A Manual of the Operations of Surgery: For the Use of Senior Students, House Surgeons, and Junior PractitionersBell, Joseph
Science
A Manual of the Operations of Surgery: For the Use of Senior Students, House Surgeons, and Junior Practitioners
Bell, Joseph
Surgery, Operative
The principle of Mr. Bowman's most excellent operation is, that the
punctum, canaliculus, and nasal duct resemble in many respects the
urethral passage, and in cases of stricture require to be treated on the
same principle. If, then, it were possible to pass instruments gradually
increasing in size through the seat of stricture, it would be gradually
dilated. It is, however, in the normal state of parts, impossible to
pass any instrument beyond the size of a human hair past the curve which
the canaliculus makes on its entrance to the duct, hence the proper
dilatation cannot be performed. Again, it is found that the puncta,
specially the lower one, are themselves very often to blame, in cases of
watery eye, sometimes because they are inverted or everted, more often
because, sympathising with the lid, they are turgid, angry, and
inflamed, pouting and closed like the orifice of the urethra in a
gonorrhoea.
Mr. Bowman found that by slitting up the inferior punctum and
canaliculus as far as the caruncula, several advantages were
gained:--(1.) The swollen, angry, displaced punctum no longer impeded
the entrance of the tears; (2.) and chiefly when the canaliculus was
slit up, the curve, or rather angle, which impeded the passage of
probes, was done away with, and the nasal duct could be readily and
thoroughly dilated.
_Operation._--The surgeon stands behind the patient, who is seated, and
leans his head on the surgeon's chest. The affected lid is then drawn
gently downwards on the cheek, so as to evert and thoroughly expose the
lower punctum. Into this the surgeon introduces a fine probe of steel
gilt, the first inch of which is very thin, especially at the point, and
deeply grooved on one side, exactly like a small (and straight) Syme's
stricture director.
Keeping the canal relaxed by relaxing his hold on the lid, the surgeon
now gently wriggles the probe along the canaliculus, gradually
stretching it as the probe advances, so as to avoid catching of the
sides of the canal before the point of the instrument, till he is
satisfied that it has fairly entered the nasal duct. He then stretches
the eyelid, brings the handle of the probe out over the cheek so as to
evert the punctum as much as possible, and then with a fine
sharp-pointed knife enters the groove (Fig. IX.), and fairly slits up
the punctum and the canal to the full extent. The incision should be as
straight as possible, and through the upper wall of the canaliculus. A
dexterous turn of the instrument upwards on the forehead will generally
enable it to be passed at once fairly into the nose through the nasal
duct, the usual rule being observed of passing it downwards and slightly
backwards, the handle of the probe passing just over the supraorbital
notch.
[Illustration: FIG. IX.[84]]
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