SYRINGING IN LACHRYMAL DISEASE. BY W. H. BATES, M. £., ASSISTANT SURGEON, NEW YORK EYE INFIRMARY. Reprinted from the New York Polyclinic, Afrit if, i8q6. DANBURY, CONN. DANBURY MEDICAL PRINTING COMPANY. 1896. SYRINGING IN LACHRYMAL DISEASE. BY W. H. BATES, M. D., ASSISTANT SURGEON, NEW YORK EYE INFIRMARY. Reprinted from the New York Polyclinic, April 15, 1896. DANBURY, CONN. DANBURY MEDICAL PRINTING COMPANY. 1896. 5 YRING ING IN LA CHR YMAL DISEASE * Anel published at Turin in 1 New Method ■of Curing Lachrymal Fistulce," in which he ad- vocated syringing. This method is painless and not objectionable to the patient, and in chronic cases requiring tedious treatment is a great ad- vantage over operation and probing. There are but few cases which cannot be cured by syring- ing. A definite prognosis can be given after a few days, which is not the case with the other operation. Syringing, when it is indicated, does good at once. In an acute inflammation of the lachry- mal sac and surrounding tissues, the swelling, redness and pain subside in a few days. In chronic cases the benefit is usually felt after the first treatment. If there be no improvement by daily treatment for a week or less, an operation for opening the sac and nasal duct is necessary. The cases cured by syringing have been acute catarrhal and acute purulent inflammation of the sac, phlegmonous inflammation of the sac, blennorrhoea of the lachrymal passages, and lachrymal fistulse. Syringing has failed to cure some cases of epiphora in which there was good drainage, ♦Read before the New York County Medical Association March 16, 1896. 4 syphilitic cases, organic stricture of the duct and some inflammatory or catarrhal cases. The reason syringinghas cured so many cases of lachrymal disease is (i) that the infectious material is thoroughly washed away; (2) the ap- plication of remedies cures the inflammation of the mucous membrane and (3) with the subsi- dence of the swelling of the mucous membrane, the nasal duct opens and the drainage is rees- tablished. It is rare to find a stricture of the duct not due to a swollen condition of its mu- cous membrane,or in which a fine probe cannot be passed. (Stellwag). The syringe employed for washing out the sac and nasal duct after operation was an ordi- nary eye dropper. Sometimes a large piston syringe was used when it was desirable to inject large quantities of fluid. There were cases which required a syringe with a fine tip. Cases which were syringed without operation required an instrument which was light and easily handled. The sac was washed out by inserting the tip of the syringe usually in the lower punctum, and sometimes in the upper punctum. The syringe used for injecting fluid through the punctum is an ordinary glass eye dropper,, three inches long with a fine tip bent at an angle of nearly 90° and about % of an inch long. The tip enters the smallest punctum and 5 widens so abruptly that after being introduced a short distance it fills up the largest punctum thus preventing a return flow of fluid. The opening is so small that to fill the syringe with water, requires several seconds, and to fill the syringe with oil may require a number of min- utes. The tip does not break easily-one can hammer the point against the palm of the hand with great force without breaking the glass. It is impossible to break the tip by ordi- nary manipulations in the eye. The syringe is light and easily handled. The injection can be made gradually and with light pressure or the fluid can be forced in strongly; water can be thrown more than ten feet by sudden strong pressure on the rubber bulb. The glass syringe is easily cleaned and one can see when it is soiled. With the glass syringe one can tell when the water is entering the duct by observing the column of liquid. The syringe has been in use more than five years and is very satisfactory. A syringe made with a glass barrel and me- tallic tip was unsatisfactory. Objections to the metallic syringe: (i). The metal point being opaque one cannot see when the injection is taking place. (2). Astringent solu- tions tarnish the metal. (3). Piston syringes in time get out of order and leak. (4). On account 6 of their greater weight they are more difficult to manipulate. (5). It is difficult to cleanse them. Objections to the glass syringe: (1). Care must be taken not to break the glass. (2). The rubber is spoiled by contact with oil. (3). The point is easily clogged. Care of the syringe is important. A syringe which has the proper shaped tip is valuable and difficult to obtain. The point breaks easily when the syringe is placed among other instruments. A box should be prepared with a bed of cotton and soft cloth for the reception of the syringe when not in use. The tip should be covered with a rubber cap-a bulb from an eye dropper may be used for this purpose. The syringe should be cleansed immediately after using. Cotton fin ds its way into the opening. When the opening be- comes blocked, the obstruction can be removed as follows: Takeoff the bulb and fill the syringe with water through the large end. Replace the bulb. Cautiously heat the point in a gas or alcohol flame. The glass expands with the heat the opening enlarges,pressure on the bulb forces the water out of the opening and the obstruction is carried out by the current of water. Nitrate of silver produces an obstruction which can be removed with a saturated solution of iodide of potassium. 7 To make the injection the operator sits in front of the patient. Light from an Argand burner is reflected by a forehead mirror on the inner side of the eye, or daylight may be used. The operator may stand behind the patient. The patient is directed to look upwards and out- wards. A piece of cotton about one-fourth of an inch in diameter is placed over the semilunar fold and held in place with the forefinger of the left hand with slight pressure against the upper punctum; this procedure prevents the fluid from entering the eye from the punctum of the upper lid. The thumb of the left hand everts the lower lid sufficiently to expose the punctum- The syringe, partly filled with the fluid to be in- jected, is lightly held by the bulb with the thumb and the first two fingers of the right hand, the tip is inserted into the punctum and the syringe turned until the tip is at a right angle to the margin of the lid and parallel to the conjunc- tival surface of the lower lid. Pressure is made on the bulb and the level of the fluid in the syringe is seen to descend as the injection is be- ing made. When the injection is finished, and as the syringe is removed, press the cotton, against the lower punctum to absorb any over- flow of liquid. When the fluid is bland, like salt and water, it may not be necessary to close. 8 the upper punctum. The injection can be made with the eye closed. Among the difficulties noted is the fact that the punctum maybe so small that the tip of the syringe does not enter readily. Dilatation with a pin remedies this. Some puncta are hard to find and when discovered the opening should be first dilated with the point of a pin before introducing the tip of the syringe. In some •cases there is a tremulous movement of the lids which makes it difficult to introduce and keep in place the point of the syringe. Much patience is required in such cases. Co- caine does not always relieve. An appeal to the patient's self-control is sometimes success- ful. Sometimes the injection is difficult after the tip is introduced into the punctum, and manipulation of the syringe up, down, and in various directions will be required to free the point from the obstructing conjunctival fold There are cases in which it is easier to make the injection through the upper punctum- the lower punctum may be small or occluded, and in some cases there is swelling and tender- ness of the lower lid which makes it difficult to insert the tip of the syringe. The amount of fluid injected should be suffi- cient to cleanse the sac-the syringing should be continued until the water comes away clear. The amount used in each case may be as much as a pint. The more thoroughly the sac is cleansed, the better. 9 Frequency of the injections: Daily use of the syringe may be necessary. Cases treated three times weekly, or less often, may not im- prove at all. The time necessary to cure acute cases may be less than a week or a month. Chronic cases are tedious and usually require several months. Fluids Used. In my experience water has been used more than any other fluid. The benefit has resulted in two ways: i. Cleansing. 2. By reducing congestion. In some cases it was found desirable to dis- solve salt in the water ( 3 j to the pint) to make it less irritating. Oils. Some cases seemed to do better when olive oil was syringed down the nasal duct. Experiments were made with various oils for cleansing, reducing congestion and for dilatation of strictures. All the oils employed caused irritation, and for the treatment of lachrymal disease, had no advantage over water. Astringents. In exceptional cases, astringents were useful. Among those employed were nitrate of silver, sulphate of copper, alum, zinc, •cadmium, tin, gold salts, etc., etc. The strength of the solution varied from gr. v- | j in most cases, up to a saturated solution in a few cases. Nitrate of silver, gr. 480- 3 j, caused no appar- ent trouble when injected into the healthy and diseased sac of a number of cases. As a rule the weaker solutions were more satisfactory than the stronger. 10 Antiseptic Solutions. In purulent and other cases it could not be demonstrated that anti- septic solutions were any better than ordinary water. Many cases were treated for a time with one and then with the other, and most of them improved faster from the use of water. Antiseptic solutions irritate and possibly tend to close the nasal duct, and thus interfere with drainage. Bichloride of mercury, 1-5000, boric acid 3%, and carbolic acid 2%, was used. The diagnosis of stricture of the nasal duct in cases of epiphora and lachrymal inflammation can be made promptly and painlessly by the use of the syringe. If water can be injected through the punctum and sac down the nasal duct and out the nose, no stricture is present. In some cases it is necessary to close the other punctum to prevent a return flow of the fluid. Only after a number of unsuccessful trials should a diagnosis of stricture be made. The following cases reported represent but a small portion of the total number treated. A CASE OF ACUTE PHLEGMONOUS INFLAMMATION OF THE SAC RELIEVED BY SYRINGING. Mrs. N., aged 30, was treated at the New York Eye Infirmary, service of Dr. H. D. Noyes. She had redness and swelling in the neighbor- hood of the right lachrymal sac. The eye was nearly closed by the swelling of the lids. A muco-purulent fluid came from both puncta by pressure over the sac. The sac was syringed with bichloride, 1-5000. Some of the fluid found its way into the nose, showing that the 11 nasal duct was open. The bichloride solution was ordered as an eye wash, and hot poultices to relieve pain. Two days later the patient re- turned cured. The cure in this case was prob- ably due to the removal of the infecting pus in the sac by the syringing, and also to the fact that it reestablished the drainage. A CASE OF DACRYOCYSTITIS CURED BY SYRINGING. Mrs. T., aged 65, was seen February 27th, 1895. Herright lachrymal sac had beenswollen and tender for a year. Pressure over the sac caused a yellow fluid to exude from both puncta. The sac was syringed three times weekly with salt and water, and nitrate of silver, gr. v-f j. The fluid did not enter the nose until after two weeks treatment. Cure resulted in less than a month. No relapse after six months. The treatment by syringing compared favor- ably with the operative treatment and probing, which was employed to relieve the same disease in the other eye. The left eye had been oper- ated upon 33 years previously for dacryocysti- tis of five years duration. Cured in four months by operation and the use of probes. A CASE OF ACUTE PHLEGMQNOUS INFLAMMATION OF THE SAC RELIEVED BY SYRINGING. RELAPSE. Mrs. M., aged 40, had suffered with epiphora for three months. September 22nd, 1895, swell- ing and redness developed over the right sac. The sac was syringed with bichloride solution, 1-5000, three times weekly. Some of the fluid entered the nose, showing that there was not an impermeable stricture of the nasal duct. The 12 patient also used hot flaxseed poultices. In less than two weeks she was well. January 31st, 1896, the patient returned for treatment with a relapse of her former trouble. The lower lid was so tender and swollen that it was impossible to syringe the sac through the lower punctum. The sac was washed out with bichloride solution, with the syringe introduced into the upper punctum. Ordered poultices. The patient was not seen again until ten days later. The swelling had subsided. The skin in the region of the sac was still red and tender. Water was syringed through the lower punc- tum into the nose, when the upper punctum was closed with a pledget of cotton. Similar cases treated more frequently im- proved more promptly. Operation is not indi- cated in acute lachrymal inflammation, in which the nasal duct is open. Exceptionally, opera- tion may be required to prevent perforation of the skin, when daily syringing fails to relieve. A CASE OF IMPASSABLE STRICTURE OF THE NASAL DUCT WITH A LACHRYMAL FISTULA. SYMP- TOMS RELIEVED BY SYRINGING. A woman aged 35, was treated in 1887. She had had a purulent discharge from a lachrymal fistula for some time. She also suffered from epiphora. The left nasal duct had been opened with the knife a number of times, but had soon closed after each operation-the probes being unable to maintain the opening. At the time the patient came under observation, a No. 1 Bowman probe when passed through the nasal 13 duct, caused great pain and some haemorrhage. The neighborhood of the sac was red and some- what swollen. The fistulous opening on the side of the nose was covered by a large crust or scab. Syringing the sac, the water spurted out of the fistulous opening, and did not enter the nose. It could not be demonstrated even after the patient was cured that water passed down the nasal duct. The sac was syringed with hot water, until the water came away clear, and then a solution of nitrate of silver, gr. v- 3 j, was injected. This treatment was continued daily for six weeks, with gradual but steady improvement of all the symptoms. The inflam- matory swelling disappeared, the fistula closed, and the epiphora ceased. She seemed cured. Six months later there was no return of the symptoms. A number of similar cases were treated. Daily treatment for at least a month seemed necessary. Very little benefit resulted from treatment three times a week. NASAL DUCT OPEN. PURULENT DISCHARGE FROM THE SAC. EPIPHORA. A woman, aged 34, was treated in 1888. She had been operated upon for chronic dacryocys- titis, and later, probes were used. The alum wash used to bathe the eye, found its way into the throat and could be tasted. A No. 9 probe was easily passed through the nasal duct into the nose. Syringing the sac the fluid flowed out of the nose in a stream. Although the drain- age seemed good, the patient had tenderness 14 and swelling of the sac with a purulent dis- charge at times. Syringing with cleansing so- lutions and astringents relieved the symptoms after operation and probing had failed. Remarks. The discharge in this class of cases is due to an inflammation of the mucous membrane of the sac from infection. There is inflammatory swelling. The condition obviously requires something more than drainage and treatment by probes. There is also a class of cases readily cured by operation and the use of probes. A large probe used at the operation may be passed down the nasal duct several days later without difficulty, showing that the stricture has little tendency to return. With care the probe can be introduced without haemorrhage. For this class of cases syringing is superfluous. There are cases of stricture of the nasal duct which close again very soon after operation, although probes are used frequently. A blood clot in contact with an abraded surface be- comes organized. This new tissue forms ob- structing bands across the duct. It is in this way that the operation fails to cure the stric- ture. Unless the blood clots can be removed, the operation is useless. The probes, when they cause bleeding, fail to keep the passage open for the same reason. Such cases have been cured in the following way: i. The usual operation was done, and a large sized probe inserted in the duct, and allowed to remain until the haemorrhage had ceased. 15 2. The sac and duct were syringed with warm water, until the water came from the nose clear. 3. Probes were used daily for several weeks, and then less often. After the duct was probed it was syringed freely to lessen the irritation caused by the probes, and to remove the blood. To succeed, it was necessary to use the water often and in large quantity. The patients cured were under treatment several months. To have the water force its way beneath the skinof the eyelids is a disagreeable accident. No harm followed in four recent cases. The swelling subsided in all the cases observed, in a few days. A CASE OF STRICTURE OF THE NASAL DUCT. RE- LAPSES AFTER TWO OPERATIONS. CURED BY A THIRD OPERATION AND SYRINGING. Jennie D., aged 12, was treated early in Jan- uary, 1895, for stricture of both nasal ducts. She had been operated upon in 1893, and the stricture returned. The sac was syringed with bichloride, 1-5000, three times weekly for sev- eral months without benefit. March 31st, a second operation was done on both ducts, and large sized probes were used. At first Theo- bald's probe No. 16 was passed down the ducts; later, as the stricture returned, smaller sizes were employed. In ten days, as the stricture had returned, a third operation was done. The last two operations were by Dr. Noyes. Immediately after the last operation the case was turned over tome with directions to syringe the ducts freely and often, to prevent the re- turn of the stricture. There was considerable 16 blood washed from the ducts by syringing. After one month's treatment the stricture showed no tendency to return. It had contracted to the size of probe No. 6. Probes were used for several weeks, and were then gradually stopped. Feb. io, 1896, almost a year later, the stricture had not returned. Probe No. 6 was easily passed down both ducts. The epiphora was less. A num- ber of similar cases were treated, (more than fifteen during the last three months.) A woman, aged 47, who had relapsed after two operations, was operated upon a third time, and the duct syringed three times weekly. The stricture re- turned. A fourth operation was done, and the duct probed and syringed daily, until the bleed- ing ceased, which required nearly two weeks. The duct was then syringed three times weekly for a month, and then less often. She was cured in three months. » As a general rule daily syringing was neces- sary after operation and probing to cure ob- stinate cases. Conclusions. 1. Syringing is a valuable method of treatment of lachrymal disease, and should be tried in all cases. 2. Acute cases are often promptly cured by syringing. 3. Chronic cases are usually benefited, and may be cured. 4. 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