3 > > >;») 3£>oj3 j>j»>'> ,>£»> -> ' • ^ > S - ■■■> > > > l> > *> ^ > > > J> T5 :-* > :> o * -.o ^^ 3^^>- > > >> » > ^LA^ u ^^ >■■->-'^*- O > 2g >.3 -r- »^ ^»> T 1~> » rt - ^ ") >' J) > >> )■> -~ >^> >> i> J? > D > > >> >> > > > _3» ^ > ^> J> >^1 >> > > Ed » > j> > > > -> j** > > ~ » 1 ~> > ~>> ,< S3 ~>> •^ > >' !i« •• >^ ) > )' 9 » >> }> ,J>'|T >> • ^> >' ri -13653> y ■ i "> JO > 4. * Surgeon General's Office *8 'Up fc ft 72,....................'.......... I // ' / / ki a TREATMENT LACHRYMAL AFFECTIONS. Ferdinand PROFESSOR ARLT, PROFESSOR OF OPHTUALMOLOGY AT THE UNIVERSITY OF VIENNA. TRANSLATED, WITH PERMISSION OF THE AUTHOR. FROM THE THIRD PART, FOURTEKNTH VOLUME, OF THE GRAEF-. ISCIJEN ARCHIVE FUR OPHTUALMOLOGIE, JOHN F. WE1G11TMAN, M.D. 'l i it 2.9 PHILADELPHIA: LIXDSAY & BLAKISTOK 186 9. WW An 2.51 1SG9 CAXTON PRESS OF SHERMAN & CO. PREFACE. In presenting this pamphlet to the notice of the medical profession, the translator offers no excuse further than the importance of the subject. The author has spent many years in studying this subject, and has only recent- ly given the results of his observations to the public. By following the rules laid down by him, the lachrymal probe may nearly always be introduced with ease and safety, where pre- viously the introduction was attended with much difficulty. The numbers, 5, 6, etc., refer to the different sizes of Bowman's probes. The term " lachrymal passages " has been used in a collective sense, to indicate the lachrymal sac and nasal duct, as the original word, IV PREFACE. " thranenschlauches" has no English synonym, and is used collectively by German ophthal- mologists. Translator. Vienna, March 1st, 1869. TREATMENT OF LACHRYMAL AFFECTIONS. In conversing with various colleagues, at the last Ophthalmological Congress, held in Paris, I was convinced that the views held in relation to treating lachrymal affections were very much at variance, and there still re- mained much to be explained. I hope to make the subject more easily understood by adding plates of three anatomical preparations, as every one is not so situated as easily to ob- tain them, and these show those mechanical relations to which it is necessary to pay atten- tion when the probe is introduced. Fio-. 1 represents the lower portion of a horizontal section of a head, previously frozen hard and cut by means of a fine saw at the height of the internal palpebral ligament, through the eyeball and lachrymal sac. A 6 TREATMENT OF bristle has been passed through the inferior canaliculus, so that it is more dilated than in nature. The section has cut the inferior canal- iculus in its ascent towards the roof of the sac, which has here been removed, about one and a half lines in front of the internal opening, so that the bristle appears free, and pushed further posterior than the point of opening is usually found. The sac presents a nearly tri- angular or half elliptical opening, with an an- teroposterior diameter of about two lines, and lateral diameter of three quarters of a line. The outer wall is straight, while the inner corresponds to the concavity of the bone. It will be observed, in order to enter the sac by means of the inferior canal, that the point of the probe must not only always be held on the anterior inferior wall of the canal- iculus, but the punctum be drawn down and to the outside; in other words, be stretched toward the point of exit of the subcutaneous maxillary nerve, because however slight the arching of the eyeball, especially in myopia or exophthalmia, it so resists or impedes the introduction of the instrument that it is only possible to introduce the probe toward the roof of the sac without injuring the tender LACHRYMAL AFFECTIONS. 7 structure of the canaliculus, by stretching or arranging the canal in the manner just men- tioned. The introduction of the probe is fa- cilitated by the eye rolling naturally upward, but this may be counteracted by the patient closing the lids tightly. The canaliculus must be kept stretched while the probe is being pushed in the proper direction, toward the roof of the sac, until it is evident that the in- strument rests on the lachrymal bone. Only at this time is it proper to elevate the probe from a nearly horizontal to a nearly perpen- dicular position. Should the instrument be elevated sooner, the point may remain fixed in the canal or in the folds at its opening, and cannot be passed further, lest the wall of the canaliculus be perforated, and the danger be imminent of pushing the probe down outside the wall of the sac. When the instrument is passed toward the roof of the sac, if the lach- rymal bone is not suddenly felt, and the skin forms folds when the probe be alternately moved backward and forward, there is reason to believe that the point still remains in the canal, provided the tension of the canaliculus was relaxed previously to the elevation of the instrument, and the probe be not too large for 8 TREATMENT OF the diameter of the canal. Likewise in begin- ning the third movement, passing the probe into the nasal duct, the skin in front of the lachrymal sac must not be pushed in the least inward or posteriorly. It will be further seen from the drawing that only half of the canaliculus is slit, and only half can be changed into a channel which will remain open, as the inner half of the canal is situated so far from the conjunctival sac that the probability of its remaining open is not even to be expected, though the canaliculus be slit along its whole length. This circumstance has an essential influence on the third move- ment of probing, elevation. To effect this, the tension of the canal must first be relieved, as it would prevent the second movement of the instrument. The patient is told to look upward, because a closure of the lids at the moment of elevation might cause the probe, which now rests on the internal wall of the lachrymal sac, to be pushed from this point and forced into a false position. The opposite end of the instrument, or the plate on Bowman's probe, describes an arc of about ninety degrees dur- ing this movement. When the elevation has been completed, the probe does not stand quite LACHRYMAL AFFECTIONS. 9 parallel to the vertical median plane of the face, and while the instrument is being tilted, it passes the eyeball more or less closely, and turns its convexity posteriorly. At the com- pletion of this movement, elevation, the point of the probe rests on the internal wall of the sac, with the convexity on the supraorbital process in front of the notch or somewhat to the outside of it. The instrument does not yet stand in the line of the duct, caused by the resistance which the intact portion of the canal exerts on the probe. This resistance, this tendency of the probe to be pushed outward, must be overcome by the hand holding the instrument in the third movement of introducing the sound into the nasal duct, without allowing the instrument to slip from the inner wall of the lachrymal sac, and also without pressing it on or into the same. The probe is now helob between the thumb, index, and middle fingers; and, when it is wished to pass through the opening of the sac into the maxillary portion of the nasal duct, in other words, in the line of the nat- ural passage, the hand guiding the instrument must endeavor to prevent the declination of the probe inferiorly and posteriori}-, to which 10 TREATMENT OF points the remaining portion of the canal pushes it. Where the position of the lach- rymal sac is relatively deep to the supra-orbi- tal process, the probe must be laid close on the latter, and the eyebrows raised with the other hand, especially where the patient frowns. In general, slightly curved probes are introduced with more ease than those having greater curvatures; but where the supra-orbital process is very prominent, it is necessary to bend the instrument more. Bow- man's probes are curved toward the plate. The position which the plate must now be given depends on the lateral obliquity of the lachrymal sac. This is determined by drop- ping a line from the middle of the tarsal liga- ments to the side of the ala of the nose. Where the nose is narrow below, and the lat- eral obliquity of the sac therefore little or nothing, the plate must look directly forward, and the convexity posterior; but where, on the contrary, and this is the rule, the nose is broader below and the lateral obliquity con- siderable, the plate must look diagonally out- ward (in front and to the outside), the con- vexity diagonally inward (posteriorly and to the inside). With tliis position of the instru- LACHRYMAL AFFECTIONS. 11 ment, the point goes all the more to the out- side the greater the curvature. In other words, it must be endeavored, from the forma- tion of the face, to ascertain as nearly as pos- sible the position of the nasal opening of the duct, and the probe pushed toward this point so soon as it has entered the maxillary portion of the nasal duct. By continuing in this di- rection, the probe is passed carefully forward, and, on meeting with a tough resistance, drawn back, and sometimes slightly rotated, the point being turned more or less to the outside, then again pressed forward without in the least forcing it. I never trouble patients more than five minutes at a time, and never introduce the probe twice in the same day. Where great tenderness exists, I omit the treatment for a day or two. I have sometimes only succeeded in effecting a passage at the expiration of the eighth or tenth day. In some cases Nos. 3 and 4 passed where it was impossible to effect the same with No. 2; and in the last few years I have almost never used No. 1, as it appeared to me that the touch was more un- certain and the danger of a false passage greater. It appears that in many cases a diminution 12 TREATMENT OF in the swelling of the mucous membrane takes place within a few days after the canaliculus has been slit, and the lachrymal sac frequently evacuated by pressure. I have then, some- times, passed contractions in the region of the inferior turbinated bone quite easily. In order to be convinced of the presence of the probe at the bottom of the nasal duct, it is not necessary to enter the nose with a hook-shaped instrument, but it may be de- cided from the relative height of the plate of the probe on the supra-orbital process. To determine this, I lay the end of the probe, at the time the lateral obliquity of the sac is found, on the ala of the nose, so far down that it rests at the same height as the border, and then note the relative position which the plate occupies on the supra-orbital process. If the plate stand at the same height after the introduction of the instrument, then I am sure the point has reached the nasal opening. With long noses the plate takes a deeper position than with short ones. It is not difficult to prove the correctness of these assertions in re- gard to the direction and length of the lach- rymal passages. I have arrived at the conclusion, from this LACHRYMAL AFFECTIONS. 13 method of probing, that not only laying the bone bare is of very rare occurrence, as 1 stated some ten years since, but also that com- 2)Iete impassabiUty from adhesion is the excep- tion. Those cases in which improper methods of probing have been made use of, I do not include in this assertion ; likewise, cases in which syphilis and lupus have caused cicatri- zation of the nasal opening of the duct. I confidently believe that other observers will arrive at the same result, as this has already- appeared with regard to the so-called carious lachrymal fistule, and that adhesions will be found to exist scarcely more frequently than caries. With respect to the course and cavity of the lachrymal passage, I have had two of many dozen preparations which are in my posses- sion, drawn by Dr. Heitzmann to give a clear idea of the relations. In both the posterior inner wall has been removed. The orbital portion, as it was very appropriately named by Prof, von Hasner, is easily recognized as the lachrymal sac. The preparations show distinctly the isthmus at the border between the sac and nasal duct or maxillary portion, which has been denied by many observers, or 14 TREATMENT OF considered as a somewhat inconstant sinus or recess of the sac. At its lower border a ledge of bone has been left, which forms the base for the attachment of the inferior turbinated bone. Below this ledge the nasal portion ap- pears, in Fig. 3, as a triangular gutter; in Fig. 2, as a pocket or valve, about three lines below the ridge for the attachment of the inferior turbinated bone. In Fig. 2 the lachrymal sac presents the general opening, but in Fig. 3 an unusually large one. With every figure a smaller one has been added, in order to bring distinctly to view the relations of space in the nasal portion. Figs. 4 and 2, belonging together, show the opening of the sinuous widened lower portion of the maxillary part into the nasal portion, with a view from above. Figs. 5 and 3, belonging together, show the same opening, but much larger, with a view from below. In neither of the subjects from which these preparations were taken, was the slightest trace of a diseased condition found, except in the conjunctival sac. The points at which I have found cica- tricial tissue in probing, have been the open- ing into the maxillary portion and the region of the inferior turbinated bone. That cica- LACHRYMAL AFFECTIONS. 15 trices existed, I concluded from the probe en- countering or sliding over cartilaginous-like, resisting ledges or cords; but I have, as yet, had no opportunity of examining such con- tractions in the dead body. If we disregard, then, the obstructions which prevent the flow of tears into the lachrymal sac, insufficiency of the palpebral muscle, or changes in the position of the puncta, we must next state that cases of lachrymation occur where tears are conducted into the lachrymal sac, but not into the nose from it, notwithstanding a moderate pressure with the finger suffices to force the contents, which are often very thick, into the nasal passage. The anterior wall of the sac is not, necessarily, therewith much distended, although it gener- ally is the case. The observation is likewise made in many cases of chronic lachrymal blen- norrhoea, that, notwithstanding the possibility of introducing thick probes, 5 and 6, through the cut canal into the nose, yet the conduction of the tears does not take place. The patients are no better than before treatment. This fact is inexplainable to me, if it is accepted that for the tears to flow into the nose it is only neces- sary for them to enter the sac; however, I 16 TREATMENT OF comprehend the process when it is presumed— corresponding to my theory of the conduction of the tears—that the orbicularis muscle and the portions arising from the tarsal ligaments cause a momentary compression of the lach- rymal sac (which is otherwise protected on all sides by bone) with every movement of the lids. In the condition under consideration, the sac is quite frequently, perhaps always, distended, not only anteriorly, but laterally; indeed with displacement of the bone poste- riorly and to the inside, while the muscular fibres covering it, either absolutely or rela- tively insufficient, more or less lengthened, perhaps also displaced or changed in their structure. Be this as it may, still, in treating lachrymal blennorrhoea, great distension of the sac must always be considered a matter of im- portance. It may be attempted to control the distension by frequently evacuating the con- tents, or by a strong methodical compression; it may, perhaps, also be attempted to produce a diminution of the cavity and an alteration in the amount of secretion by cutting out a portion of the anterior wall, or cauterization of the mucous membrane after the sac has been slit. At all events, it must not be for- LACHRYMAL AFFECTIONS. 17 gotten that in spite of the restoration of the necessary permeability of the lachrymal pas- sages, the tears may still continue to flow over the cheek, particularly in cases where such a distension is of long duration, and where it may be concluded a large cavity exists, if not from the curvature of the anterior wall, from the amount of fluid repeatedly evacuated by pressure with the finger. I pass now to those means which have here- tofore been employed in order to remove the obstructions which prevent the conduction of the tears through the nasal duct. The perforation of a new way is, perhaps, obsolete. The method of Dupuytren, to pro- cure an outlet for the tears by means of a metallic tube, has been generally and correctly abandoned. Recently two old methods have again been brought into notice : the perforation of the strictured part in the line of the natural duct, and the perforation of the lachrymal bone by means of a trocar or trephine. I have not been able to determine upon either the for- mer or latter of these methods, because the prospect of keeping such a channel open is even a priori very small. I have preferred in such cases rather the immediate destruction of the 18 TREATMENT OF sac, as I attach less importance to the slight amount of lachrymation which sometimes re- mains afterward, together with the operative invasion, than to these methods of forming and keeping open a new way, which are accompa- nied moreover with painful, troublesome, tedi- ous, ancl^ finally very uncertain procedures. The dilatation of the natural passage I have practised for nearly two years, with slight modifications, exactly according to Bowman's method, only the idea from which I proceeded, or, rather, to which I was led in the course of my observations, is other than that which appears to have been in the mind of the great reformer of the treatment of lachrymal affec- tions. I hold the opinion, that for the restora- tion of the normal function, so great a distension as is produced by Bowman s probes Nos. 5 and, 6 is neither necessary nor 'without danger. It is not necessary, for in the course of the last three years I have seldom employed No. 5, and never No. 6, and yet I have obtained many lasting results. Indeed, since that time I have had in scarcely a case to complain of adhesions of the canaliculi or nasal duct as a consequence of using the probe. It is the large probes, according to my mind, which may LACHRYMAL AFFECTIONS. 19 cause wounds and after-adhesions, even though the instrument be correctly introduced. We will next consider the procedure in probing through the inferior canaliculi. A portion about three lines in length cannot be slit, or, at least, converted into a channel which will remain open. The diameter of this portion is smaller than the diameter of No. 5. If we admit even, that the size of the probe may be gradually increased from smaller to larger instruments, indeed until No. 6 can be introduced without danger of stripping off the epithelium of the mucous membrane, still we are not always sure but that we may burst or lacerate the canaliculus. The line of the in- ferior canal forms an acute angle with the line of the lachrymal passages, so that in elevating the instrument, the end of the intact portion of the canal must be all the more displaced and dragged upon the longer it is and the closer it surrounds the instrument. The outer as well as the inner parts only permit of a slight displacement, and especially can lacera- tions of the inner ends not always be avoided, notwithstanding the probe be slowly elevated. When No. 6 has been easily introduced, and a long pause takes place in the treatment, it is 20 TREATMENT OF suddenly found that not a single instrument, or only the smallest, can be made to enter the lachrymal sac. Besides this, I will mention that sometimes where even No. 1 did not enter, I have succeeded in effecting a passage with a conical probe, by keeping exactly in the proper direction, and could then gradually employ larger instruments. Whether complete adhe- sion has taken place at a later period, I do not know, because unfortunately so soon as the patients were not troubled by the tears flowing over the cheek, they remained away. Where the attempt just mentioned did not succeed, the superior canaliculus was slit, and the probe introduced through it. I do not know whether mischief may be caused where larger probes than No. 4 can be easily introduced into the nasal portion of the duct, in which, as is known in the greater number of cases, the opening is small, but fear that such may be the case. When the nose of the patient bleeds after the removal of the instrument, I consider it as an inducement to cicatricial contractions or adhesions, and al- ways permit several days to elapse before re- suming the treatment. Should the nose bleed after the first introduction, it is a fault in either LACHRYMAL AFFECTIONS. 21 the entrance or withdrawal of the probe. I commence these latter cases, having the head fixed, just as carefully and nearly as slowly as the former. If bleeding occurs at a later period when large probes are used, it is very probable that the epithelium has been stripped off, or a rupture been produced, perhaps only because the instrument was too large. When large probes are used, if the instrument produces the impression, on being removed, as if it were held fast by the duct, I omit the treatment for several days, and take a smaller sound the next time. Sometimes, instead of Nos. 3 and 4, I employ slightly curved probes of vulcan- ized rubber, which pass in many cases where silver instruments of equal size could not be introduced without danger. Probing through the superior canaliculus I have only instituted where the inferior was impassable from adhesions. It appears to me that slitting the canal, as well as the correct introduction of the probe, is less easily accom- plished, especially where the supra-orbital pro- cess is very prominent. It is not always easy to stretch the canaliculus in the proper direction in order to cut it correctly, still less to keep it tense and introduce the instrument below and 22 TREATMENT OF inwards on the anterior inferior wall of the canal. The elevation is not only easier, but attended with much less danger, as the intact portion of the canal forms a very obtuse angle with the line of the lachrymal passages. By using probes which are relatively too large, the danger is imminent even here of stripping off the epithelium or bursting the canal; and should the instrument be elevated before it is certain the point has passed the internal open- ing, a perforation of the wall may be injurious to the inferior canaliculus. This method is distinguished from Anel's by the outer portion of the canal being slit, which permits the intro- duction of larger probes with far less danger of dragging on the canaliculus, or catching the point in the internal wall of the sac. Large probes are more easily directed, admit of a better touch, and do not bend so easily as the thin instruments which Anel must employ. I have never made use of Weber's system* because, at the time of its publication, I was engaged in examining the method of Bowman. During the course of this examination it be- came gradually evident to me that it depended * Graefe, Archiv. f. Ophthal. VIII-I. LACHRYMAL AFFECTIONS. 23 not so much on the smoothing out of the walls as on the restoration and maintenance of the duct, which is large enough, in order to pre- sent no insurmountable obstacle to the passage of the tears forced down by the action of the orbicularis muscle. Can it be supposed that Anel has never produced a cure with his thin probes ? A reliable old practitioner, Dr. Schmalz, of Perna, informed me he had ob- tained the best results by simply introducing a seton after the method of Ad. Schmidt. Too much stress cannot be laid on the anal- ogy which exists between the nasal duct and the urethra. In the latter, we are so often able to correct and control our conjectures by autopsies regarding the position and character of the stricture, that we acquire a certain amount of accurate information for the con- tinuance and indications of treatment. In the former, however, the results of dissection are generally, or nearly entirely, wanting, and the relations of such results to previous observa- tions on the course of the affections, employ- ment of caustics and probes, will long remain a prime desideratum. The urethra is sur- rounded by soft, somewhat elastic tissue ; the nasal duct, on the contrary, inclosed by bone. 24 TREATMENT OF What happens to the circulation of the mucous membrane when it is compressed between the probe or bougie and bone ? What condition follows generally after this contusion ? May it not occur by the introduction or removal of probes made of laminaria digitata, that the union between the mucous membrane and bone is rather loosened than the cohesion broken which exists between the probe and mucous membrane ? The affections of the urethra are mostly in consequence of local irritations, but the lachrymal passages are scarcely accessible to anything but the tears. It is a well-known fact, even in cases of blen- norrhoea of the conjunctiva, acute or chronic, occurring either in new-born children or adults, that an extension of the inflammation to the lachrymal sac is comparatively seldom ob- served. Almost all lachrymal affections are referable to a chronic catarrhal inflammation of the mucous covering of the sac, and this is connected, certainly in the majority of cases, with extensive disease of the mucous mem- brane of the nose, of the throat, with scrof- ula, unsuitable mode of living, and unfavor- able relations of life. Have we then to seek the cruise always with chronic relapsing ca- LACHRYMAL AFFECTIONS. 25 tarrhal inflammation, or at first in insufficient local treatment ? May not inflammation and contractions take place anew in a totally dis- tended sac ? I consider the use of the probe as one, but not the only remedy for chronic catarrhal affections of the mucous membrane of the lachrymal passages. I have seldom em- ployed injections of medicated fluids, particu- larly moderately strong solutions of sulphate of zinc or nitrate of silver, but will use them at some future time with the syringe-probe recommended by Wecker,* yet I do not expect to obtain much from them. That I cannot persuade myself to incise the point of stricture, with subsequent dilatation, the reader has probably already presumed from previous remarks. It is almost impossi- ble to introduce the necessary instruments, and control them, without other parts being wounded at the same time than those which are intended. Stilling's system,"}* which War- 1 aniontj praised, demands, according to the re- sults, at least further trial. In cases of lachrymal fistule I never intro- * Maladies des Yeux, Paris, 1868, t. i, p. 890. t Cassel, 1808. X Ami. d'Ocul. t. Ix. 4 2e«: cc c^C r5c. c c c cc or r CC cc ^C X CC C roc <^e. (^ Ccc< t