upon eversion of the upper lid the cyst may be brought into view as a semi transparent, elastic swelling, consisting, perhaps, of several nodules. During a spell of crying the cyst may become markedly increased in size.

Treatment. This consists in establishing a permanent opening between the cyst and the conjunctival sac. This may be done by removing a portion of the cyst wall and preventing the closure of the wound by the repeated introduction of a probe, or, as suggested by von Graefe, a silk thread may he passed through the wall of the cyst, tied in a loop, and left to cut its way out.'

Dacryoliths (Lachryntal Calculi). Chalky concretions, known as dacryoliths, occasionally form in the lachrymal gland. As they are apt to cause mechanical irritation, their early removal (through a conjunctival in is indicated.

Dislocation of the Lachrymal Gland. This affection, sometimes described as hernia or prolapse of the gland, has been met with as a spontaneous condition, and also as a consequence of injury involving the neighboring parts.

Cases of spontaneous dislocation of the gland have been reported by Snell, Noyes, Mauthner, and Briere. In Briere's case the luxation of the gland was due to caries of the orbit, and was accompanied by ectropion of the upper lid.

Von Graefe and Rampoldi have reported cases of traumatic dislocation of the gland.

If possible the gland should be restored to its normal position, as was done successfully in von Graefe's and in Snell's cases, and a compress bandage should be applied and worn for a time to prevent a redislocation. If this cannot be accomplished, removal of the gland may become necessary (see page 596).

Hypertrophy of the Lachrymal Gland. This condition occurs more frequently in children than in adults, and has been known to be of congenital origin. The enlargement of the gland may become so great as to force the eyeball from the orbit, and destroy the sight through stretching and compression of the optic nerve.

accompanying illustration (Fig. 181) represents a striking example of a case of this character which occurred in the practice of the late Prof. Christopher John of Baltimore. The hypertrophied gland, which was about the size of a lien's egg and contained numerous dacryoliths, was removed through an incision made parallel with the orbital margin. The eye subsequently resumed nearly its normal position, and retained vision equal at least to counting fingers.

the enlargement of the gland is so great as to endanger the integrity of the eye, it should be removed without unnecessary delay (see page 596); but if it is not so great as to interfere with vision, less radical measures, such as the local application of iodin or mercury and the administration of the iodides, may be tried. The fact that the hypertrophic process may be of origin (syphilis of the lachrymal gland) should not be lost sight of in considering the treatment to be adopted.

Atrophy of the Lachrymal Gland. This has been observed in xeroplithalmia (see page 296). Ant has described a case of this character in which the gland was reduced to one third its normal size and its efferent duets obliterated. In paralysis of the trigeminus the functional activity of the lachrymal gland my be abolished.

of the Lachrymal Gland. These are rare, and, not infre are traceable to some previously received injury. They are usually of slow growth and occur oftenest in advanced life. As they increase in size they interfere with the movements of the eyeball, giving rise to diplopia. Later they produce exophthalmos, and eventually may not only destroy sight by the pressure which they exert upon the optic nerve' but which they rarely invade but may cause death by the involvement of the brain.

following varieties of tumors believed to have bad their origin in the lachrymal gland have been observed: adenoma, myxoma, myxo sarcoma, lympho sarcoma, spindle cell sarcoma, epithelioma, cylindroma, chloroma, and carcinoma.

and complete removal of the growth is of course indicated. Whether this can be accomplished successfully without sacrifice of the eye will depend upon the size of the tumor and the extent to which it has invaded the deeper portions of the orbit. (See page 596 for description of operation for removal of lachrymal gland.)

DISEASES OF THE DRAINAGE APPARATUS.

All parts of the drainage apparatus are liable to pathological changes, and, whether these changes affect the puncta, the canaliculi, the lachrymal sac, or the nasal duct, a common symptom characterizes them all : the tears are no longer carried from the conjunctival sac to the nasal cavity, as in the normal state, but, instead, overflow the lids, giving rise to the annoying condition known as epiphora or stillicidium lacrymarum. Not only is this condition, in itself, very annoying, but it leads to chronic conjunctivitis, blepharitis, and not infrequently to eczeina of the lids and cheek.

Artesia of the Lachrymal Puncta. This condition is met with as a congenital and as an acquired anomaly.

Congenital atresia of the puncta, of which not many authentic cases have been reported, may be attended by absence of the corresponding canaliculi. The writer has encountered one case of this character, in which, however, only one punctum with its canalictilus was absent.

Complete obliteration of the puncta as an acquired condition seldom occurs, except as the result of destruction of neighboring tissue, such as happens, for example, from burns of the eye by lime, etc. It has also been known to follow the cicatrization of a small pox pustule and of a chancre of the lid.

A superficial occlusion of the lower punctum, which is easily overcome, and which is chiefly due to desiccation of the parts, is often observed in blepharitis marginalis complicated by ectropion.

. Whether the occlusion be congenital or acquired, it is, as a rule, overcome without much difficulty, provided the canaliculus is not involved. A slight depression usually indicates the site of the occluded punctum, and with a straight, moderately sharp pointed probe, such as is represented in Fig. 182, an opening may be drilled into the canaliculus at this point and kept from reclosing by the occasional introduction of a somewhat larger probe. If, however, the canaliculus as well as the punctum be occluded, or if the latter be everted, the canaliculus will require to be slit up to its point of juncture with the lachrymal sac. (For description of this operation see page 596.)

As congenital anomalies double puncta and double canaliculi have been observed, and in connection with absence of the puncta the canaliculi have been represented by slight furrows along the lid margin.

Malpositions of the Puncta. In their normal position the puncta lie in contact with the eyeball. Malpositions of the tipper puncta are not common, but faulty positions of the lower puncta are frequently met with.

Eversion of the puncta is present in nearly all cases of ectropion ; it also occurs in inflammatory thickening of the lid margin, in senile relaxation of the palpebral tissue, and in facial paralysis.

Inversion of the puncta is met with in entropion. Occasionally, owing to the small size or deeply set position of the eyeball, the puncta are not in apposition with it, and epiphora results, as it does when the puncta are everted, through failure of the tears to find their way into the canaliculi.

Treatment. The efficient remedy in all malpositions of the puncta is division of the canaliculus. It not only relieves the epiphora, but usually leads to the rapid disappearance of the conjunctivitis and blepharitis which are its common accompaniments.

Artesia of the Canaliculi may occur as a congenital defect in connection with absence of the puncta, as has already been mentioned ; it may also be of traumatic origin.

strictures of the canaliculi, located usually near the juncture of the canaliculi and the lachrymal sac, are of frequent occurrence, especially in association with stenosis of the nasal duct.

When the canaliculi are completely obliterated their restoration by operative procedure is impracticable; but it may be possible to make a passageway directly into the lachrymal sac, and by repeated probings cause it to remain patulous, as was done in the case to which allusion has been made tinder the bead of Atresia of the Puncta. The circumscribed strictures may usually be overcome by, the passage of a small lachrymal probe or of the straight probe shown in Fig. 182. Division of the canaliculus may be called for if the stricture is difficult to overcome or is disposed to recur.

Dacryoliths occasionally form in the canaliculi. They were formerly supposed to be simply concretions of lime, but are now known to be composed in great part of a fungus believed by some investigators to be identical with the leptothrix buccalis. Cohn, however, denies this, and suggests the name streptothrix Forsteri. Goldzieher has met with cases in which a cilium occupied the center of the dacryolith, and was probably the exciting cause of its development. The presence of dacryoliths in the canaliculus, which may be detected by the circumscribed swelling to which they give rise, causes epiphora and may excite conjunctivitis. Their early removal, which may necessitate division of the canaliculus, is indicated.

Polypi have been known to form in the canaliculi, and may project through the puncta. They should be removed, the canaliculus, if necessary, being divided, as soon as their presence is recognized.

bodies, such as eyelashes, bits of the beard of wheat and barley, occasionally find their way into the canaliculi, where they may remain for a long time, causing considerable annoyance. If they project through the puncta, they may be seized with forceps and easily withdrawn; otherwise division of the canaliculus may be necessary to effect their removal. In one instance (reported by Haffner) an ascaris lumbricoides was removed from the lower canaliculus.

Dacryocystitis. Inflammation of the lachrymal sac, or dacryocystitis, occurs as a chronic and as an acute affection. The former is usually denominated blennorrhea of the lachrymal sac, while the latter is often spoken of as abscess of the sac.

Etiology and Symptoms. Primary inflammation of the lachrymal sac is of rare occurrence. It is oftenest met with in the newborn, usually in the form of a mild blennorrhea; it is said to occur in strumous children, and it may be excited by external violence or the entrance into the sac of an irritant fluid. In the large majority of cases dacryocystitis is secondary to, and dependent upon, stricture of the nasal duct.

Although inflammation of the lachrymal sac frequently gives rise to conjunctivitis and keratitis, the reverse rarely happens. The truth of this statement is strikingly illustrated in gonorrheal conjunctivitis. Although the gonococci doubtless find their way in great numbers into the lachrymal sac, dacryocystitis as a complication of gonorrheal conjunctivitis is, so far as the writer can learn, practically unknown.

On the other hand, there is the closest pathological sympathy between the lachrymal sac and duet and the nasal passages, and doubtless in a majority of cases dacryocystitis is traceable, directly or indirectly, to nasal disease. Such being the case, it is not surprising, when one bears in mind how almost universally prevalent catarrhal affections of the nasal mucous membrane are, that inflammation of the lachrymal sac and nasal duct should be of comparatively frequent occurrence.

of the eyes is a usual symptom of acute rhinitis, and probably in most pronounced cases of this affection the mucous membrane lining the lachrymal drainage apparatus participates to a greater or less extent in the general nasal catarrh. With the subsidence of the rhinitis the lachrymal catarrh and the transient occlusion of the nasal duct which has probably accompanied it usually disappear, and the parts return to a healthy condition.

Exceptionally,. however, because of the severity of the inflammation, the occurrence of a second or third attack before the first has been recovered from, a congenital narrowness of the nasal duct, or a peculiar susceptibility of the lachrymal passages to disease (a susceptibility which is not infrequently inherited), the inflammation of the walls of the duct does not subside with the nasal affection, and presently assumes a more serious character.

Under such circumstances the inflammation, which at first was simply a catarrh of the mucous membrane, invades the underlying periosteum, and the temporary occlusion of the duct from engorgement of the submucous plexus of veins gives place in time to a permanent stenosis from periosteal and osteal thickening. In this way and, perhaps, still more frequently from the extension of chronic inflammatory affections of the nose to the lachrymal passages stricture of the nasal duct, which, as has been said, is the usual forerunner of dacryocystitis, commonly arises.

The chronic nasal affections of inherited and acquired syphilis, it may be remarked, are especially liable to involve the lachrymal apparatus. Blows upon the bridge of the nose or about the inner angle of the eye may not only cause inflammation of the lachrymal sac, as has been indicated, but may lead to the development of stricture of the nasal duct.

When once the occlusion of the duet is complete, the tears, mucus, and epithelial debris which collect in the lachrymal sac are invaded by bacteria and undergo putrefactive changes. This soon leads to inflammation of the lining membrane of the sac, and the condition known as chronic dacryocystitis or blennorrhea, of the lachrymal sac becomes established.

This condition does not give rise to pain, but the attendant epiphora and regurgitation of mucus and muco pus through the puncta into the conjunctival sac not only cause great annoyance, but, as has been stated, may bring on chronic conjunctivitis and blepharitis, and even corneal inflammation.

The accumulation of tears and mucus frequently leads to a perceptible distention of the sac (mucocele), which disappears under slight pressure with the tip of the finger, the contents of the sac usually regurgitating through the puncta, but exceptionally, when the stenosis of the duct is incomplete, escaping into the Dose (Fig. 183).

In some instances this state of chronic catarrhal inflammation lasts indefinitely, without undergoing appreciable influence of cold, a slight tratimatism, the entrance into the lachrymal sac of pyogenic organisms of unusual virulence, some constitutional disorder or, as seems to happen Hot infrequently, the sudden occlusion of the canaliculi at their point of junction with the sac, the inflammation undergoes a sudden and acute aggravation.

Severe pain, accompanied by great distention of the sac and marked edema of the lids and surrounding parts, comes on, and decided evidences of constitutional disturbance, such as fever, loss of appetite, sleeplessness, etc., manifest themselves. These are the symptoms which characterize acute dacryocystitis or abscess of the lachrymal sac (Fig. 184), and which in many cases of stricture of the nasal duct recur from time to time so long as the occlusion of the duct is permitted to remain.

After several days of intense suffering the integument over the sac assumes a yellowish appearance, becomes thinned, and, if left to itself, usually gives way at a point just below the internal palpebral ligament, permitting the purulent contents of the sac to escape, and affording the individual immediate and almost complete relief from his sufferings. Exceptionally, the inflammation subsides without perforation of the sac, and the pus ultimately escapes through the canaliculi and puncta.

It is a fact worthy of remark that during an attack of acute dacryocystitis it is scarcely ever possible to empty the distended sac by externally pressure, although after the subsidence of the acute inflammation pressure will usually cause the contents of the sac to regurgitate through the canaliculi and puncta, as, in all probability, was the case before its onset. From this it would seem probable that when the sac is unduly distended a valve like closure of the canaliculi at their point of juncture with the sac occurs; and it may be that this is often a potent factor in the causation of acute dacryocystitis.

After the contents of the acutely inflamed lachrymal sac have been evacuated, either spontaneously or by an incision, the inflammation rapidly subsides, and within ten days or two weeks the opening through which the discharge has occurred usually closes, and the sac resumes its previous condition of chronic blennorrhea.

Exceptionally, however, the cicatrization of the opening is prevented by the continual discharge through it of tears and muco pus, and the condition known as lachrymal fistula becomes established to remain, perhaps, for an indefinite period.

Treatment of Dacryocystitis. There is but one effectual and rational way of curing dacryocystitis, and that is by eradicating the stenosis of the nasal duct upon which, as has been stated, it almost invariably depends.
During an attack of acute inflammation of the sac, and for some days after its subsidence, operative interference with the strictured duct is out of the question, and we must, for the time being, content ourselves with the administration of anodynes and such other constitutional remedies as the condition of the patients may seem to call for, and the local application of soothing fomentations, to be followed, in all probability, by an early incision through the anterior wall of the sac, below the internal palpebral ligament. Such an incision, if made in the direction in which the skin tends to wrinkle that is, from above and toward the nose downward and outward does not leave a perceptible scar, and gives a freer exit to the retained pus than does an incision into the sac along the canaliculus.

pad of gauze wet with a lotion of opium and boric acid (ext. opii, gr. x xv, acid. boric., gr. x-xv, acid.aboric., gr. lx, aq.destil., 3iv), and covered with a, piece of rubber "protective" to prevent evaporation, forms a cleanly and convenient substitute for a poultice, and will be found a very useful application in these cases.

In chronic blennorrhea of the sac, if for any reason it is Dot practicable to treat the strictured nasal duct, a considerable measure of relief may be obtained from slitting the lower canaliculus and prescribing a collyrium, either of bichlorid of mercury (1 :12,000) or of alum (gr. ij) and boric acid (gr. xxv to an ounce), to be dropped into the eye two or three times a day, explicit instructions being given to empty the sac of its contents by pressure with the finger tip before each instillation of the drops.

is well to bear in mind that abscesses occasionally occur in the neighborhood of the lachrymal sac (prelachryinal abscess), which, from their appearance only, cannot always be distinguished from dacryocystitis. The history of the case, however, showing the absence of pre existing symptoms of lachrymal disease, will usually make the diagnosis plain.

Stricture of the Nasal Duct. As to the etiology of obstructions of the nasal duct, little need be added to what has already been said upon this subject in treating of Dacryocystitis. How often syphilis, both inherited and acquired, is a factor in their causation, especially when it has invaded the nasal passages, has already been pointed out.' Syphilitic gummata have been met with in the lachrymal sac, as well as in the duct. Tuberculosis of the nose, through extension to the lachrymal passages, has been known to cause stenosis of the duct, and polypi of the lachrymal sac to produce a like effect. The exanthematous fevers measles, scarlet fever, and small poxalso may lead to occlusion of the duct through the inflammation of the nasal mucous membrane which attends them.

As to the location of the strictures, there is no part of the duct in which they are not frequently encountered, although their most common situation is at its upper extremity. Multiple stricture, at least in cases of long standing, is the rule.

As the strictures are the outcome of periosteal inflammation, they are almost invariably, in part at least, of bony structure. They may be circumscribed and annular in form (a thin bony septum being sometimes encountered), or ill defined and of wide extent, involving a considerable part of the length of the duct. When situated at the lower extremity of the duct their existence is not so easily recognized, and it may happen that a mistake of this kind will render the treatment of no avail.

stenosis of the lachrymal duct which occurs in the new born is usually of an entirely different character, being due simply to tumefaction of the membranous wolls of the canal, and in consequence it generally yields readily to treatment , operative interference being only exceptionally called for. A similar condition is occasionally met with in adults, and may be suspected if the symptoms of occlusion of the duct are of but short duration.

and Treatment. The confessedly poor results which, in the main, have been obtained in the treatment of strictures of the nasal duct are ' in the writer's opinion, attributable chiefly to the inadequate size of the probes which are commonly employed to overcome the stenosis. The great merit of the invaluable operation devised by Bowman of slitting the canaliculus as a preliminary step in the treatment of lachrymal strictures (see page 596) is that it permits the passage of probes sufficiently large to overcome entirely the stenosis and restore completely the normal caliber of the canal. Nevertheless, Bowman himself fell far short of appreciating this fact, as is shown by the small size of the probes which he employed,' and, owing to an unreasoning conservatism, which those who have emancipated themselves from its influence can scarcely comprehend, the same may be said, even at the present day, of the great majority of those who have followed his plan of treatment. The absurdity of attempting with a probe of 1.50 mm. diameter to restore to its normal dimensions an occluded canal which in health has an average diameter (measured in its shortest axis) of somewhat more than 4 MM.,3 it would seem should be evident to all; but experience shows that such is far from being the case.

The accompanying illustration (Fig. 185), which represents graphically the results of measurements of the nasal duct made by the writer, and described in the paper to which reference has been given, is in this connection instructive :

Besides the treatment by means of probes, there are other methods of dealing with steno sis of the duct and its accompanying dacryocystitis which have their advocates. Although the gold canula of Wathen and Dupuytren is probably scarcely ever used at the present day, there are many who still employ styles of difrerent patterns made of lead, silver, or aluminum, and others who practise division of the strictures as recommended by Stilling, to whom the credit of having originated this method of treatment is usually given. The interesting fact, however, has recently come to the writer's knowledge that as early as 1846 the late Prof. Nathan 11. Smith of Baltimore dealt with lachrymal strictures in this manner, and devised a knife of peculiar pattern for this especial purpose.'

intractable cases of dacryocystitis dependent upon occlusion of the nasal duct, which have failed to yield to less radical measures, removal of the lachrymal gland (see page 596), and also excision of the lachrymal sac (see page 597) or its destruction by means of caustics or the galvano or thermo cautery (see page 597), are practised by some ophthalmic surgeons. and, it is claimed, with excellent results. The writer has bad no experience with these last mentioned procedures, not having encountered cases in which such radical measures seemed to be indicated. As to the employment of styles, his experience with them has not been satisfactory, and leads him to regard them as of limited applicability, being useful only when time will not permit of the proper carrying out of the probing treatment.

Briefly described, the writer's method of dealing with strictures of the nasal duct, which he has employed almost without exception in all cases that have come into his hands during the past twenty years, and which has yielded, as a rule, most gratifying results, is as follows :

lower' canaliculus, after having been slightly dilated by the passage of a No. I or No. 2 probe (cocain having been previously instilled into the conjunctival sac), is divided well up to its juncture with the lachrymal sac with Weber's beak pointed canaliculus knife (Fig, 415), or, preferably, with the modification of the knife represented in Fig. 416. An effort is then made to pass into the sac and through the duct a No. 5 or No. 6 of the writer's series of lachrymal probes (usually the former)' (see Fig. 419, page 598). If the probe enters fairly into the lachrymal sac, any reasonable amount of force which may be necessary to pass it through the occluded duet to the floor of the nose is employed without hesitation, care being exercised that it does not take a wrong course. If, owing to a constriction at the juncture of the canaliculus and the sac (a condition which is not infrequently met with, and which occasionally greatly complicates the treatment), the point of the probe is arrested and prevented from entering the sac, a smaller probe, No. 4 or No. 3, is tried. If neither of these can be introduced, it is best to desist from further efforts and to wait for forty eight hours, when very often the difficulty previously experienced in entering the sac will be found to have disappeared. If this does not prove to be the case, an opening is drilled through the constriction with the sharp pointed, straight probe (Fig. 182), or, the lid being kept well upon the stretch, a No. 5 probe is passed along the canaliculus to the point of resistance and is then turned vertically and forced into the sac a procedure which, if possible, should be avoided, as it may result in the making of a false passage directly from the canaliculus into the duct. Exceptionally, the constriction must be divided with a sharp pointed knife, the old fashioned cataract knife of Sichel being especially convenient for this purpose.

The probe, after being passed entirely through the duct to the floor of the nose, is allowed to remain in situ for from ten to twenty minutes. The probing is repeated during the early stages of the treatment every other day, usually a size larger probe being passed each time. The size of the largest probe which it is desirable to use will of course vary in different cases, but there are very few in which it is well to stop short of No. 14, for it is to be borne in mind that our purpose is to obliterate the stricture completely (not simply to make a small opening through it) and to restore the normal caliber of the duct. In about two thirds of all his cases (including children as well as adults) the writer introduces No. 16. In passing the larger pyobes considerable force is sometimes employed. This has been found not only to be permissible, but, instead of doing harm, as many maintain must necessarily be the case, its effect upon the carious walls of the duct is distinctly curative, the result being not unlike that produced by the curetting of diseased bone in other parts of the body.

as large a probe has been introduced as is deemed necessary, the interval between the probings is gradually increased, first to three or four days, then to a week, a fortnight, and finally to a month or two months; and when several of these longer intervals have elapsed without any tendency to recontraction having manifested itself, the case is dismissed with full assurance that a permanent cure has been effected. Including these longer intervals the treatment frequently extends over a period of eight or ten months; but the active treatment, involving the frequent probings, is comprised within as many weeks.

Electrolysis has been tried by the writer to a limited extent, to promote the more rapid absorption of lachrymal strictures; but, so far as could be judged, its effect was inappreciable. The chloride of silver, " dry cell," battery is convenient for this purpose. From eight to twelve cells may be used, the negative pole being connected with a probe which has been introduced into the duct, while a moist sponge connected with the positive pole is held in contact with the cheek.

No attempt is made by neans of syringes to inject antiseptic or other solution into the lachrymal sac, but, instead, a collyrium is prescribed, which the patient is instructed to drop into the inner corner of the eye three times a day, after having pressed out the contents of the sac with the finger tip. The collyria which have been found most useful are a solution of bichlorid of mercury (1 :12,000) and one of alum and boric acid, containing 2 per cent. of boric acid and one half of 1 per cent. of alum. Formaldehyd (1 :2000) is much employed by some surgeons, as are all of the usual antiseptic and astringent collyria.

The presence of a lachrymal fistula, even when accompanied by caries of the underlying bone, has not seemed to call for especial treatment. The fistula has been found to heal promptly, and the carious bone to become re covered with periosteum as soon as the stenosis of the duct has been overcome by the passage of the large probes.

The frequent dependence of lachrymal disease upon nasal catarrh is kept constantly in mind, and treatment is directed to the nasal passages whenever it seems to be indicated. For this purpose a weak solution of bichlorid of mercury (1 :5000), to which is added a small quantity of chlorid of sodium and glycerin, applied to the nose several times a day by means of a handatomizer, has been found especially efficacious. (For full particulars in reference to measures suited to such conditions see sections devoted to diseases of the rhino pharynx.)

The length of time during which the probing must be kept tip varies considerably in different cases; but it is a safe rule not to discontinue the use of the probe altogether as long as there is any evidence of dacryocystitis or any roughness of the walls of the duct noticeable on passing the probe. In obstinate cases, however, it is well to lengthen the interval between the probings, as it sometimes happens that the inflammation is kept up by the too frequent introduction of the probe. In several instances, when patients from a distance could not remain under treatment as long as was thought desirable, it has been found practicable to teach them to probe their own nasal ducts with the large probes which had been previously introduced, cocain being first instilled to minimize the pain. In this way relapses, which otherwise might have occurred from the too early discontinuance of the treatment, have been avoided. The probe represented in Fig. 186 was devised by the writer for this purpose, and has been found very useful.

In the transient occlusion of the nasal duct which occurs in the new born operative interference, as has been stated, is seldom called for; nevertheless, if the collyria of bichlorid of mercury, of alum and boric acid, and, perhaps, a weak solution (gr. ¼ to 3j) of nitrate of silver, have been tried per severingly without effect, it may become necessary to divide the canaliculus and introduce a probe. The outcome of this treatment is usually very satisfactory, and it is seldom necessary to repeat the probing oftener than four or five times. In a case of this character in a child fifteen months old recently under treatment, and in which a complete cure was effected, the duct was probed in all ten times, No. 12, the largest probe used, being introduced upon five successive occasions.

The writer's experience with the radical treatment of strictures of the nasal duct by the use of large probes now extends over a period of nearly twenty years, during which time he has employed it in a large number of cases, and has had the opportunity of seeing many of them, from time to time, for long periods after the discontinuance of the probing; and his observation is that the cases in which the treatment is systematically carried out in the manner which has been described are, with comparatively few exception completely and permanently cured.

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