SECT. XII.—ON ECTROPION, OR EVERSION OF THE LOWER EYELID.
Ectropion of the under lid is occasioned by the same causes as lagophthalmos of the upper, only that it does not occur naturally, but arises sometimes from relaxation produced by medicines possessed of this property, which have been applied for inflammation; and sometimes the eversion is occasioned by the suture or burning having been improperly performed. Taking, therefore, a needle, armed with a double thread, we perforate the fleshy mass, pushing it through from the left canthus to the right, and then by means of the thread fastened to both of its extremities, we stretch the skin with the needle, and cut down upon it with a scalpel, removing the needle at the same time. Then, if the eyelid resume its proper shape and is turned inwards, this operation will be sufficient. But if the eversion continue after the removal of the flesh, we apply the back of the specillum to the divided eyelid; and on the inside of the eyelid, having made two incisions, beginning at the two angles of the incision formerly made, and terminating in an acute point, and meeting together like the Greek Λ, we remove this substance, so that its acute point may be below at the eye, and the broad above at what is called the tarsus. Afterwards we unite the separated parts with a needle containing a woollen thread, being satisfied with two sutures. But if the ectropion be occasioned by the operation of the suture or burning we make a simple incision along the first cicatrix below the hairs of the tarsi, and having separated its lips, we fill up the wound with pledgets, using the same methods as for lagophthalmos (except fomentations) until the parts which have been stitched unite.
Commentary. See Aëtius (vii, 74); Celsus (vii, 7); Albucasis (Chirurg. ii, 14); Haly Abbas (Pract. ix, 20.)
Aëtius gives a full account of the treatment of ectropion from Demosthenes and Antyllus. When the disease is occasioned by fungous flesh on the inner membrane of the eyelid, he recommends us to burn it down with escharotics, such as misy, chalcitis, &c. (See the [Third Book].) He describes the surgical operation in the following terms:—when the fleshy excrescences are very large they are to be dissected out with a scalpel, and the part touched with burnt copper or the like. When the eversion is greater, he directs us to perform an operation upon the inner part of the eyelid, making two incisions, which unite below like the Greek letter Λ, and afterwards dissecting out this lambdoid or triangular piece, and along with it the flesh below, which, he remarks, is not cartilaginous like the upper eyelid, but taking care to preserve the skin untouched. The edges of the incisions are then to be united by one suture at the eyelids. When the ectropion is occasioned by an external cicatrix, we are to operate upon the inner surface of the eyelid in the manner just now described, only avoiding to make deep incisions, and uniting the edges of the incisions as before directed. Then stretching the cicatrix with a hook, and pushing a needle armed with a double thread, under the thickened flesh from the smaller canthus to the larger, we are to cut down upon the needle and divide the thickened flesh. A pledget of lint is then to be put into the external incision, and a compress, moistened with cold water, applied with a bandage. He directs us to avoid warm fomentations until the ligatures drop out. When ectropion arises from the excrescence called encanthis, he recommends us to dissect it out. When the disease is occasioned by paralysis, or arises from too large a portion of the eyelid having been cut out in the operation for entropion, he pronounces it to be incurable. It is also said to be incurable when occasioned by the sloughing of carbuncles.
Celsus says that ectropion arises either from an operation for inversion improperly performed or from old age. In the former case he directs us to make an incision like that for lagophthalmos, only with this difference, that the horns of it are to be turned to the jaws (maxillas) and not to the eye. When it arises from old age he recommends us to burn the excrescence with a slender piece of iron, and then to anoint it with honey.
Albucasis describes the operation in nearly the same terms as Aëtius. Thus, he directs us to pass a needle armed with a double thread, below the fleshy excrescence from the left canthus to the right, and stretching it by means of the threads to cut it out with a broad scalpel. If this incision does not relieve the eyelid, he directs us to take the specillum (radius) and applying it to the incision, to evert the eyelid with it, and then to make two incisions in the inner surface of the eyelid so that they may meet at an angle below, like the Greek letter Λ. Then this triangular portion is to be dissected out, and the edges united by a suture with a woollen thread. When the disease arises from a cicatrix he directs us to divide it, and then to keep the lips of the wound separate by the application of a pledget. He concludes with the remark that, as the disease puts on various forms, a prudent surgeon will show his skill by restoring the parts to their natural state.
Haly Abbas evidently borrows his description from Aëtius or our author.
The operation here described is very similar to the one practised by the late Sir William Adams. In the days of Fabricius this operation was condemned as cruel and troublesome. It will be remarked that the V operation of modern times is a modification of the operation now described.
SECT. XIII.—ON ANABROCHISMUS AND BURNING WITH IRON.
When the hairs which irritate the eye are not numerous, but only one, two, or at most, three, close to one another, we approve of the operation called anabrochismus. Taking, therefore, a very slender needle, we pass through its ear (eye?) a woman’s hair or a fine flaxen thread, and unite the two extremities together in such a manner that the thread or hair which is passed through may have a double loop; and we pass another such thread or hair through the loop, and pushing the needle through the tarsus where the preternatural hairs appear, we introduce the hair or hairs into the loop by means of an ear-specillum, and draw it upwards. And if the hair of the eyelash be fixed in it, we draw up the loop; but if one or more, fall out, we again, by means of the one at first introduced, draw down the loop, and once more introducing a hair or hairs, draw them upwards. But if there is only one slender hair that irritates the eye we draw up another of the ciliary hairs along with it, anointing them with gum or some other glutinous substance, and bending them until they unite to the skin. Some preferring burning to the operation of anabrochismus, turn the eyelid outwards, and with a hair-forceps dragging out the offending hair, if there is but one, or two, or three; if there be as many, they apply a double-headed specillum, or an ear-specillum, or some such small instrument heated, to the place whence the hair or hairs were removed. For the skin being thus constricted, no other hair is produced.