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BULLER: A Peculiar Case of Alopecia of the Eyelids. 38I
A PECULIAR CASE OF ALOPECIA OF THE EYELIDS. (PLATE-FIGS. I, 2, 3, 4, 5.)
By F. BULLER, M.D., MONTREAL, CAN.
THE microscopic specimens, and the drawings miiade from them, to which I would call your attention are eyelashes taken from the u)per eyelids of a young lady seventeen years of age, who states that for about eighteen miionths she has noticed something wrong with her eyelashes-that they were falling out fronm the upper eyelids. For some months the disfigurements from this cause has been quite conspicuous. She is of somewhat delicate appearance, but enjoys very good health, lives in a healthy locality in the city of Montreal, and her parents are in good circumstances. No other memiiber of the family has ever been affected in the same way. In every other respect the eyes are perfectly normal. The disease is confined to the upper eyelids, the lower lids being provided with a strong growth of healthy lashes. The edges of the upper lids are neither reddened nor thickened, nor is there any desquamation about the roots of the lashes. She experiences no discomfort, not even itching of the eyelids, and oiily comes on account of the disfigurement caused by the wasting of the
eyelashes. The left eyelid was first affected, and is the worst of the two, its outer half being alnmost comipletely bald; the inner portion has lost fully half its lashes, and those remaining are for the most part small and thin. Some of them, however, are quite short, thick, and dark in color. They are easily l)ulled out, and she scarcely feels it when they are extracted with forceps, though the extraction of the lower lashes causes the usual amiiount of discomfort. Most of the lashes, when removed, are seen to have thick, black, knob-like roots. The right upper lid seems to be provided with about half the normal amount of eyelash. On rubbing the finger along the row, several of the larger lashes appeared to break off on a level with the
382 BULLER: A Peculiar Case of Alopecia of the Eyelids. skin, and tapered abruptly at the root-end. The others, when ptulled out, were similar in every respect to those of the left lid. Examined under the microscope, the appearance of the eyelashes is striking and peculiar. There are three distinct classes of lashes. First.-Normal hairs, with normal axis cylinders, the roots and root-bulbs being pale and almiiost colorless, the root-sheath adherent. Second.-Dark hairs, thicker toward the root, with interrupted or defective axis cylinders, and in place of a bulb, having a thin spindle-shaped or tapering root. Third.-Black hairs, with defective or no axis cylinders, large roots and root-bulbs, which are heavily loaded wvith dark, granular pigment. Most of these are bent like a walkinig-stick at the junction of the bulb with the shaft, and often peculiarly twisted as if a half turn had been given to the hair at this part. It will thus be seen that the diseased hairs present opposite conditions as regards the hair-bulbs. In one case there is atrophy, in the other hypertrophy. The apparent atrophy may be due to absorption of the bulb, or to a softening of its peripheral portions, so that in making the extraction only the central portion of the bulb comes away. The root-sheath of the diseased lashes does not in any case comiie away with the hair. The peculiar feature, however, commoni to both classes of diseased lhairs, is the presence of a thread-like material wound around the hair, extending fromn the bulb to a certain distance ul) the shaft, but never, so far as 1 can discover, beyond the point of emiiergence of the hair fromi its follicle. Around the shaft the appearance may be comiipared to that of a piece of whip-cord loosely woven and knotted, around a walking stick. This simile has been suggested by the bent condition of the hair, in nmany instances just at the junction of the builb with the shaft. In some, as mDay be seen in Figtures 2 and 5, the network apparently commences by several turns of the cord bound tightly around the hair at this part-that is, about the point of junction between bulb and shaft-and one miiight readily believe this constriction to have something to do with the bending of the hair were it not for the fact that some abnormiial hairs are met with bent in a precisely similar manner, but without a trace of the cord-like n-iaterial around
theml. On the other hand, the peculiar arrangemi-ent of the network around. the shaft of the lhair, as well as its appearance when seen in l)rofile at the edge of the hair, raises the question whether it may
BULLER: A Peculiar Case of Alopeciaof the Eyelids. 383 not be a mere exaggeration of the normal imbrication of the epithelial structure of the hair at this part (see Fig. 3); indeed, it is not difficult to conceive how a series of epithelial cells, flattened as these, imiight, by being curled up at their free edges, give rise to an appearance simiiilar to what we here see in so many of the disease(d hairs. But this explanation would fail to account for what we see so plainly in Figures 4 and 5. The network begins in such a way and at such a point that the explanation suggested is out of the question. The imiaterial composing this network is characterized by its indifference to the chemical action of acids and alkalies. Caustic potash in strong solution at most causes it to swell a little, but does not materially alter its appearance. I have not as yet been able to satisfy mnyself as to its real n'ature, but from a clinical standpoint I should say we have to deal with somiie sort of parasitic growth; if, however, this thread-like structure is actually a fungous growth, it differs very widelv from any species of tricophyton hitherto described. Neither have I succeeded in finding anything I could recognize as fungus spores or conidia, and for this reason, if for none other, I hesitate to place the imiorbid condition of the eyelashes in the category of parasitic diseases of the hair. Its non-infectious character may be inferred from the coinplete immunity thus far shown by the lower eyelids. In default of any successful experiments in the cultivation of the fungus-if it be such-the precise nature of the disease must remain a matter of uncertainty. Since the case has been under imiy observation, the only treatment employed has been thorough epilation as fast as the growing lashes would admit of removal, and painting the edges of the lids with tincture of iodine. So far the result is entirely negative, recently grown cilia showing exactlv the same characters as their predecessors. REMARKS.
DR. HASKET DERBY, of Boston, asked Dr. Buller whether he had used pilocarpin by subcutaneous injection in any cases of alopecia of the eyelids. It was reported to cause growth of hair to take place on bald places of the scalp and to preven-t the hair of the scalp fromii turning gray. 25
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BULLER: A Peculiar Case of Alopecia of the Eyelids. 38I
A PECULIAR CASE OF ALOPECIA OF THE EYELIDS. (PLATE-FIGS. I, 2, 3, 4, 5.)
By F. BULLER, M.D., MONTREAL, CAN.
THE microscopic specimens, and the drawings miiade from them, to which I would call your attention are eyelashes taken from the u)per eyelids of a young lady seventeen years of age, who states that for about eighteen miionths she has noticed something wrong with her eyelashes-that they were falling out fronm the upper eyelids. For some months the disfigurements from this cause has been quite conspicuous. She is of somewhat delicate appearance, but enjoys very good health, lives in a healthy locality in the city of Montreal, and her parents are in good circumstances. No other memiiber of the family has ever been affected in the same way. In every other respect the eyes are perfectly normal. The disease is confined to the upper eyelids, the lower lids being provided with a strong growth of healthy lashes. The edges of the upper lids are neither reddened nor thickened, nor is there any desquamation about the roots of the lashes. She experiences no discomfort, not even itching of the eyelids, and oiily comes on account of the disfigurement caused by the wasting of the
eyelashes. The left eyelid was first affected, and is the worst of the two, its outer half being alnmost comipletely bald; the inner portion has lost fully half its lashes, and those remaining are for the most part small and thin. Some of them, however, are quite short, thick, and dark in color. They are easily l)ulled out, and she scarcely feels it when they are extracted with forceps, though the extraction of the lower lashes causes the usual amiiount of discomfort. Most of the lashes, when removed, are seen to have thick, black, knob-like roots. The right upper lid seems to be provided with about half the normal amount of eyelash. On rubbing the finger along the row, several of the larger lashes appeared to break off on a level with the
382 BULLER: A Peculiar Case of Alopecia of the Eyelids. skin, and tapered abruptly at the root-end. The others, when ptulled out, were similar in every respect to those of the left lid. Examined under the microscope, the appearance of the eyelashes is striking and peculiar. There are three distinct classes of lashes. First.-Normal hairs, with normal axis cylinders, the roots and root-bulbs being pale and almiiost colorless, the root-sheath adherent. Second.-Dark hairs, thicker toward the root, with interrupted or defective axis cylinders, and in place of a bulb, having a thin spindle-shaped or tapering root. Third.-Black hairs, with defective or no axis cylinders, large roots and root-bulbs, which are heavily loaded wvith dark, granular pigment. Most of these are bent like a walkinig-stick at the junction of the bulb with the shaft, and often peculiarly twisted as if a half turn had been given to the hair at this part. It will thus be seen that the diseased hairs present opposite conditions as regards the hair-bulbs. In one case there is atrophy, in the other hypertrophy. The apparent atrophy may be due to absorption of the bulb, or to a softening of its peripheral portions, so that in making the extraction only the central portion of the bulb comes away. The root-sheath of the diseased lashes does not in any case comiie away with the hair. The peculiar feature, however, commoni to both classes of diseased lhairs, is the presence of a thread-like material wound around the hair, extending fromn the bulb to a certain distance ul) the shaft, but never, so far as 1 can discover, beyond the point of emiiergence of the hair fromi its follicle. Around the shaft the appearance may be comiipared to that of a piece of whip-cord loosely woven and knotted, around a walking stick. This simile has been suggested by the bent condition of the hair, in nmany instances just at the junction of the builb with the shaft. In some, as mDay be seen in Figtures 2 and 5, the network apparently commences by several turns of the cord bound tightly around the hair at this part-that is, about the point of junction between bulb and shaft-and one miiight readily believe this constriction to have something to do with the bending of the hair were it not for the fact that some abnormiial hairs are met with bent in a precisely similar manner, but without a trace of the cord-like n-iaterial around
theml. On the other hand, the peculiar arrangemi-ent of the network around. the shaft of the lhair, as well as its appearance when seen in l)rofile at the edge of the hair, raises the question whether it may
BULLER: A Peculiar Case of Alopeciaof the Eyelids. 383 not be a mere exaggeration of the normal imbrication of the epithelial structure of the hair at this part (see Fig. 3); indeed, it is not difficult to conceive how a series of epithelial cells, flattened as these, imiight, by being curled up at their free edges, give rise to an appearance simiiilar to what we here see in so many of the disease(d hairs. But this explanation would fail to account for what we see so plainly in Figures 4 and 5. The network begins in such a way and at such a point that the explanation suggested is out of the question. The imiaterial composing this network is characterized by its indifference to the chemical action of acids and alkalies. Caustic potash in strong solution at most causes it to swell a little, but does not materially alter its appearance. I have not as yet been able to satisfy mnyself as to its real n'ature, but from a clinical standpoint I should say we have to deal with somiie sort of parasitic growth; if, however, this thread-like structure is actually a fungous growth, it differs very widelv from any species of tricophyton hitherto described. Neither have I succeeded in finding anything I could recognize as fungus spores or conidia, and for this reason, if for none other, I hesitate to place the imiorbid condition of the eyelashes in the category of parasitic diseases of the hair. Its non-infectious character may be inferred from the coinplete immunity thus far shown by the lower eyelids. In default of any successful experiments in the cultivation of the fungus-if it be such-the precise nature of the disease must remain a matter of uncertainty. Since the case has been under imiy observation, the only treatment employed has been thorough epilation as fast as the growing lashes would admit of removal, and painting the edges of the lids with tincture of iodine. So far the result is entirely negative, recently grown cilia showing exactlv the same characters as their predecessors. REMARKS.
DR. HASKET DERBY, of Boston, asked Dr. Buller whether he had used pilocarpin by subcutaneous injection in any cases of alopecia of the eyelids. It was reported to cause growth of hair to take place on bald places of the scalp and to preven-t the hair of the scalp fromii turning gray. 25
