•The Treatment of Chronic 
Dacryo-Cystitis. 
BY 
THOMAS A. JOYE, M.D., 
ASSISTANT SURGEON TO THE BROOKLYN EYE AND EAR 
HOSPITAL. 
REPRINTED FROM 
Ebe Neto Yorft fHebical 
for May 16, 1885. Reprinted from the New York Medical Journal 
for May 16, 1885. 
THE TREATMENT OF 
CHRONIC DACRYO-CJYSTITIS. 
By THOMAS A. JOYE, M. D., 
ASSISTANT SURGEON TO THE BROOKLYN EYE AND EAR HOSPITAL. 
In the normal condition the amount of fluid secreted 
from the lachrymal passages is very small, but under irritat- 
ing influences it is liable to be not only increased in quan- 
tity, but greatly changed in character. The important fac- 
tors which conspire to bring about a condition of chronic 
dacryo-cystitis are swelling and hypertrophy of the mu- 
cous membrane, a lessening of the caliber of the nasal duct, 
and a secretion of inflammatory products of a thick, tena- 
cious character, which are retained and consequently cause 
distension of the sac, and ultimately erosion of the lachrymal 
bone. From the fact that in these cases there are, as a rule, 
swelling and stenosis of the nasal duct, the conclusion is 
easily arrived at that the fundamental principle in the treat- 
ment is dilatation. Hence it is we are taught that any treat- 
ment to be effective must be that which will enlarge the 
passage-way to the nose, thus giving exit to the pent-up 
secretions in the lachrymal sac. The remedies most recom- 
mended are the slitting up of the lower canaliculus and the 
subsequent passing of probes into the nasal duct. Various THE TREATMENT OF 
2 
methods of dilatation have been practiced from time to time 
with varying success. Dupuytren attempted to render the 
nasal duct permeable by introducing tubes made of gold or 
silver, having at their upper end a border to give them sup- 
port. In a majority of cases the bony passage became worn 
under the pressure of the cannula, and the tube sank down. 
In others, intractable disease of the bones occurred, render- 
ing a removal of the tube necessary. Leaden styles have 
been and are at present occasionally used. Some commence 
the treatment by introducing them, and allow them to 
remain, removing them from time to time, in order to 
cleanse the duct, or try its permeability. The uncertainty 
of success and the annoyance to the patient have made this 
method less preferable than the treatment by probes. Bou- 
gies of Laminaria cligitata have also been used. Their 
advantage consists in their absorbing the fluid from the 
lachrx mal passages, and swelling up to many times their 
original size. The objection to their use is that they are 
likely to swell to such an extent that their removal causes a 
laceration of the lining membrane of the duct. The same 
objections apply to the bougies of catgut, saturated with 
nitrate of silver, that have been recommended by some sur- 
geons. Forcible dilatation, on the principle of Holt's dila- 
tation for urethral stricture, has been suggested, but is not 
popular. Stilling's practice is to pass a knife of the shape 
of a right-angled triangle into the nasal duct, and incise in 
three or four directions; no dilator or probe is introduced 
afterward. Warlomont speaks in praise of this method, and 
says the cure is immediate and permanent, though this is 
not in accord with the experience of others. Causing ec- 
tropion of the lower lid and punctum, which limits the con- 
duction of tears to the sac, has been recommended as a 
curative measure. Destruction or obliteration of the sac 
has been practiced, but at present would hardly be regarded CHRONIC DACRYO-CYSTITIS. 
3 
as a justifiable procedure. Astringent preparations, such 
as nitrate of silver, sulphate of zinc, etc., are injected into 
the sac, and have attained reputation as curative agents. 
Tincture of opium and tincture of iodine have been advo- 
cated, but are objectionable because of the impossibility of 
preventing their passage into the pharynx. It may be said 
here that no method known at the present day gives assur- 
ance of permanent benefit. In a considerable number of 
cases the result is only palliative, and the relief obtained 
does not always compensate for the pain and inconvenience 
to the patient. While all authorities agree as to the efficacy 
of passing probes into the nasal duct, there is much diversity 
of opinion as regards the benefit derived from the introduc- 
tion of large ones. De Wecker,* as a preface to his remarks 
on treatment, says: " There are two points of capital im- 
portance on which much of the success of the treatment will 
depend. One is to realize that we are not called upon to 
remove any obstacles which oppose a definite resistance, 
such as occlusions or constrictions. All methods, therefore, 
in any way rough or coarse, are to be deprecated. The 
second is to realize that any treatment adopted should dis- 
turb the physiological functions of the tear-passages as little 
as possible." Further on he remarks: "I reject all large 
probes, and never use any in excess of Bowman's No. 3." 
Swanzy,t speaking of Weber's conical probes, says: "I do 
not use them, because, when passed into the nasal duct, their 
thickest part, which is 3 to 4 mm. in diameter, corresponds 
with the upper end of the duct, which is its narrowest part, 
being only 3 mm. in diameter; consequently the probe be- 
comes more or less impacted at this place at each operation, 
and is apt ultimately to give rise there to hypertrophy of 
the periosteum, and finally to stricture, so that, while the 
f "Diseases of the Eye." 
* " Ocular Therapeutics." 4 
THE TREATMENT OE 
immediate effect is good, the ultimate result is often the 
opposite." Stell wag* remarks: "It is scarcely ever neces- 
sary to use the very large probes (Bowman's 5-6). On the 
contrary, such a large caliber might easily become danger- 
ous from the excessive laceration of the canals." Soelberg- 
Wellsj- says : "I, as a rule, use Bowman's probes, but fre- 
quently employ a considerably larger size than Bowman's 
No. 6." His practice is to begin with No. 3 to 4, and to 
gradually increase the size until No. 6 is arrived at. Noyes J 
remarks: "My conviction is that the stricture should be 
expanded to the fullest degree-much beyond No. 6 Bow- 
man-and I have a size, No. 10, which measures 11 mm. in 
circumference." Nettleship * says : " The object aimed at 
is the permanent dilatation of the stricture, the rule being 
to use the largest probe that will pass readily." A popu- 
lar method of treatment as practiced at present is thorough 
dilatation, the objective point being the absorption of the 
stricture; and, for this, probes larger in diameter than 
the caliber of the duct are forced through, benefiting, in 
some cases at the expense of the soft parts, by simply open- 
ing a passage-way for a thick, tenacious secretion that will 
hardly flow on a free surface. That many patients suffering 
from this disease have not stricture of the nasal duct is 
proved by the fact that the contents of the sac can be readi- 
ly forced through the duct by pressure over the lachrymal 
sac. Neither does it follow that after thorough dilatation a 
cure will result. I have at present in mind a patient who, 
for about a year, has been under the care of one of my col- 
leagues, at the Brooklyn Eye and Ear Hospital, on whom a 
No. 12 probe (Theobald) could be passed with the greatest 
ease. She has also worn a leaden style for months at a 
* " Diseases of the Eye." 
| " Diseases of the Eye." 
f " Diseases of the Eye." 
* " Diseases of the Eye." CHRONIC DACRYO-CYSTITIS. 
5 
time. Yet the trouble persists. Noyes says: " Making 
haste slowly is the password to success in these cases, but I 
am convinced that the gate must be opened widely, and 
made to stay open." This success, I believe, consists in 
treating the effect while the cause persists and the condition 
remains unchanged, except in so far as a more thorough 
drainage tends to improve it. It seems to me that the 
essential factor necessary for the successful treatment of 
these cases must be to restore the sac and its contents to 
their normal condition ; then it will be found that the duct 
in the majority of cases will be sufficiently large for drain- 
age purposes. This can be more readily believed when it 
is known that " in the normal condition the quantity cf fluid 
secreted from the lachrymal passages is so small that evapo- 
ration and secretion balance and nothing passes into the 
nose " (Noyes). A correct appreciation of the conditions 
which aid in producing and continuing this disease is neces- 
sary for its successful treatment. The most important is 
the palpebral conjunctivitis, which is always present. It is 
well known that atmospheric conditions, which excite an 
excessive secretion of tears in the normal eye, invariably 
cause an aggravation of the symptoms. Appropriate treat- 
ment here will materially aid in the improvement by arrest- 
ing the over-secretion from the lachrymal gland, and conse- 
quently lessening the contents of the lachrymal sac. During 
the last year I have successfully treated three cases of this 
disease where the ordinary methods had failed. The first 
was cured by instilling a solution of sulphate of atropine 
into the conjunctival sac; the two succeeding ones, by in- 
jecting this agent directly into the lachrymal sac. My atten- 
tion was accidentally called to the effect of atropine in cases 
of chronic dacryo-cystitis while treating a case of ulcer of 
the cornea in the person of a patient wdio had chronic da- 
cryo-cystitis on the same side. Treatment applied to the 6 
THE TREATMENT OF 
lachrymal sac vw*h difficulty by myself and others had 
proved ineffectual, and was abandoned as useless. In treat- 
ing him at a later time for ulcer of the cornea, a solution of 
atropine was employed. After a few days, improvement of 
the lachrymal disease was noticed, which continued untd a 
cure was effected. 
Case I.-A. W. called on me for treatment June 7, 1884, 
and stated that for several years he had been troubled with a 
swelling at the inner canthus and an annoying discharge. He 
had been under the care of specialists for two years. Bow- 
man's operation had been performed, and probes passed into 
the nasal duct at intervals, without benefit. The lachrymal 
tumor was prominent, and was emptied by pressure over the sac 
through the lower canaliculus. A Bowman No. 4 was passed 
through the nasal duct with ease. Palpebral conjunctivitis was 
present, for which a solution of argent, nitras, gr. v, ad aquae 
3J, was applied. An ointment of hydrarg. oxid. flav., gr. iv, 
ad vaseline, 3 'j, was ordered to be applied to lids at night; also 
a lotion of acid, boric., gr. xvi, ad aquae, § j, to be used three 
or four times daily. His visits were made at intervals of three 
days. Bowman's probe No. 6 was introduced each time after 
the first visit, and the treatment for the lids continued. After 
three weeks, there being no improvement, he became discour- 
aged and left off treatment. In July he called, suffering from 
an ulcer of the cornea of the same eye, for which a solution of 
atropine was instilled and ordered for home use. Three days 
later he called again. The cornea was then in better condition. 
He remarked that the tear-sac trouble was much better, that the 
swelling was not so great, and that the secretion from the sac 
passed of itself into the nose. One week later he called. The 
cornea was entirely healed; the lachrymal disease had continued 
to improve. I ordered that the atropine be continued for two 
weeks, and that he should report again in a month, at the end of 
which time his cure was perfect. 
Case II.-Mrs. C. called October 20,1884, and stated that for 
three years she had been troubled with O. D. She complained of CHRONIC DACRYO-CYSTITIS. 
7 
a swelling at the inner cantbus, and an annoying discharge which 
blurred her vision. The tumor was emptied into the eye by press- 
ure over the lachrymal sac. Two years ago she was under the 
care of a specialist. Bowman's operation was performed and 
probes were introduced into the nasal duct at intervals for some 
weeks, without benefit. One year ago the same treatment was 
resorted to, but failed to improve the condition. A Bowman's 
probe No. 4 was introduced into the nasal duct, but required some 
force to get it through. Conjunctivitis was present, for which a 
solution of argent, nitras, gr. v, was applied. Hydrarg. oxid. flav., 
gr. iv, ad vaseline, 3 ij, was ordered as an application to the lids at 
night, and a lotion of acid, boric., gr. xv, zinci sulph., gr. ij, ad 
aquae camph., ? j, to be used two or three times daily; gtt. vj 
of a solution of atropin. sulph., gr. iv, were injected into the 
lachrymal sac. 
October 2Jfth.-Tumor less marked; secretion not so abun- 
dant; atropine solution, gtt. vj, injected into the lachrymal sac. 
Solution of argent, nit., gr. v, applied to the lids. Ilome treat- 
ment continued. 
27th.-Marked improvement; lachrymal tumor less marked ; 
contents of the sac pass readily into the nose. Treatment con- 
tinued. 
November Jfth.-Reports to-day that she is not conscious of 
anything wrong; swelling has entirely disappeared. Treatment 
the same. 
9th.-Patient seems to be completely cured, and says she 
thinks further treatment unnecessary. Atropine again injected. 
27th.-Patient states that she is entirely relieved, and suffers 
no inconvenience whatever. 
Case TIL-Mrs. R. was under my care in 1882, suffering 
from chronic dacryo-cystitis, which had existed for about a year. 
Bowman's operation was performed at that time, and probes 
were introduced into the nasal duct at intervals of three days for 
several weeks without material improvement. 
October 188^.-She called and said she had determined 
to try again and persist, as I had told her that the disease was 
very obstinate and the treatment must be long continued. Ex- 8 
THE TREATMENT OF 
amination showed marked distension of the lachrymal sac, which 
was emptied on pressure into the conjunctival sac. Bowman's 
probe No. 4 caught at the mouth of the lachrymal sac, but 
passed into it; probe not introduced into the nasal duct. Pal- 
pebral conjunctivitis was present, for which a solution of argent, 
nitras, gr. v, ad aquae, §j, was applied; gtt. vj of a solution of 
atropin. sulph., gr. iv, were injected into the lachrymal sac. An 
ointment of hydrarg. oxid. flav., gr. iv, ad vaseline, 3 i.h was 
ordered to be applied to the lids at night. A lotion of acid, boric., 
gr. xv, ad aquae camph., § j, to be used as a wash for the eyes 
three or four times daily. 
29th.-Very much improved. The discharge is less, and 
more watery; atropine solution injected, and a solution of ar- 
gent. nit., gr. v, applied to the conjunctiva. Home treatment 
continued. 
November 3d.-Continues to improve ; slight watery dis- 
charge on pressure over the lachrymal sac. Treatment the 
same. 
8th.-Complains of no trouble, but is anxious that the cure 
be complete. Treatment continued. 
16th.-Patient seems to be entirely relieved. Atropine solu- 
tion injected. Home treatment to be continued, and to return 
in three weeks. 
December 16th.- Says that she suffers no inconvenience 
whatever, and is discharged cured. 
While the cases reported give promise of further suc- 
cess in the treatment of this disease, the number is too 
small to warrant definite conclusions. The fact that the 
ordinary methods were fairly tried, and failed to effect a 
cure, makes it probable that atropine will at least be of 
benefit. The physiological effects of atropine are well known 
to the profession. The dryness of the skin, throat, and 
larynx, produced by its use, has been demonstrated clinic- 
ally. The hectic sweats of phthisis, those of articular rheu- 
matism, and profuse suppuration are more or less relieved 
bv its administration. Local and unilateral sweats have CHRONIC DACRYO-CYSTITIS. 
9 
been controlled by its topical application. Its efficiency as 
a remedy in the treatment of galactorrhcea is well known. 
The beneficial effects observed from its use in sialorrhcea 
and leucorrhcea make it probable that the experience ob- 
served in the cases reported will be borne out. The single 
objection to its use is that it seems impossible to apply it 
without causing dilatation of the pupil. The lew York Medical Journal, 
A WEEKLY REVIEW OF MEDICINE. 
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