Fabricius ab Aquapendente treats of these operations among those of the ancients, qui ne sont plus en usage (Œ. C. ii, iv); even Tagliacozzi speaks of them as being cruel and dangerous. However, a surgical operation, similar in principle, called the “long issue of the scalp,” is still practised in certain hospitals of Great Britain. See the ‘Transactions of the Provincial Association,’ (vol. xi.)
SECT. VIII.—ON SUTURE OF THE UPPER EYELID, AND OTHER MODES OF OPERATING FOR TRICHIASIS.
Distichiasis is a preternatural growth of hairs, superadded to the natural order of hairs of the eyelids; and derives its origin from a defluxion, when there happens to be a flow upon the part of a humour which is not pungent or acrid; for that which is more acrid, saltish, or otherwise pungent, when it lodges in these parts, consumes the natural series of hairs. For this state then we sometimes have recourse to the suture of the upper eyelid, and sometimes also for phalangosis when the eyelid inclines inward, the phalanx or row of the hairs being inverted; and sometimes for relaxation of the eyelid, when the natural row of hairs hurts the ball of the eye. Having placed the patient on a seat, either before us or on the left hand, we turn the upper eyelid outwards, and, if it has long hairs, we take hold of them between the index-finger and thumb of the left hand; but if they are very short we push a needle having a thread, through the middle of the tarsus from within outwards; then stretching the eyelid with the left hand by means of his thread, with the point of a scalpel held in the right hand, having folded out the eyelid and everted it, behind the thread we make the under-incision within the hairs which irritate the eye, extending from the larger canthus to the smaller, along the tarsus. After this subsection, having extracted the thread, and putting a small compress under the thumb of the left hand, we stretch the eyebrow upwards. Then arranging other small compresses on the canthi at the extremities, we direct the assistant who stands behind to stretch the eyelid by means of them. Then by means of the scalpel used for sutures we make the first incision, called the veruted (shaped like a verutum or short dart) a little above the hairs, which are in their natural state, extending from canthus to canthus, and penetrating only the depth of the skin; and afterwards we perform the incision called the lunated, beginning at the same place as the former, and carrying it upwards to such a height as to comprehend the whole redundant skin, and ending in like manner as it did. Thus the whole skin comprehended within the incisions will have the shape of a myrtle leaf, of which portion, having perforated the angle on the right hand with a hook (tenaculum), we dissect away the whole skin: then washing away the clots with a sponge, we unite the lips of the incision by three or four sutures, beginning at the middle, and passing the needle itself through the under-section. The thread should be made of wool; and having cut away the superfluity of the thread, not close to the sutures, but so as to leave a superfluity of three fingers’ breadth, we stretch this remainder along the forehead and fasten it by means of any of the agglutinative plasters. But the hairs of the eyelid are to be freed from the sutures with the point of a needle. Such is the common and safe mode of performing this surgical operation. Some avoid the dissection of the skin, and therefore after the under-incision, having stretched the redundant skin by means of the forceps used in operations on the eyelids, they cut it off with a scalpel, and apply sutures as described above. But if the irritation from the hairs is produced only by a part of the eyelid, it will be proper to confine the operation to that part. Then soaking the compresses in oxycrate, and laying them on the part, we secure them with bandages, continuing to moisten the dressings with diluted oxycrate until the third day; after which we remove them, and cutting away the superfluous parts of the threads, we anoint the eyelids either with saffron, glaucium, or some of the anti-inflammatory collyria, such as that formed of saffron and roses. But if the sutures inflame, we apply some one of the softening plasters, and soothe the eye by an injection of eggs mixed with milk. When the ligatures slacken we cut and extract them. I know a certain person who having made the dissection of the skin of the eyelid, as mentioned above, did not have recourse to sutures, but effected the cure with a healing ointment. For when the wound cicatrised, the eyelid being somewhat contracted, forced the hairs to incline outwards. In like manner, another person not practising the dissection of the eyelid, nor the two external incisions, but only making the under-incision, stretched with his fingers or by a hook the fold of the eyelid, two reeds or plates of the same length as the eyelid, and as broad as for venesection, he twisted a ligature round it at both its extremities; and thus the whole skin behind not being nourished, and on that account being deprived of life, fell off within ten, or at most fifteen days along with the reeds or plates, so as to leave scarcely any scar.
Commentary. On suture of the upper eyelid, and other methods of operating for distichiasis, see Hippocrates (de Victu acut. 66); Aëtius (vii, 71, 72); Celsus (vii, 7); Albucasis (Chir. ii, 11); Rhases (Divis. i, 30; ad Mansor. ix, 26; Contin. ii, 3); Avicenna (iii, iii, 3, 32); Avenzoar (i, 8, 6); Serapion (ii, 7); Mesue (ii, 18); Jesu Hali (ii, 10); Canamusali (vi, 26); Haly Abbas (Pract. ix, 19); Vegetius (Mulom. ii, 15.)
The description of the operation given by Aëtius from Leonidas being nearly the same as that described by our author, we shall confine ourselves to an abridged account of it, and merely make a few remarks to illustrate the description of Paulus. In order to facilitate the operation, he recommends the operator to have two assistants instead of one, as directed by our author. He also recommends him, in the first place, to mark with ink the portion of skin which requires to be cut out. He then directs him to make the under-incision, by which he seems to have meant an incision within the ciliary hairs along the tarsus, and extending from canthus to canthus. He recommends it to be made pretty deep, and even in certain cases suggests the propriety of making two under-incisions, one as above described within the ciliary hairs, in order to relax the tarsus; and the other upon the preternatural hairs. He next directs first a transverse incision to be made along the eyelid above the ciliary hairs, and then a lunated one beginning and ending like the other, after which the skin, thus separated, is to be dissected out. He recommends the edges to be united by means of five sutures, one in the middle and two at each extremity of the incisions. The other steps of the operation are exactly the same as those described by our author, and cannot be misunderstood. Hippocrates describes an operation for trichiasis, which Heister thought the same as that recommended by Aëtius, but the description is so obscure that we must confess our inability to explain it.
Celsus describes three methods of cure for trichiasis. 1. By burning the roots of the hairs. 2. The anabrochismus, which will be explained in [the 13th section]. 3. The anarrhaphè or suture, as described by Aëtius and our author. As the steps of the operation described by him are almost exactly the same as those of Aëtius, we need not dwell upon the explanation of them. Lest, however, there should be any misapprehension about the under-incision, we shall give his directions about it in his own language: “præter hoc, in superiore palpebrâ sub pilis ipsis incidenda linea est ut ab inferiore parte diducti pili sursum spectant; idque si levis inclinatio est, solum satis est.” Instead of five sutures, as directed by Aëtius, he recommends only three.
Albucasis states that there are four modes of curing trichiasis. 1. By the actual cautery. 2. By the potential cautery. 3. By incision and the suture, which operation he describes at great length. He directs us in the first place to evert the eyelid, either by taking hold of the ciliary hairs, or by passing a needle, armed with a hair, through the tarsus, and raising the eyelid with it. He then, like the others, directs us to make the under-incision within the ciliary hairs, from the greater canthus to the smaller, to cut out the redundant skin of the eyelid, and unite the surfaces with sutures. In short, his operation is exactly the same as our author’s. He mentions, however, another method of making the incision by elevating the redundant fold of the skin with hooks or a trident, and cutting it off with a pair of scissors. 4. The fourth method consists of making the under-incision, as in the last operation, and then twisting the redundant skin firmly about reeds or small pieces of wood until it mortifies: after which the wound is to be cured upon general principles.
Serapion’s account of the operation is defective, and need not be particularly noticed. Canamasuli directs us to cut out the hairs and burn the part with a cautery of gold.
Avicenna merely mentions, in very general terms, that the cure may be accomplished by agglutinative applications, by the cautery, or by excision.
Mesue briefly describes four modes of cure: 1. By means of agglutinants. 2. By passing a needle, armed with a hair, through the tarsus, as will be explained in [the 13th section]. 3. By plucking out the hairs and cauterising the part. 4. By applying medicines calculated to prevent the renewal of the hairs after they have been plucked out.