Part 33

_Of Inflammation of the Lachrymal Sac._—When the lachrymal sac becomes inflamed, it enlarges considerably; the swelling is small, hard, circumscribed, deeply seated, and extremely painful, more especially on pressure. At first the integuments are of their natural appearance, the increased action being confined to the sac, but they are soon involved, and often to a considerable extent; they become red and swollen, and as the surrounding parts are affected, the swelling increases. In some cases, the eyelids, the caruncle, and the conjunctival covering of the eye, participate in the inflammatory action. The inflammation is in most instances caused, or at least preceded, by some obstruction in the nasal duct, in consequence of which, the tears are interrupted in their natural course downwards, and either accumulate in, and distend the sac, or flow over on the cheek, the puncta lachrymalia remaining open. After increased vascular action has been produced, the lachrymal secretion is increased to a greater or less degree, and much inconvenience is caused to the patient by the profuse discharge following an unnatural course. When inflammation is intense, lymph is effused into the passages, producing obstruction sometimes complete. The mucous lining of the nasal duct becomes swollen, from the vascular excitement, either throughout its whole extent, or at one point only; and in either case the flow of the tears must be interrupted, either partially or wholly, according to the degree of swelling. The vitiated secretion of the part may also contribute towards narrowing the canal, by lodging and concreting there. But a more complete and permanent obstruction is formed by effusion of lymph, under or on the mucous lining, as happens in other canals of similar construction: and in this case also, the stricture may be partial or complete, according to the quantity of effused matter, and the extent of surface affected.

As the inflammation abates, mucous fluid is copiously effused from the surface of the sac, and the swelling increases, though the pain is less. The collected fluid may be partially evacuated through the puncta, either spontaneously, or in consequence of the patient instinctively pressing with his finger on the swollen part; or the puncta may be obstructed by the same causes as the nasal duct, and then the discharge of the fluid is prevented in both directions; it consequently accumulates still more, and causes greater bulging. Fluctuation is perceptible, and the collection protrudes outwards and forwards, being least resisted in these directions. It is seldom that the puncta are obstructed, and consequently the swelling does not attain any great size, the sac being relieved by some of its contents always flowing upwards, after a certain degree of distension. As the inflammation farther subsides, the mucous secretion diminishes, and the accumulation and swelling are less: in fact, the patient may at this period prevent a tumour from forming in the corner of his eye, by from time to time pressing gently on the sac, and forcing the lachrymal secretion upwards, as it begins to accumulate. This state of matters may continue for a long period, without causing much inconvenience, and getting neither better nor worse; the patient is merely obliged to apply his finger and handkerchief more frequently to his eye than would otherwise be required. In almost all cases, the obstruction of the nasal duct is complete, or nearly so, and consequently the fluid cannot pass downwards into the nose, though it may occasionally appear to do so, on account of the discharge from the Schneiderian membrane being increased at the same time with that of the lachrymal sac. The ductus ad narem, though wide in the skeleton, is of very limited dimensions in the living body, and is in consequence readily made impermeable to mucous fluid, by even slight thickening of its lining membrane.

It has been already observed that the above-mentioned condition of the parts may continue for a considerable period; but in other cases purulent matter soon forms within the distended sac; or, at least, the contents of that organ are so altered in colour and consistence as to resemble intimately purulent fluid. The secretion may or may not be pus, probably it is not in some cases; but as the decision of this point is practically unimportant, the description of it as purulent can scarcely be objected to. In most cases, when the puncta either are or become clear, no suppuration, or deterioration of mucus into fluid like pus, occurs; merely chronic distension of the sac continues, the patient being able to avert incited action, by occasionally squeezing out the contents, and thereby removing tension. There is merely an Epiphora; or, as it is otherwise called, Blenorrhœa, or Stillicidium lachrymarum. The last term is by some applied to increased lachrymal secretion, without affection of the sac, the tears being secreted more quickly than the puncta can carry them away, and consequently running over on the cheeks, excoriating the surface, and producing an irritable condition of the eye. The simple epiphora may be of long duration, yet the parts are extremely liable to assume inordinate action, in consequence of slight injury, or exposure to cold; thus suppuration will ensue.

When purulent matter forms, fluctuation becomes more distinct, the pain increases, and there is slight headache and fever. The integuments inflame more and more, and, if the case is neglected, ultimately give way by sloughing. A small ragged opening, often indirect, is formed, and the contents of the sac are not thereby all discharged; the thinner fluid only escaping, whilst the more viscid remains and clogs the aperture. The swelling is not much diminished; the margins of the aperture thicken, become indurated, and contract, the purulent contents of the sac are gradually discharged, and the tears afterwards flow through the opening. The parts are now in that condition to which the term _Fistula lachrymalis_ is with propriety applied. The swelling of the canal may gradually subside, the tears resume their wonted course, and the opening may then contract, and the parts cicatrise; but frequently the fistula remains open for a long period, gradually diminishing in diameter, and only a small passage, almost imperceptible, ultimately remaining, through which a few drops of lachrymal fluid are occasionally discharged. Sometimes the fistula closes entirely without the obstruction of the nasal duct having been removed, and the lachrymal sac remains in consequence distended; then the tears or mucus, either clear or turbid, can generally be squeezed through the puncta.

It frequently happens that the meibomian glands are the seat of morbid action, along with the lachrymal passages; their secretion is changed, becoming in some cases thick and caseous, in others puriform. By some, affection of the meibomian glands has been considered as the cause of inflammation and abscess of the lachrymal sac. This opinion, however, cannot be agreed to, for the diseases are not always coexistent; and besides, the affection of the surface of the lachrymal sac and ductus ad narem is as likely to be the consequence of morbid action, extending upwards from the nostrils, as of morbid secretion from the eyelids blocking up and irritating the puncta and the lachrymal passages. Disease of the meibomian glands in the under eyelid often exists along with disease of the lachrymal passages, but the latter is generally the primary affection; the conjunctival covering of the eyelid is at the same time inflamed, swollen, and often granulated.

In some cases of abscess in the lachrymal sac, before the integuments give way, the subjacent bone becomes diseased in consequence of the pressure of the confined matter; portions are affected by necrosis, and after their separation considerable deformity is produced. The exfoliation is often very tedious, and is attended with discharge of fetid thin fluid from the nostril, and from the ill-conditioned lachrymal fistula.

Fistula lachrymalis is often merely one of the symptoms of disease in the bones of the nose, with obstruction of the nasal duct,—as in patients who have suffered from mercury.

_Treatment._—In the treatment of epiphora or blenorrhœa—that is, chronic collection of a mucous fluid in the lachrymal sac, with weeping of the eye—a primary object of attention is the state of the general health. The habit of the patient will commonly be found weak, and, if not decidedly strumous, at least inclining towards that diathesis. In such cases the digestive organs must, if possible, be brought into a vigorous state by tonics and nourishing regimen. The local treatment chiefly consists in applying stimulants to the internal surfaces of the palpebræ and lachrymal sac. For this purpose, solutions of stimulating and astringent substances, termed collyria, and various ointments, are employed. At first they ought to be used of rather a mild nature, and their stimulating power must be afterwards increased gradually. The applications are placed between the eyelids, and, becoming mixed with the natural secretion, pervade the diseased surfaces; and, being taken up by the puncta lachrymalia, are afterwards conveyed into the sac. It was formerly the custom to inject the fluids into the sac; but this is unnecessary so long as the puncta and canaliculi remain pervious, and the permeability of these can be readily ascertained by means of a small probe. Permanent pressure on the sac can be productive of no good effect, and is extremely liable to do harm. The repeated application of very small blisters over the sac has been found useful.

Introducing minute gold probes through the puncta has been much recommended, but in the generality of cases can be of little service. The probes are too limber for removing mechanical obstruction, or for affecting in any way the contracted or strictured duct. But passing of the probe may tend to remove the irritability of the passage, as happens in the urethra, and thence some relief may follow. Much dexterity is required in using either the probe or syringe. The puncta are often very small, and it is in general necessary to dilate them by means of the point of a common pin, before any instrument can be passed through them into the sac. The point of the probe being introduced into the punctum, either superior or inferior, must first be carried towards the nose for about 2-10ths of an inch, the instrument being lightly held betwixt the fore and middle fingers of the right hand. It is then directed downwards and backwards. Care must be taken to prevent entanglement in folds of the membrane. Should obstruction be felt, the instrument is withdrawn a little, and then carefully and gently carried in the right direction. The small syringe is managed with one hand, whilst, with the forefinger of the other, the punctum not occupied by the pipe is compressed.

Neither can much or any benefit be expected to follow attempts to force obstruction in the lachrymal passages, by the weight of a column of mercury. A plan of dilating and rectifying the nasal duct by styles introduced through the puncta has been proposed, but scarcely deserves to be mentioned as a means of cure.

When suppuration is threatened, with increase of the swelling, inability of the patient to empty the sac by pressure, redness of the integuments, &c., an early opening should be made into the tumour, in order to prevent further and more serious mischief. A small opening into the sac cannot be productive of so much injury as forcible dilatation of the canaliculi, followed by and causing ulceration. The point of a straight narrow bistoury is to be entered into the sac, and carried on into the nasal duct, the knife being pushed downwards, backwards, and a little inwards, in the direction of that passage. The point to be punctured can always be readily ascertained by feeling for the firm ligament which attaches the orbicularis palpebrarum to the nasal process of the superior maxillary bone, as the upper orifice of the ductus ad narem is situated immediately below this tendon; by introducing the knife below the ligament, and within the sharp edge of the orbit, and then carrying it forward in the direction already mentioned, the surgeon cannot fail to enter the nasal duct. The knife should be followed by a probe, and ought not to be entirely withdrawn till the probe is fairly lodged in the duct, otherwise the surgeon will experience much difficulty in the after proceedings. If the knife be not pushed into the duct, a blunt instrument can scarcely be introduced afterwards. Some force is required, but is not hurtful, provided it be made in the proper direction, so as to remove the obstruction in the duct without injuring the bones and other parts in the neighbourhood. After the operation, some drops of blood should escape from the corresponding nostril, showing that it has fairly entered this passage; or the patient being made to expire forcibly, the nostrils being at the same time compressed with the fingers, air, blood, and mucus are forced upwards through the opening made.

Many and various modes have been pursued with a view of securing a pervious state of the nasal duct. Instruments of different kinds have been introduced through the puncta, through the opening in the sac, and through the termination of the duct under the spongy bone, and have been retained for a longer or shorter period, according to the fancy, or theory, or plan of the surgeon. The first of the methods of introduction is abandoned, as already stated. By the ancients the passages in fault were got rid of altogether, being either cauterised or destroyed by escharotics.

The passing of probes into the duct from its lower aperture is useful in removing trifling obstructions caused by concretion of deteriorated mucus, or slight thickening of the lining membrane, and in chronic dilatation of the sac with probable contraction of the duct. But, at the same time, it is an operation requiring much dexterity, and which ought not to be attempted till after much practice on the dead body. The first introduction of the instrument is always the most difficult, from obstruction by a valvular projection of the membrane at the lower orifice, the use of which in the healthy state of the parts must be apparent. Destruction of it renders after-introduction of instruments much more easy.

But the preferable practice is making an opening into the sac, and then introducing instruments from the upper orifice of the duct; more especially in cases where the swelling and pain are considerable. The instruments employed for dilatation of the passage are tubes and styles. The tubes are made either of silver or gold, of equal calibre throughout, and of the same length as the passage. For some time after their introduction they cause much irritation; this gradually diminishes, and the wound heals over them. But, according to my experience, the effects are not satisfactory. The irritation which they at first occasion generally subsides, but abscess again occurs, with much swelling, and it becomes necessary to remove the foreign body. Again, the tube sometimes becomes obstructed by thickening and concretion of the discharge, and then, when it is necessary to remove it, the process is found to be by no means an easy one; a free incision is required; a screw must be fastened into the tube, or, when that cannot be accomplished, the foreign body must be laid firmly hold of with strong forceps; altogether the extraction is very painful, and often extremely tedious. In short, the practice of introducing tubes does not appear to be founded on sound surgical principles.

After extensive and impartial trial of both the tubes and style, I decidedly prefer the use of the latter. On the point of the bistoury being fairly lodged in the lachrymal duct, a probe is passed along it; the knife is then withdrawn, and the passage is gently dilated by the probe. The probe again is followed by the style, which should be made of silver, of the same thickness throughout, of the same length as the duct, and with a flattened head placed obliquely to the body of the style. The size of the style should be at first small, and gradually increased. The irritation caused by the first introduction is in many cases very severe, but the parts soon accommodate themselves to the presence of the foreign body; the pain and swelling diminish, as also the discharge. If a large style be pushed forcibly in at first, violent inflammatory action will ensue, and much mischief may be produced. After irritation has gone off, the tears pass readily down in the nose by the sides of the style, according to the laws of capillary attraction, little or no fluid escapes from the external opening, the wound contracts around the instrument, and, its head being covered with black wax, no deformity is produced. The instrument should be removed from time to time, cleaned, and replaced. When, by the continued use of styles gradually increased in size, the duct has been dilated to its full extent, and appears restored to a sound condition, the instrument may be withdrawn, and afterwards introduced only occasionally. The external aperture, which has become fistulous from the long presence of the foreign body, then begins to contract, and, on its completely closing, the tears continue to follow their usual course, and the disease is overcome. But sometimes a small fistulous aperture remains, and there appears to be a disposition towards the renewal of the affection; in such a case, a small style, not exceeding a thin gold probe in diameter, should be introduced every evening, and retained for some hours: this causes little or no inconvenience to the patient, and insures the permeability of the canal.

Such is the method by which a permanent cure may often be obtained, and which, in my opinion, is preferable to the use of tubes. If these are to be employed, they should, as already mentioned, be nearly of equal calibre throughout; the external opening must not be allowed to close for a considerable time after the introduction of the instrument; and the tube must be kept pervious for some time by a style introduced through it. But by these means, which are essential for the success of the practice, the main advantage arising from the use of a tube, viz., little irritation being produced at first, and the parts being allowed to close soon over it, are completely done away with.

The practice of perforating the os unguis never can be required; it is cruel, unnecessary, and unsurgical.

Sometimes the lachrymal passages are entirely destroyed. In such cases, it has been found that no great inconvenience arises from their obliteration, as the lachrymal gland ceases, in a great measure, to secrete fluid, and the conjunctival secretion, after having performed its office, evaporates from the surface. In truth, the lachrymal gland always enjoys long periods of repose, and is only called into active exercise of its functions occasionally, as the eye in its ordinary condition is sufficiently lubricated by secretion from its conjunctival covering.

The treatment of fistula lachrymalis, as has been well remarked by an eminent author, must be varied and regulated according to circumstances;—by the degree of obstruction in the duct, by the state of the coverings of the sac, of the sac itself, and of the subjacent bone, and by the general state and habit of the patient.

_Encanthis_ is a tumour situated in the corner of the eye. The caruncula lachrymalis appears to be the original seat of the disease, at least it is involved at an early period. The growth is at first small, and appears to be simple enlargement of the caruncle: it is of a reddish colour, and its surface is studded with numerous granulations. It often attains a very considerable size; and, on account of its propinquity to the lachrymal passages, is accompanied with watering of the eye, the puncta being either involved in the growth, or compressed or displaced by it. Sometimes the whole inner corner of the eye, from the margin of the cornea to the inner junction of the eyelids, is occupied by the granulated swelling; and in such cases it is not uncommon for the tumour to extend itself outwards, in the form of a lunated appendage, on the under surface of each lid; thereby the motions and functions of the ball are much impeded, and a prominent deformity is occasioned. In most instances the growth seems to be a simple enlargement of structure, and is of a benign nature; but sometimes it is firm, hard, of rather a livid hue, with a smooth slimy surface, and is decidedly malignant,—enlarging, and gradually involving the surrounding parts.

Cancerous ulceration, attacking and destroying the eyelids, and the parts around the ball of the eye, often commences in the situation of the caruncle, or in a wart on the edge of the lid. Cancer, though a rare and uncommon disease of the eyeball, frequently seizes on the appendages of the eye, extending rapidly in all directions, and often completely detaching the ball by ulceration. Warty tumours also occur on the conjunctiva of the lids, or of the ball, and are inconvenient as a source of much irritation to the neighbouring parts, even though of a benign nature in themselves.

Extirpation, by means of a small pointed knife, or curved scissors, is the only means to be relied on for the cure of such warty tumours, and of encanthis. The growth must be fixed and pulled outwards with a small hook, and carefully dissected away; the eyelids, and, if necessary, the ball of the eye, being kept fixed with the fingers, or by means of a speculum: the fingers are generally sufficient, and more convenient than any instrument. If from the appearance of the parts, and from induration surrounding the tumour, malignant action has evidently taken place or is dreaded, then the incisions must be made wide of the base of the swelling. For malignant, open, and extensive ulcerations, nothing can be done farther than to allay the pain, and soothe the constitutional disturbance. On the whole, encanthis is a rare disease; however, I have seen, and operated on, several instances of it.