SOME OASES 
OP 
OBSTRUCTIVE DISEASE OF THE LACHRYMAL PASSAGES 
AND THE 
ASSOCIATED INTRA-NASAL LESIONS. 
BY 
G. E. I>F. SCHWEINITZ, M.D., 
PROFESSOR OF OPHTHALMOLOGY IN THE PHILADELPHIA POLYCLINIC; LECTURER ON MEDICAL 
OPHTHALMOSCOPY, UNIVERSITY OF PENNSYLVANIA; SUKUF.ON TO THE 
PHILADELPHIA HOSPITAL, ETC. 
REPRINTED KROM THE TRANSACTIONS 
OF THE PHILADELPHIA COUNTY MEDICAL SOCIETY, 
MARCH 23, 1892. SOME CASES OF OBSTRUCTIVE DISEASE OF THE 
LACHRYMAL PASSAGES AND THE ASSOCIATED 
INTRA-NASAL LESIONS. 
By G. E. de SCHWEINITZ, M.D., 
PROFESSOR OF OPHTHALMOLOGY IN THE PHILADELPHIA POLYCLINIC; LECTURER ON MEDICAL 
OPHTHALMOSCOPY, UNIVERSITY OF PENNSYLVANIA ; SURGEON TO THE PHILADELPHIA 
HOSPITAL, ETC. 
[Read March 23, 1892.] 
Tiie intimate relationship between diseases of the lachrymal appa- 
ratus—that is, of the drainage system of the eye—and various types of 
inflammatory changes in the nasal mucous membrane is an old storv. 
Indeed, the close association of ocular and naso-pharyngeal disease is 
not limited to these conditions. The great majority of phlyctenular 
ophthalmias depend upon some type of rhinitis, and are often the 
direct outcome of adenoid growths in the pharynx. Many obscure 
symptoms which we are wont to describe under the general term 
asthenopia, have been shown to depend upon intra-nasal disease, and 
a variety of orbital, ocular, and post-ocular pains are frequently 
“ referred painsthat is, their origin is from some lesion within the 
nasal cavity, the frontal sinus, ethmoid cells, or antrum of Highmore. 
In fact, as Harrison Allen has remarked, a good deal of the success 
of treatment depends upon a proper attention “ to the commonality 
of the various parts of the cephalic mucous membrane.” 
The following cases are reported, not because they illustrate new 
points, but because they emphasize some old ones, and still more 
because they emphasize that the cure of obstructive lachrymal disease 
is materially facilitated not merely by the ordinary measures adopted 
for rendering the passages patent, in association with what may be 
called routine intra-nasal treatment (for I take it no one attempts to 
treat lachrymal disease without due attention to the nasal mucous 
membrane), but that more radical measures are frequently of value 
when applied to the nasal chambers and the vault of the pharynx, 
which in the vast majority of cases are the regions primarily affected. 2 
DE SCHWEINITZ, 
Case I. Purulent dacryocystitis; traces of old rhinitis and abnormal shape of 
the lower turbinated bone.—D. D., a boy aged seven years, reported for treat- 
ment November 3, 1890. Three years ago pus began to exude from the right 
punctum lachrymale, and in spite of treatment this condition has continued 
ever since. The boy was healthy in other respects; he had never suf- 
fered from measles or scarlet fever; was free from the evidences of inher- 
ited syphilis, and had sustained no injury. His voice was slightly nasal in 
tone. 
The lower canaliculus was slit, and a firm stricture was found at the be- 
ginning of the nasal duct. The probe was not forced; neither was the 
stricture incised. 
The patient was referred to Dr. Alexander MacCoy for nasal examination, 
who reported as follows: “ The right nostril shows an abnormal shape of the 
lower turbinated bone, also some evidence of a severe rhinitis during the 
past. I believe that the position and form of the lower turbinated body 
have had much to do with the disease of the duct on account of the obstruc- 
tion to its entrance at its lower portion into the nasal chamber. The boy 
also has a pharyngeal tonsil which obstructs the posterior nares somewhat.” 
Dr. MacCoy undertook the treatment of the nasal condition, and after a few 
days the stricture was incised, the probe passed, and the usual treatment 
instituted. After the intra-nasal obstruction was removed the epiphora 
ceased, and has not reappeared. 
I have referred to this case in a paper on the use of pyoktanin in 
dacryocystitis (University Medical Magazine, vol. iii. p. 181), and 
may repeat that my colleague, Dr. Gould, as well as myself, has had 
favorable effects from this drug in the treatment of unhealthy lach- 
rymal secretions. 
The case is now utilized, however, to illustrate what seems to me a 
very important point to which Dr. MacCoy calls attention in his 
report, namely, that although the stricture of the duct, which in this 
case existed high up, was penetrated, and although the fluids and the 
probe passed readily, the epiphora continued because of the malposi- 
tion of the turbinated bone. Indeed, this obstruction sometimes exists 
only in the form of a small flap of mucous membrane, which closes the 
entrance of the duct into the inferior meatus very much as a valve 
would do. This effectually prevents the drainage of the eye, and 
unless it is removed good results will not follow. In this particular 
instance it was very easy to see the obstruction by first passing a 
probe and then exposing the entrance of the duct into the meatus by 
means of a nasal speculum—a slight precaution which will often lead 
to the discovery of the cause of a persistent overflow of tears in spite 
of apparent permeability of the passages. 
Case II. Catarrhal dacryocystitis; bands of adhesion from the inferior tur- 
binated body to the septum.—Ella H., aged twenty-eight years, reported for OBSTRUCTIVE DISEASE OF LACHRYMAL PASSAGES. 
3 
treatment at the Philadelphia Polyclinic, October 24, 1891, on account of an 
inflammation of the right eye, which had existed for several days. There 
was a small abscess at the inner margin of the lower lid, with a fistulous com- 
munication into the lachrymal sac. A free muco-purulent secretion dis- 
tended the sac in the form of an ordinary mucocele. The canaliculus had 
been slit at some previous time, but a probe did not pass readily. 
She was referred to the throat department, and examined by Drs. Arthur 
W. Watson and Walter Freeman, who reported as follows: “ Atrophy of both 
inferior turbinates; unable to obtain a posterior view ; former ulceration of 
the posterior wall of the pharynx ; bands of adhesion from the inferior tur- 
binates to the septum; also one from the middle turbinate to the septum on 
the right side.” 
Even in the absence of definite history the pharyngeal condition seemed 
to indicate syphilis. The patient was ordered an astringent lotion, given 
potassium iodide and bichloride of mercury, and referred to the throat depart- 
ment for treatment. In January of this year an operation was made upon 
the lower turbinated bone, and the condition has improved without the 
passage of probes, the secretion and the epiphora having materially lessened.1 
This case, it seems, illustrates the ordinary intra-nasal lesions which 
were evidently at the bottom of the lachrymal trouble, and is further 
interesting because these lesions gave confirmatory evidence of the 
syphilitic condition, so much so that relief was facilitated by the proper 
constitutional remedies. 
Case III. Lachrymal abscess ; spur on the septum opposite the middle turbin- 
ated bone; chronic pharyngitis.—Sarah S., aged forty-five years, reported for 
treatment at the Philadelphia Polyclinic, November 24, 1891. In April, 
1891, epiphora began in the left eye, for which she seems to have undergone 
no treatment. It continued until about one week ago, when suppuration of 
the lachrymal sac took place. When she presented herself there was a very 
marked lachrymal abscess. The pus was evacuated by an external incision, 
the sac freely irrigated with an antiseptic fluid, and the patient referred to 
Drs. Watson and Freeman for an examination. 
They reported as follows: “ On the left side there is a spur on the septum 
opposite the middle turbinated bone; also hypertrophy of the tissues. The 
turbinates are small. There is chronic pharyngitis, a thick phlegm covering 
the tissues.” 
Unfortunately this patient has failed to report with any regularity, 
and the ultimate result cannot be given. This example illustrates the 
course of so many of these cases, namely, a chronic pharyngitis and 
hypertrophy and inflammation of the intra-nasal mucous membrane; 
involvement of the lachrymo-nasal duct; epiphora, owing to an ob- 
1 Recently there has been a relapse in this case. Attention to treatment has not been 
regular. 4 
PE SCHWEINITZ, 
struction primarily from swelling of the mucous membrane, and later 
from the formation of a positive stricture. Under the influence of 
the pressure and of the stricture, the fluids of the conjunctival 
sac are not drained, but distending the lachrymal sac, become 
infective, an abscess forms, and the condition which has been de- 
scribed results. 
Case IV. Epiphora ; atrophic catarrh.—Jane C., aged sixty years, reported 
for treatment at the Philadelphia Polyclinic, November 14, 1891, complain- 
ing of pain in her eyes, constant epiphora, and inability to read on this 
account. There was considerable hypermetropia and some astigmatism, and, 
as epiphora is frequently caused by the strain of uncorrected ametropia, 
proper glasses were ordered, but the overflow of tears continued. Both 
canaliculi were then slit. There was narrowing of the ducts, but no stricture, 
and probe and fluids passed readily. The epiphora improved, but did not 
disappear. 
She was referred to the throat department, and the following report was 
received: “ There is an atrophic condition on both sides, and a spur on the 
septum on the right side near the opening of the lachrymal duct, but it does 
not interfere. The closure is probably due to contraction from atrophic 
changes.” 
This is a good example of a very common condition, most frequent 
in elderly people, where there is neither disease of the sac, stricture 
of the duct, nor pressure from a spur or hypertrophy of the turbin- 
ated bodies, but where the obstruction depends upon contraction from 
atrophic changes. 
Case V. Phlegmonous dacryocystitis ; deflection of the septum ; spur on the left 
side pressing on the inferior turbinated bone.—Matthew L., aged twenty-seven 
years, presented himself for treatment on account of an extensive lachrymal 
abscess with a small opening and widespread infiltration of the tissues, pro- 
ducing a large swelling involving the lower lid and cheek. The abscess was 
incised, the pus cavity freely washed out, and an antiseptic dressing applied. 
In a day or two the swelling had subsided, and nothing remained but a 
slight brawniness of the tissues and a fistulous opening at the point of 
incision. The canaliculus was slit, but all efforts to introduce the probe 
proved futile. The patient had been much exposed to weather; had a his- 
tory of an old injury, but denied syphilis. The obstruction to the tear pas- 
sages had existed since the early fall. 
He was referred to the throat department, and the following report was 
received: “ The septum is irregularly deviated in front; there is a spur on the 
left side pressing on the inferior turbinated body, which also contains an 
ulcer in its anterior portion.” 
He was warned that ‘‘ catching cold,” which would increase the nasal 
obstruction, would certainly bring about a relapse of the abscess. He went OBSTRUCTIVE DISEASE OF LACHRYMAL PASSAGES. 
5 
to work, however, and returned a few days afterward with all of the lesions 
previously described in a very much more aggravated state. The same 
treatment was instituted, and he was again referred to the throat department, 
and on the 23d of February the hypertrophy on the left side was removed. 
On the same day a probe was passed, and since this time its passage has been 
repeated. Epiphora still continues, but is decreasing day by day. 
This example illustrates the mechanism of relapse in many of the 
tear-passage cases, in this instance producing a very serious phleg- 
monous inflammation. Under treatment and rest sufficient drainage 
takes place to produce amelioration of the symptoms; then swelling 
from congestion, owing to exposure, is added to the organic obstruc- 
tion already present, producing complete closure with an exacerbation 
such as has been detailed. 
Case VI. Stricture of the nasal duct; moderate hypertrophy of the inferior 
turbinated on the left side and a spur on the right side.—Bridget R., aged fifty 
years, applied for treatment to the throat department of the Philadelphia 
Polyclinic, and the following lesions were found: A moderate amount of 
hypertrophy of the left inferior turbinated near the nas al duct, and a spur 
on the septum of the right side close to but not obstructing the opening of 
the duct. With these lesions there were epiphora, most marked in O. D., and 
slight lachrymal conjunctivitis. She had not been able for a number of 
months to use her eyes with any comfort. She was referred by Drs. Watson 
and Freeman to the eye department. The canaliculi were slit, and a stric- 
ture was found at the mouth of each sac. A No. 2 Bowman’s probe was 
passed without difficulty. 
It is evident that although there were lesions in the nasal passages* 
they were not obstructing the duct, but under the influence of the 
chronic nasal inflammation a stricture had formed in the lachrymal 
canal. 
Case VII. Epiphora from swelling of the mucous membrane of the lachrymo- 
nasal duct; atrophic rhinitis.—A. K., ail unmarried woman, aged twenty-six 
years, was referred to me by Dr. Ralph W. Seiss, on account of epiphora of 
the right eye, which had persisted for some time in spite of the nasal treat- 
ment. There was no swelling of the lachrymal sac; no catarrhal or puru- 
lent secretion, but simply au overflow of tears. The general health was 
good, the eyes not far from emmetropic, and there was neither asthenopia 
nor headache. 
Dr. Seiss has kindly furnished the following report of the nasal lesions: 
“ Atrophic rhinitis presenting the ordinary appearances of tissue-destruction, 
combined with some odor and much secondary laryngo-bronchitis.” 
The canaliculus was slit, and a No. 3 Bowman’s probe was passed without 
meeting a stricture, but with a resistance to its passage which is character- 6 
DE SCHWEINITZ, 
istic of obstruction from swelling of the mucous membrane. After the pas- 
sage of this probe the duct was irrigated on several successive days with a 
solution of boric acid and common salt—without, however, passing the 
canula into the duct. The fluid trickled readily through the nose. The 
epiphora stopped after a few treatments, and has never returned, although 
many months have gone by since she originally reported. 
This patient represents a common class of cases of epiphora asso- 
ciated with chronic inflammation of the naso-pharynx. A somewhat 
similar inflammation occurs in the nasal duct, but does not produce a 
true stricture; the occlusion is from swelling, not from cicatricial 
changes. In many cases it is sufficient to do what was performed 
in this case; in others even milder measures suffice. Above all 
things, this is an example of a class of cases the successful treatment 
of which I have learned especially from Dr. Risley, by obeying the 
principle which he was wont to instil not to be too ready to pass 
probes and canulas, lest their introduction scrape away some of the 
mucous membrane, and really do more harm than good. It is un- 
necessary to do more than medicate the swollen mucous membrane 
with any solution that is suitable; I like boric acid and common 
salt very much. 
Many more cases might be quoted, but these seven representatives 
of various classes are sufficient to illustrate the points which I desire 
to make: 
1. A large class of cases exists characterized chiefly by epiphora 
without catarrhal or purulent secretion, in which the obstruction in 
the lachrymo-nasal duct depends upon swelling of its mucous mem- 
brane, and not upon true stricture. The primary origin of these 
cases in the great majority of instances is a chronic or subacute post- 
nasal catarrh. The evident indication is the treatment of the latter 
condition and the medication of the swollen mucous membrane of the 
lachrymo-nasal duct, so that it may regain as nearly as possible its 
natural condition, which it will do without much instrumental inter- 
ference—an interference that may of itself, if unskilfully performed? 
be the cause of a cicatrizing band that never originally existed. Case 
VII. of the series illustrates this class. 
2. The life history, if I may so express myself, of many cases of 
obstructive disease of the lachrymo-nasal duct and the formation of a 
lachrymal abscess is illustrated by Cases III. and YI. First, a chronic 
pharyngitis occurs ; later, hypertrophy and inflammation of the intra- 
nasal mucous membrane, followed by swelling of the lining tissue of OBSTRUCTIVE DISEASE OF LACHRYMAL PASSAGES. 
7 
the lachrymal duct. Gradually cicatricial changes arise, and a true 
stricture is formed. The drainage of the conjunctival cul-de-sac 
ceases; the micrococci natural to the part, and those which readily 
find access to this region, permeate the contents of the lachrymal sac 
because this can no longer be emptied; the pathogenic microorgan- 
isms exercise their true function, and suppuration occurs. 
8. A number of cases develop, chiefly in old people, in which there 
is epiphora, again without the presence of pus or muco-pus, depend- 
ing upon obstruction in the lachrymal duct from atrophic changes, the 
whole being part of a similar atrophic process in the intra-nasal 
passages, and generally described under the term atrophic catarrh. 
The obstruction in these instances is not from swelling, not from 
stricture, but from contraction. Case IV. of the series is an example. 
4. A very common cause of an exacerbation of lachrymal disease 
is due to the pressure of a hypertrophic turbinated body, or similar 
intra-nasal obstruction, which under treatment has gradually sub- 
sided, but which, owing to exposure, swells up again, and exercises 
its obstructing influence. At once there is occlusion of the lachrymal 
passages and recrudescence of the symptoms. The very serious nature 
of such cases is illustrated in Case V. of the series. 
o. In every case of local disease the physician should be mindful 
of constitutional causes; the value of confirmatory evidence by 
pharyngeal and intra-nasal examination is illustrated in Case II., an 
example of constitutional syphilis. Local treatment may be very 
necessary; local treatment without general medication is ineffectual. 
6. Finally, I come to the class of cases in which there exists an 
obstruction at the intra-nasal end of the duct (it may be trivial), 
permeable by the fluids used in a syringe, but an impassable barrier 
to the outflow of tears. Even the slightest obstructions, under these 
circumstances, may defeat the most classical treatment of lachrymal 
disease. The ready detection of such a lesion is illustrated in Case 
I. of the series. 
It has not been my intention this evening to refer to what are the 
best means of treating lachrymal disease, except in so far as these are 
implied by the descriptions of the lesions which existed in the exam- 
ples I have reported. Whether we believe that small or large probes 
should be passed ; whether we class ourselves with those who believe 
that the probes should not be used at all; whether we are the advo- 
cates of this or that antiseptic and astringent fluid; whether we 
think that strictures should be incised or should not be incised, or 8 
OBSTRUCTIVE DISEASES OF LACHRYMAL PASSAGES. 
whether we believe in the permanent wearing of styles or canulas, it 
is evident that the rational treatment of certain types of obstruc- 
tive lachrymo-nasal disease must also include not alone the ordinary 
intra-nasal treatment with sprays and powders, but a systematic and 
thorough examination of the naso-pharynx, and, if necessary, the best 
operative interference known to intra-nasal surgery.