Chronic suppurative dacryocystitis and its radical treatment : read before the British Medical Association, Toronto, Canada, Thursday, August 23rd, 1906 / by Fred T. Tooke.

  • Tooke, Fred T.
Date:
1906
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Licence: In copyright

Credit: Chronic suppurative dacryocystitis and its radical treatment : read before the British Medical Association, Toronto, Canada, Thursday, August 23rd, 1906 / by Fred T. Tooke. Source: Wellcome Collection.

Provider: This material has been provided by UCL Library Services. The original may be consulted at UCL (University College London)

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    8- abrasion of the cornea by a wisp of straw or the end of a twig. Although many have acknowledged that the complete removal of the lachrymal sac in diseased conditions is imperatively indicated, the operation has been unpopular on account of the haemorrhage which takes place during the operation. Further, the field of operation being frequently hidden by blood, fragments of the secreting membrane of the sac are left remaining in the wound cavity, epitheliation occurs, and fistulae result. Axenfeld's9 work on the subject and the technique employed and recommended by him have rendered the operation decidedly easier, and have removed many of the difficulties which formerly prevented ophthalmic surgeons from excising the sac, appreciating though they did that a total extirpation was indicated as the best prophylactic measure to be adopted against future corneal trouble. The method employed by Axenfeld is as follows : The field of operation is rendered as aseptic as possible by the use of soap and water and then by an application of a solution of bichloride of mercury. Should one prefer to operate under local anaesthesia, a few drops of a 4 per cent, solution of cocaine in 1 in 1,000 adrenalin is injected into the tissues about the sac fifteen minutes before the patient is placed upon the table. The injection is repeated immediately before the operation. I, however, prefer to operate using general anaesthesia, because, after seeing a great many diseased sacs removed under a local anaesthetic, I am not satisfied that the method is a pain- less one. A veil of sterilized gauze, with an opening large enough to expose the patient's eye, side of the nose, and upper part of the cheek, is spread over the face. The initial incision is made from the inner canthus directly above the internal angular ligament, 2 or 3 mm. in front of the crista lachrimalis. The incision should be directed downwards and outwards in a crescentic direction for about Zi cm. The incision must be quite deep, cutting through the periosteum. A shorter incision than the one I have specified should not be attempted. There are occasions where a very prominent crista lachrimalis will almost occlude a view of the sac in the underlying fossa, and unless an aperture is made sufficiently large to expose this fossa and its contents there is always the danger of leaving a part of the secreting membrane of the sac in situ. Subsequent fistula formation is the inevitable result. The consideration of a slightly smaller incision from a cosmetic standpoint is not to be considered; the wound heals by primary intention, and after a short time little or no evidence can be found of the previous line of incision. One of the chief difficulties in this operation is the suppression of a violent and obstinate haemorrhage. The employment of Pean's forceps is impossible on account of the smallness of the oavity and because the vessels are situated so deeply that they cannot be seized. After the primary incision is made digital pressure is exerted over the wound for one or two minutes, and then Mailer s