TRICHIASIS AND DISTICH I AS I S; Reflections upon their Nature and Pathology. WITH A RADICAL METHOD OF TREATMENT: By Charles B. Michel, M. D. Professor of Ophthalmology and Histology n the Missouri Medical College. Reprint from the St. Louis Courier. of Medicine, Feb. No., 1879. TRICHIASIS AND DISTICHIASIS; Reflections upon their Nature and Pathology. WITH jv RADICAL METHOD OF TtjE/TME^T. By Charles E. Michel, M.D., Prof, of Ophthalmology and Histology in the Missouri Medical College. BOTH of these affections are characterized in a general way by a deviation inwardly of the cilia, which lean towards or touch the globe. From the above, must be ex- cluded such cilia as are only accidentally turned inwards. Healthy and properly-directed cilia, softened by moisture, may be swept backwards between the lids, and, drying in that position, give great annoyance ; this is not trichiasis, and simple, self-evident measures will relieve. Sometimes cilia, that are apparently normal in every other respect, touch the globe permanently: a vicious change of direction of the hair follicle is the cause. The cilia themselves are frequently distorted and twisted in various directions, and, independently of the inclination of their follicles, curve backwards, so as to irritate the eye ; here a diseased papilla is to blame. Often a single hair is observed to spring from a part of the free or flattened tarsal margin, which physiologically 2 Michel. — Trichiasis and Distichiasis. does not give rise to such appendages, or several may make their appearance, all of them inclined backwards: these are new products, which must occupy us for a few moments. Two varieties of the above-named supernumerary hairs must be distinguished; in the one form, “ distichiasis,” when it is uncomplicated, we have true cilia precisely like the normal ones, arranged with great regularity in a row ; they spring from the flattened tarsal margins, near their posterior or conjunctival edge, in the neighborhood of the openings of the Meibomian glands, and are directed towards the globe. Generally, only the third of the supe- rior eyelid, towards the external canthus, is affected, and in the cases which I have seen, the deformity was sym- metrical and bilateral; that is, the right and left superior palpebrm were similarly conditioned. This malformation is of embryonic origin. The second variety, namely, “ trichiasis,” differs widely from the foregoing; the orig- inal cilia may affect an irregular distribution, but rarely present any analogy to a double row ; the upper and lower lids are always more or less involved, and the cilia, besides touching the eyeball, are most generally distorted; again, although both sides may be diseased, there is no corres- ponding double row of cilia on each. Moreover, before trichiasis has reached this stage, supernumerary newly- fonned hairs have made their appearance ; these scarcely ever resemble the cilia, which they are not, but are thin, whitish hairs, mostly distorted, of variable length, several (at times) making their exit from one and the same follicu- lar opening; they resemble the lifrihgo. Scattered broadcast, they grow indiscriminately from every portion of the tar- sal margins; I have seen them spring from the edges of the mucous lining membrane of the lids. When many of these are added to the already diseased cilia, the case is one of “general trichiasis.” Newly-formed hairs make their appearance on the tarsal margins only after marked ■exciting causes; irritations and inflammations. Brudenell Carter1 makes the following assertion: “In 3. Prac. Treat, of Diseases of the Eye. London. 1875. Micliel,—Trichiasis and Distichiasis. 3 many text-books we find a distinction between £ trichiasis,’ a state in which the eyelashes are simply incurved, and ‘ distichiasis,’ in which it is assumed that there is a double row, the outer of normal growth and position, the inner directed towards the eye. I have never seen what could be properly described as distichiasis, but I have frequent- ly seen some hypertrophy of the tarsal margins, attended by growth of cilia in abnormal numbers, some of them being misdirected.” This is a description of trichiasis, and I readily believe, as the author states, that he has never seen a true distichiasis ; certainly not an uncompli- cated case. This deformity exists, nevertheless, and with an example before him, the most casual observer could not have the slightest room for an assumption; indeed, the affections are radically different in origin, and patho- logically, could not be treated of under the same head. When distichiasis is uncomplicated, we have before us nothing but fully developed true cilia ; their arrangement is the same as that of the physiological cilia, but the sym- metrical row is posterior to, and distinctly separated from, the latter, by the normal, healthy structure of the lid. The follicles and lashes being directed backwards towards the globe. Often the affection is bilateral and symmetrical, as I myself have seen it. The history of the case dates the deformity back to early infancy ; although present, it may have escaped observation at birth, for eyelashes are then very rudimentary affairs. The cilia, however, may not have grown until later. Galezowski,1 quoting Vidal on this subject, says: “When this affection occurs without hav- ing been preceded by any disease of the eye, we can ad- mit with Vidal (de Cassis) and Quadri, that the hair bulbs lying dormant in an embryonic state, at a given moment have been rapidly developed in a vicious direction.” This “ moment of rapid development,” however, I am not ready to admit happens later than adolescence, when a second growth of hair physiologically takes place. I look upon these supernumerary cilia in the same light that I do su- 1. Galezowski. Traits des Maladies des Yeux. Paris. 1875. 4 Michel.—Trichiasis and Distichiasis. pernumerary fingers and toes; they are deformities of un- doubted embryonic origin; confirmatory evidence of this is obtained from the presence of other malformations in the same individuals. Schweigger1 states that, “in many cases, there exist still other congenital anomalies: for instance, in one case which I observed, there was epican- thus, and bilateral ptosis congenita; in another case, I found a cleft in the soft palate.” That modified trichiasis is not distichiasis, is easily proven ; thus, it is never observed unless disease or injury of the lids* has prceeded it; in the modified form, which is mistaken for, or improperly named distichiasis, the new hair products grow, to a certain extent, indiscriminately from all parts of the palpebral margins ; no symmetrical row exists in reality. The newly grown hairs are not true cilia ; they rarely resemble true cilia, but are essentially pathological new products ; the papillae which grow them were originally simple, cutaneous papillary elevations, which, from continued irritation, have taken on an abnor- mal action, resulting in a pathological formation. The symptoms of trichiasis and distichiasis are in some respects identical. The mechanical irritation of the globe, common to both, may result in its total loss as an organ of vision; it is most remarkable, however, to witness the amount of irritation which the ocular conjunctiva will bear at times ; I have seen persons, with quite a number of large ingrowing cilia constantly sweeping the cornea and adjacent parts, who scarcely complained of any in- convenience, the eye being reddened only occasionally ; this more frequently in distichiasis. This is no doubt to be explained by an hypertrophic thickening of the epithe- lial layer taking place ; the irritation induces the excessive secretion of cells, which serve to protect the ordinarily ex- posed nerve terminations. In general trichiasis, when the stage of madarosis (bald- ness of the lids) has been nearly reached, the tarsal mar- 1. Prof. C. Schweigger. Hand-Book of Ophthalmology. (Translation.) Philadelphia, 1878. Michel.—Trichiasis and Distichiasis. 5 gins lose their well-defined edges ; they are rounded off by cicatricial transformation, which occasionally results in the drawing up, over the external margins of the lids, of the loose integuments of their facial aspect, without, however, displacing the tarsal cartilages. When this happens, we have a never-ending source of trouble to contend with; for the papillae of the take on an increased action, and the hairs become sufficiently long and stiff to do harm. I shall not enter further into the consideration of the va- rious symptoms attending these affections ; most of the text- books in ordinary use give good descriptions of them. I shall content myself by simply calling attention to the fact, that ciliary blepharitis is present in all cases of trich- iasis not of traumatic origin, as well as in complicated dis- tichiasis, where the lids are diseased to any extent. Dis- tichiasis may, and does exist without ciliary blepharitis. The treatment of trichiasis and distichiasis is no unim- portant matter, even though immediate loss of vision is not threatened; trivial as these affections sometimes appear, as long as they last existence is a curse, life loses its charms, and the sufferers become profoundly despondent, and sometimes suicidal; for years they have been hope- lessly seeking relief, and finally they are frequently worse than when they applied for treatment. In the October number of the St. Louis Clinical Record, of 1875, was published an article, in which I gave an ac- count of what I then considered an improved surgical treatment of trichiasis and distichiasis; namely, by elec- trolysis. In the said article, I detailed, in a concise way, the various procedures which I had employed before ulti- mately perfecting the operation. For years, indeed, very early in my professional career, I felt the inadequacy of our means of controlling these deformities, and even then devised some of the methods which I later put into execu- tion. I at once directed my efforts to the discovery of a sure means, by which I could destroy the hair papilla, alone. 6 Michel.—Trichiasis and Distichiasis. At the very onset, I rejected epilation as inefficient and unwise, when intended as a curative measure. In the above named article I remarked : “ I have now several timid pa- tients, in whom I have been practising evulsion of cilia as soon as felt, for as long a period as ten years, who to-day have a larger number of offending lashes, that have be- come as stout as the hairs in a fine beard. I look upon the practice as decidedly worse than useless. After evul- sion, the hair not only grows with greater rapidity, the more frequently it is pulled, but it also increases in thick- ness, so that downy hairs in time become full-grown cilia. This is easily explained. In the process of evulsion, the formed material (shaft of the hair) only is removed, the hair breaking off within the follicle at a point where it is yet soft; the papilla, which secretes or forms the hair, re- mains intact; it is only irritated by the operation, which causes a hypersemia, with increased activity of function, and consequently increased rapidity of formation of the hair. “Occasionally, it maybe that evulsion does produce suf- ficient inflammatory action in the papilla to cause its sup- puration and destruction; but this is far from being the ordinary result, especially when there is no complicating blepharitis. That trichiasis and distichiasis may exist with no perceptible blepharitis, is certain. A marked case of the kind presented itself last year at my clinic at St. John’s Hospital; the affection (distichiasis) had existed since infancy; evulsion had failed to relieve, and the growth of the cilia had increased. But blepharitis com- plicates the vast majority of cases, frequently producing, after a time, that unsightly baldness of the lid—madaro- sis. Now, since the tendency of the affection is already in this direction, we can readily understand how evulsion might hasten the result, and be mistaken by the surgeon for the prime cause of the hair destruction. “ I have previously said that the operation of evulsion was worse than useless ; for since, notwithstanding every precaution, the hair is very frequently merely broken off Michd.— Trichiasis and Distichiasis. 7 at the surface of the skin, it is very soon after, long enough to scratch the cornea more severely than before, being sharper and stiller. For this reason I have frequently pre- ferred not to remove long cilia as a temporizing method; having seen the same patient, in a passably comfortable condition for a long time, while the cilia were full grown, return shortly after evulsion had been practised, with much more severe inflammation of the conjunctiva, and decidedly more suffering than when the lashes were long.” I am to-day still in accord with the above. My first attempt at destruction of the hair papilla was made in 1869. With a most delicately-constructed electro- cautery platinum point, manufactured expressly for the purpose, I successfully removed several cilia ; but I at once perceived that the destruction of the tissues could not be properly regulated with this agent, so I immediately abandoned it for a far better operation, which I described as follows d “ In a small platinum cup, or a silver spoon, a piece of nitrate of silver is fused; a flue sewing needle (No. 8) is then gently warmed, and the point dipped into the liquid silver nitrate, so as to coat about two millimeters of its point with a delicate film of caustic, which ad- heres firmly to the steel. The lid is then everted with the tip of the forefinger of the left hand; a lance-pointed needle (the old cataract-couching needle, with a rather broad point, will answer) is made to split the hair-follicle to its base, the cilium still be in situ. During the opera- tion, I generally use a oue-inch convex lens,-to assist in ac- curately locating the opening of the hair-follicle. A drop or two of blood usually escapes from the juncture. When all bleeding has stopped, and the blooct , carefully wiped away, the caustic needle-point is passed into the small in- cision, where it is twirled around a few moments, to cause the nitrate of silver to dissolve. In some of my cases the result has been absolutely perfect, leaving no trace what- ever of the minute operation ; in a few cases, the cauteri- zation set up an inflammation, which resulted in a minute 1. Loc. Cit. 8 Michel.—Trichiasis and Distichiasis. abscess of the lid, of no greater moment than an ordinary stye. This method I still regard as useful and safe, espe- cially if the needles are coated with care, not allowing an excess of the nitrate of silver to adhere to the point of the needle in the shape of a small bead, which will inevitably happen if they are dipped cold into barely-fused caustic.” The only disadvantage of this simple procedure is its tediousness, when we have to deal with many hairs. The needles have to be prepared with care, one for each hair, and not too long before the operation, else the nitrate at- tacks the steel and spoils the caustic. Practitioners not possessed of a galvanic battery, or having only a few hairs to destroy, away from the office, will find this a most ad- mirable operation. In fact, it is nearly perfect; for the cauterization is sub-epidermic, very slight, and practically limited to the papillary region. These delicate cautery points can be used in the same cases, and be applied for similar purposes as the electrolytic needles. About this time I was treating a case of epithelioma of the superior eyelid, by applications of electrolysis, and it occurred to me that I could advantageously employ the same agent for the destruction of the papillae of the cilia. Without delay, I tried it, and succeeded beyond my most sanguine expectation. I could apply the method with the utmost rapidity, security and accuracy. No apparent cic- atrices were left- I made the operation the basis of the paper already mentioned ; further on I will describe it. The ordinary surgical procedures of the day are, in my opinion, defective, inasmuch as they do not meet the exi- gencies of the case ; some are useless; others disfigure, and several are so severe and extensive that their dispro- portions stand in marked contrast to the apparent trivial nature of the affection against which they are directed. A brief consideration of the best known of them will suffice. In Prof. Schweigger’s 1 recently translated work we find the following: “ If, upon an otherwise normal lid, only a single cilium, or a very small number of them, turn inward 1. Hand-Book of Ophthalmology. Michel.—Trichiasis and Distichiasis. 9 and irritate the cornea, they may be restored to their nor- mal position in the following manner : Both ends of a tine thread, or a sufficiently long hair, are placed together, and passed through the eye of a needle, so as to form a loop. The needle is then inserted just at the root of the falsely- placed cilium, and is brought out exactly in the line of the normal cilia. The thread is then drawn through, so that the point of the cilium is brought to view between the nor- mal cilia. If the cilium do not fall out too soon, the posi- tion and direction of its follicle may be in this way perma- nently changed. This method was described by Celsus as 4 iUciqueatio.’’ Occasionally, in patients who are annoyed by a sensation as if a foreign body in the eye, there may be found, either with the naked eye or by the help of a lens, a number of very line cilia (strongly developed liin- afgo), which, with their points, touch the caruncula lacry- malis. Epilation is the only remedy.” As regards the “ only remedy,” epilation, I have already expressed my opinion, and that “ strongly developed lpnsl- go” are cilia, I deny. With respect to the other method, the author’s own remarks show what little faith he has in the operation; it hangs on the slender hopes of a constantly pulled-upon cilium “ not falling out too soon.” Comment is unnecessary. This little operation has, no doubt, occa- sionally succeeded, when it could be applied ; but, in my opinion, not in the manner intended. I explain the favor- able results under such circumstances as follows: The thread remaining in position a sufficient length of time, “ if the cilium do not fall out too soon,” acts as a seton ; a small cicatrix is thus obtained, which, when it contracts, is sufficient to pull the follicle outwardly in its direction. The principle is the same as that involved in Desmarre’s operation, in which he excises a minute fold of the skin, close to the implantation of the deviated cilium. I des- cribed, in the article already mentioned, a very simple and successful procedure to which in similar cases I had had recourse: “ In cases where a few offending lashes spring from the outer margin of the lid, I have occasionally 10 Michel.—Trichiasis and Distichiasis. passed an armed needle through a small fold of the skin, in front of, contiguous to, and parallel with the liair-folli- cle. The thread is tightly knotted, and soon cutting its way through, leaves a minute vertical cicatrix, pulling the follicle and contained cilium outwards.” I now believe it would be an improvement not to knot the thread tightly ; by leaving it loosely looped in position for a given time, it will act as a seton; a minute, hidden cicatrix will thus be obtained, which will, in the same manner as I hold it does in the Celsian operation, pull the follicle and contained hair outwards. Brudenell Carter 1 in his most excellent treatise on dis- eases of the eye, says : “ When the cilia are redundant, it may be sufficient for a time to remove them by epilation whenever they touch the eyeball, and it will occasionally happen that atrophy of the follicle will be produced. Ep- ilation, simple as it seems, requires, not only some care, but also the use of forceps with opposing surfaces which are so well fitted, and just so much roughened, that they will hold the finest hairs ; * * * badly made forceps will cut them ; * * * although epilation, in the case of mere redundancy, sometimes leads to cure, it is more com- mon for the cilia to grow again and again ; * * * it is then desirable to abandon the practice, and destroy the bulbs from which the ingrowing hairs proceed. If there are only two or three in number, this may be done by the actual cautery, for which Mr. Wordsworth’s needle, or a common sewing needle, fixed in a handle and heated in'a spirit lamp, furnishes a convenient instrument.” Now, I will ask, Why not entirely forego the epilation, which the author admits only (“occasionally”) accidentally succeeds, and frequently unavoidably fails, leaving stumps “far more irritating than a perfect eyelash? ” We should cer- tainly not, under these circumstances, employ a procedure, concerning the success of which so distinguished a surgeon and ophthalmologist further says : “ It is more common for the cilia to grow again and again.” 1. Op. Cit. Michel.—Trichiasis and Distichiasis. 11 As regards the use of the actual cautery in the form recommended, although the instruments are more readily obtained, they are not nearly as convenient of application, and certainly act no better than the galvano-cautery points which I formerly used, and abandoned as unmanageable. Williams, of Boston, 1 proposes to destroy the papillae by means of a needle dipped in caustic potassa, and passed into the follicle after the removal of the hairs, the tarsal margin having been previously greased. I admit that I never tried this, although the method is mentioned by other good authorities. Too many very patent difficulties and objections presented themselves to my mind. In my elec- trolytic method, hereafter to be described, I had, previous to the insertion of the needle, tried the anterior removal of the cilia, bnt invariably failed to find the follicular open- ings. I made use of strong and weak lenses, in a favora- ble light, besides exercising all the ingenuity at my com- mand. A slight movement of the patient, the fiowing tears, or the natural resilliency of the tissues; the minuteness —and, in fine hairs, absolute invisibility (to ordinary pow- ers) of the openings of the hair follicles, were more than I could contend with successfully. Another objection I conceived would be, the impossibility of protecting the globe, in many instances, from the caustic; tears secreted at the moment of application would diffuse the potassa over the conjunctiva. I also doubted that a liquid could be con- veyed to parts beneath the surface by the means em- ployed ; it seemed to me an invariable result would be, that all but an infinitesimal portion of the liquid would remain on the outside, when the needle was forced into the skin; nor could even that residual portion replace the point when with- drawn, as blood would follow it, if the vascular papillae had been reached. Yet the method must have succeeded; the authority of the proposer, and of those recommending and mentioning it, is a sufficient guarantee of this. I have found an explanation of the difficulty, which is satisfac- tory to myself. I had had some personal experience in a 1. 0. H. Eep’ts,” y. iii, p. 219. 12 Michel.—Trichiasis and Distichiasis. somewhat similar procedure, devised by myself, for the same purpose: I believed that the caustic had little, if any- thing, to do with the result, but that here, as in my opera- tion, the right direction of the papilla having been acci- dentally hit, the papilla itself (or, perhaps, its immediate neighborhood) having been wounded, was destroyed by an increase of the already existing inflammation which affects such cases. In my little operation, I used simply the bev- elled point of a hypodermic needle, which with its sharp- cutting, double edge, .was admirably adapted to destructive laceration, when rapidly twirled. I succeeded occasionally, but the method was too uncertain to satisfy me. When we consider the chances in our favor, of successfully trans- fixing an irregularly-located sub-epidermal point, measur- ing only about 0.1128 m.m., we are not surprised at failure, and readily see the impracticability of the method. The electro-cautery, the nitrate-of-silver-tipped needle, and the electrolytic needle succeed under similar circumstances by acting on the tissues at a distance, in every direction from the needle-points. The knife has been employed to excise hair papillm and follicles ; but while it is a more formidable means than the exigency should require, it may fail, and always leaves marked cicatrices. Thus, in my article on this subject, already so largely, quoted, I said regarding an operation of this class : “ Galezowski’s method1 of excising the hair follicle, carving out a portion of the thickness of the lid, between the conjunctiva and the skin, is ingenious, but the cicatrix resulting from the removal of one-third of the thickness of the eyelid is sufficient to deter from its em- ployment, in the few cases to which it might be applicable. When a preponderating majority of the true cilia are viciously deviated, we should, perhaps, for the cosmetic effect, prefer, and have recourse to, some one of the appro- priate operations contained in the text-books. I have used the expression “ perhaps,” because, as I will show, I have good reasons to expect that by the electrolytic method I 1. Trait6 des Maladies des Yeux; Paris, 1875. Michel.—Trichiasis and Districhicisis. 13 shall he able, in a measure, to restore to their proper direction the deviated hairs that are worth saving. I shall now describe, as heretofore published,1 the elec- trolytic method of dealing with these affections. “ The agent is electricity (a constant-current battery of 8 to 20 medium-sized cells is all-sufficient); the form, electrolysis. I pass a fine, gilt needle into the hair follicle, and allow the current to produce the electro-chem- ical decomposition of it and its papilla. The details are as follows: A three-cornered gilt needle (the finer the better, provided it be accurately inserted), mounted on an electrode about the size of a pen-handle, and connected with an insulated wire from the negative side of the bat- tery, is made ready. I have an interrupter, which I control with my foot, inserted along the wire which comes from this pole, thus enabling me to first accurately place the needle in position before completing the circuit; an ordinary elec- trode, covered with a sponge, is connected with the positive pole. The patient is usually seated in a reclining chair, facing a good light (the erect position will answer); an assistant then takes the sponge electrode (the anode), and applies it to the temporal region of the side to be operated on; or, the patient can hold it firmly in his hand. Having the needle electrode (the cathode) ready, I break the current, by means of my foot-interrupter, and gently everting the lid, accurately place the needle- point into the opening of the follicle, which still contains the deviated cilium, and steadily press the needle in the direction of, and somewhat beyond, the hair papilla. This period of the operation is made more perfect by employing a lens of one or two-incli focus, which I hold between the fore-finger and thumb of the left hand, using the middle finger to evert the lid; or, an assistant, if at hand, may hold the lid. The patient had better be warned at this juncture not to make any sudden start when the slight shock accompanying the closing of the circuit is felt, lest the needle be displaced, I steadying at the same moment 1“ St. Louis Clinical Becord,” Oct., 1875. 14 Michel.—Trichiasis and Distichiasis. the head as much as possible, to prevent such an accident. The circuit is now closed through my foot-interrupter, and the electrolytic action allowed to go on, until a slight froth- ing up around the stem of the needle is plainly perceived, when I at once break the current. The quantity of the whitish froth is a comparative measure of the effect pro- duced. Sometimes, the cilium comes away with the needle, being stuck to it by the frothy material mentioned. Generally, it is only necessary to seize the hairs with a pair of depilation forceps, or simply with the fingers ; but no force is to be used in this step, for if the cilium does not come away by merely taking hold of it, it is a certain indication that the operator either has not obtained suffi cient electro-chemical decomposition, or that the follicle and papilla have not been reached, in which case another application should be made at once. The more accurately the needle has been placed, the less the necessity for any great degree of electrolysis. With about eight ordinary sized elements, I accomplish the desired effect in from two to five seconds ; with twenty-eight elements, one second suffices. I prefer to use few elements, for the reason that when the circuit is closed, scarcely any shock is felt; this, however, can also be attained as follows: Notwithstanding many elements are used, the sponge, not too wet, must be very gradually brought in contact with some portion of the body; the palm of the hand, for instance.” Since the above was written, I have made use of this opera- tion in a vast number of cases, both in private, and at my public clinics. It has stood the test of years, and I can now, with the utmost confidence, offer it to the profession on its own merits. I treat distichiasis in the same way. Experience has suggested a few modifications, of a prac- tical nature, which are as follows: I invariably dispense with the foot-interrupter, and scarcely ever need an assist- ant. 1 never place the anode (positive pole) elsewhere than on the palm of the hand. The patient takes hold of an in- sulated electrode, and slowly closes the circuit when told to. They learn to do this very carefully; experience soon Michel.—Trichiasis and Distichiasis. 15 teaches them that sudden, firm contact produces a disa- greeable shock, so they feel their way, and graduate the pressure to suit themselves. I do not here speak of chil- dren. Those who prefer to have the pain soon over, with- out regard to its intensity, press firmly, and thus shorten the duration of the application ; the process being intensi- fied by this more perfect closure of the circuit; others, more timid, are willing to suffer longer, provided the pain is not so great—they are taught to make light pressure on the sponge. Individuals vary greatly in their sensitiveness to pain; but, although most patients seem to suffer acutely from these short applications, I have in two cases only, been forced to use an anaesthetic. Immediately on the break- ing of the current the pain seems to subside. It is far better to let the patient stop the action, by removal of the sponge from the hand, than to break the current by the removal of the needle ; for, in the first instance, no shock, or only a very slight one, is felt: whereas, in the last, a very strong shock occurs, which, besides giving pain, makes the patient start, the sudden movement causing the needle in its exit to scratch the lids ; truly an unimportant injury, but one which can be very easily avoided by pur- suing the above directions. I now use even weaker currents than I formerly did; the pain is lessened, and the effects produced more manageable. Almost any ordinary medi- cal galvanic battery can be used for this operation ; if, with its poles introduced in water, decomposition slowly takes place, the apparatus will answer. Always test the battery in this way before proceeding with the operation. Instead of using the finest needles, as I formerly did, I have found that a No. 8 sewing needle (a medium size), properly sharpened, and gilt, is preferable, for the following rea- sons : As already stated,)it is impossible, under the most favorable circumstances, to hope for more than an occasional transfixion of the papilla, and we diminish our chances of destroying it, in direct proportion as we dimin- ish the area of the acting surface of the point of the in- Michel.—Trichiasis and Distichiasis. 16 strument: hence, I do not now make the points very taper- ing. I find that, when a very tine needle is introduced into the integument, it soon decomposes the tissues in im- mediate contact with it, and then ceases to act on the solid parts ; if lield steadily, as it should he, a frothy and se- rous exudation surrounds it in the little sheath that it has made for itself. Under such circumstances more papilla? escaped than when I used larger needles. The difference in the result in either case is otherwise imperceptible. I am yet to see an appreciable cicatrix as the result of the electrolysis ; but, with very tine needles, we increase the necessity of re-applications, which are painful. These last reflections are made because it has been suggested by oth- ers that an exceedingly fine needle was an important im- provement in the method ; but I fear it might, on the con- - trary, if generally adopted, help to bring discredit on an operation which should, I think, remain until something better is discovered. A very decided improvement in the needle, however, would consist of a means of properly and permanently in- sulating its shaft, up to within 2 m.m. of its point. From the very beginning I applied to various manufacturers of surgical instruments, and also enamelers, for such a needle, but have been told that it could not practically be made. A moderately fine needle, covered with rub- ber, was the best I could obtain; but a shoulder exists where the rubber coating stops, which prevents its easy passage into the skin. Failing in that direction, I myself have coated my needles, with sliell-lac. I use the finest and hardest of photographer’s varnish, applying it with a brush or otherwise. It loosens after several applications, and must be re-applied; if carefully done, however, I believe it will answer. Just after writing the above paragraph, a trivial occur- rence has accidentally thrown in my way an instrument, which, while it is within the reach of every one, I believe will practically be perfect enough for all purposes. I had use for a pin, and selecting a black one from the family Micliel.— Trichiasis and Distichiasis. 17 pincushion, accidentally bent it; surprised at this, as I had been accustomed only to steel ones of that color, I inspected it, and found that it was an ordinary brass pin, which had been coated with a black composition. Suspecting that this was a non-conductor, I took it to my battery, and found that I was correct. The coating adheres very firmly, but can be scraped off; when heated in the flame of a spirit lamp, it emits the odor of shell-lac or sealing-wax. I am informed that they can be had at the dry-goods stores. I shall get a package, select the most perfectly coated ones (some are imperfect), and with a fine file, or better, a whetstone, make the points three-cornered. Scraping will expose as much more of that extremity as necessary. By cutting oft' the heads, and scraping that end, they can then be used in my little needle-holding electrode. This last is nothing but a delicate clamp, similar to those found on the end of the useful little tool-handles, the butts of which are filled with minute awls, chisels, saws, etc. One of my instruments is a permanent fixture of the kind ; the others consist of the terminal clamp only, which can be screwed into any other electrode handle, suitable for the mounting of different ends. Until better can be furnished, I believe that I have all that is necessary. It would be useless to gild the points of the pins, for when the coating wears off from them, the points can be cut off, and the pin sharpened higher up, or a new one substituted. Occasionally, a ciliurn is reproduced, when apparently its papilla had been destroyed. This is to be explained as follows : Since the probable position of a given papilla can only be roughly guessed at, when the needle misses it widely, from distortion of the part and displacement of the follicle, the papilla escapes, but the needle crossing the soft root of the hair sub-epidermically, at a point between the papilla and the surface of the skin, decomposes the newly- formed hair substance, and the shaft conies away easily. I have frequently recognized the accident at the time, by the appearance of the hair bulb. Recently I have attempted the preservation of all cilia 18 Michel.—Trichiasis and Disticliiasis. which were moderately healthy. In imitation of my little operation, which, by a seton thread, obtains a cicatrix near the base of the follicle, I pass my needle into the integuments in front of, and parallel with the hair fol- licle, allowing sufficient tissue to intervene, so that the fol- licle and papilla will not be injured; a very slight destruc- tion of the parts is effected; after which I keep the cilium cut close, until I find that its follicle has been sufficiently drawn outwardly. If one application does not produce the desired effect, I repeat the little operation as often as nec- essary. A number of cilia close together are treated in a similar manner; indeed, where there is simulated disticliiasis of the entire tarsal margin, I feel convinced that it could be successfully employed, and will try it. I have not yet op- erated on many cases in this manner, but so far it has suc- ceeded well, and I expect much from it. In many cases of partial, or even complete entropion, I propose carrying out the same principle. By passing- larger needles sub-cutaneously in the proper directions, and there producing cicatrices, I am satisfied that I will be able to force the lids back into their normal position. As regards the after effects of electrolysis thus practised, they are simple in the extreme. After the operation, pa- tients return at once to their ordinary avocations, feeling- relieved and comfortable. A few complain of slight sore- ness about the parts, especially if fifteen or twenty hairs have been removed at a sitting; but cold water relieves that in a short time, and by next morning it has entirely passed off. I have never seen the least continuous inflam- mation, the smallest ulceration, or other accident follow it; notably, no abscess, as once or twice did occur in the ni- trate of silver method. Something more than surgical measures is needed in the treatment of trichiasis and complicated cases of distich- iasis. Constitutional, as well as local treatment, is import- ant. The lids are to be kept scrupulously clean, but not irritated by too frequent washings ; the blandest fluids for Michel.—Trichiasis and Distichiasis. 19 this purpose are the best; Decoct. Radicis Altlise, with a slight addition [of chloride of sodium, fulfills the indica- tions perfectly. Soap must be kept away from the tarsal margins ; it is not needed; the best and mildest of them are irritants. The lids being clean and dry, apply con- stantly Unguentum Hydrg. ox. flav. (Pagentescher’s oint.); two grains to two drachms will do. See that the roots of the lashes are well anointed. This remedy almost deserves the name of specific, in the treatment of the ciliary bleph- aritis, which always exists in these cases. If the bleph- aritis is not relieved naturally, more new hair products will constantly be generated, and cause us to believe that the former hairs have not been destroyed. The constitu- tional treatment is to be tonic. I prefer the Tine. Ferri Hydro-Chlor., or the Pil. Ferri Prot. Carb. Let the iron be taken an hour or more after meals; it will not then by chemical reaction be converted into a tannate by the tea, colfee or vegetables which almost invariably enter into the diet of our patients, and will at that time meet sufficient gastric juice in the stomach to cause its easy assimilatiou. In the “ Archives of Dermatology, for October, 1878,” I find an abstract of a paper, by Dr. W. A. Hardaway, of St. Louis, read before the American Dermatological Associa- tion, at Saratoga, in August last, on the “ Treatment of Hirsuties.” His experience with my electrolytic operation, as a dermatologist, in the removal of superfluous hairs, is there given. His operations were, of course, confined to the skin proper, and especially to the complete or partially bearded faces of women. The manipulations that he em- ployed, and the results obtained, are about the same as in ophthalmic practice. Then follows the account of an in- teresting discussion, which took place upon the subject of hair destruction, during which Dr. Piffard remarked that, “ He did not see how these gentlemen were able to get the needle into the follicle while the hair was still there, on account of its minuteness,” meaning, I suppose, that the follicle is not large enough to hold the hair and the needle at the same time, Strictly speaking, this is true, but when 20 Michel.—Trichiasis ancl Distichiasis. I expressed myself thus, I supposed it would be under - stood that I forcibly introduced the needle, overdistending the follicle, perhaps rupturing it, or, more probably, split it to its base with the cutting edge of the triangular needle ; this certainly is possible with any follicle, however tine its hair may be, especially when it is remembered that the opening of the hair follicle is funnel-shaped, and that the little operation is executed under a convex lens, some- times of even an inch focus. But Dr. Piffard goes on to say : “Indeed, it is only necessary to get sufficiently near the follicle in order to accomplish the work of destruction which virtually dispenses with all difficulties even while dealing with the finest hairs. I had already given the same explanation, prior to seeing the report of this discus- sion. Further on, Dr. Piffard is made to say that “he denied that Neumann ever got into the hair follicles at all with his galvano-cautery operation, for it would certainly be most extraordinary if two wires could be introduced, without touching each other (as was essential to the pro- cess), into so small a cavity as that of a hair follicle. In Neumann’s operation there must necessarily be a great deal of burning of tissue, and this would leave an unsightly scar.” This criticism of Neumann’s operation is a rather sweeping one, and since it applies with equal, if not greater force, to my own galvano-cautery operation on the cilia, which I had already performed as early as 1869, I feel called upon to explain. Dr. Piffard is mistaken, as regards the unavoidably large size of such a cautery point; it is not necessary, as he positively asserts it is, that “two wires, not touching each other,” should constitute such a point; a little ingenuity easily does away with that difficulty. The instrument that I devised is simple in the extreme. It consists of, two insulated, stout copper wires, passing through a small ebony handle; into the terminations of these is cut two deep slits, destined to receive the point. There is a Y-shaped piece, cut from a sheet of platinum, the stem of the Y being about 6 m. m. long; the branches of the Y are tightly clamped in the slits in the copper wire, Michel.— Trichiasis and Distichiasis. 21 and the point reduced to about the size of a No. 8 sewing- needle, and sharpened. Now, when the platinum branches (which are moderately thick) are brought to a white heat, the point being but a continuation of them, is heated also, and that to a sufficient degree to cauterize. I imagine the same idea, or a similar one, probably, occurred to Neu- mann. But, when one speaks of passing an actual cautery point into a follicle to its base, from the nature of the cir- cumstances it cannot absolutely be true; for, even though the point were smaller than the follicle itself, it would de- stroy the successive parts of the follicle as it came in con- tact with it, even before it could enter its lumen ; so Dr. Piffard’s objection on this score is of no importance. That the agent is not manageable I admit; hence I discarded its use ; but the eschars are by no means as large as is inti- mated they must necessarily be, for the point is much smaller than Dr. Piffard supposes possible, and the degree of heat is not as great in the point as in the connecting branches of the platinum. Again, the point is applied only for an instant. On looking over the same number of the Archives, I find, under the head of “ Original Communications,” an article entitled, u A New Method of Permanently Removing Su- perfluous Hairs,” byL. Duncan Bulkley, A. M., M. D. It is described as follows: “ The method to be described is founded upon the idea of reaching down into the folli- cle, after extracting the hair, and throroughly breaking up its bottom and sides, thereby exciting an inflammation which seals it from its base to its orifice.” As regards the claim of originality and actual priority in the devising and execution of this method, or rather one substantially the same, I think Dr. W. A. Hardaway and some other med- ical men of this city, from their own knowledge, would not consider me uninterested. The similar proceeding already detailed in this paper is the operation alluded to ; but, as I said before, I had so poor an opinion of its success that I abandoned it long ago. It had suggested itself to me the first time that I heard of Dr. Williams’1 operation, the 1. R. L. O. H., Rep. III., 219. Michel.—Trichiasis and Distichiasis. 22 success of which, as I have already stated, I ascribed to the transfixion of an already diseased papilla. Dr. Bulkly says, in his paper : “ Two or three physicians have recent- ly mentioned to me a plan of destroying the hair follicles by means of electrolysis. * * * I am not aware that this method has been mentioned in print, nor do I know how successful or permanent the results have been.” (The results of others, of course, since the author, further on, admits that he has tried the operation himself, and, no doubt, has formed an opinion :ot liis imperfect success.) The unimportant fact, that this procedure has been in print since 1875 ; that it has also been re-copied into at least one other medical journal,1 and that a similar method is de- scribed in Piffard’s “ Treatise on Diseases of the Skin,” (London and New York, 1876), may have escaped Dr. Bulk- ley’s observation ; but, judging from the quotation above, it does appear a little singular that he seems to have for- gotten conversations on this subject, which occurred be- tween himself and Dr. Hardaway, as well as with myself, on the occasion of his visit to St. Louis, in June, 1877. Of the proposed method in Dr. paper I have a few words to say : The object of the procedure has already been quoted from the article ; the author then goes on to state that he uses a three-sided, straight, surgical, or glover’s needle, with perfectly sharpened edges; the needle is fixed in a delicate handle. Seizing the hair with a pair of forceps, he at the same time places the point of the needle at the opening of the follicle ; he now extracts the hair, and slips the needle at once into the empty follicle ; (no mention is made of a convex glass to assist in this step of the opera- tion.) The needle “is then thrust in to a little greater depth than that occupied by the hair, as shown by the root-sheatlis on the extremity of the latter, and with a del- icate touch it may be readily perceived when it has gone to the bottom, or rather when it has penetrated the latter a little, and its sides are closely embraced by the follicle,” Sutler’s Compend. Michel.— Trichiasis and JDisticliiasis. 23 The needle is then “ given a number of turns and twists, by rotating the handle between the thumb and forefinger,” thus “ thoroughly breaking up the bottom and sides of the follicle, thereby exciting an inflammation, which seals it from its base to its orifice.” This, in my opinion, is really nothing but a bad modifica- tion of my own operation. In both, the attempt is made to mechanically destroy the papilla with a needle. In my procedure the follicle is spared as much as possible, and the papilla is attacked as vigorously as possible. In the other method the follicle necessarily suffers most in degree and frequency, and the papilla least. The object of the operator and the nature of the instrument used secures this undesirable result. All of us know full well that the walls of the follicle cannot reproduce a hair, hence noth- ing can be gained by its destruction and “ sealing up.” On the contrary, should the papilla in such a case escape, as it most frequently does, there is established a most un- fortunate condition, as would naturally be expected ; hence the author is forced to admit that “ occasionally it will be found that the inflammation has sufficed to cause the ex- ternal portion of the follicle to be obliterated, while the deeper portion, where the hair is formed, still remains in- tact, or nearly so. In this event, a hair is reproduced, and not being able to gain exit, it will coil itself up, or it may run beneath the surface of the skin for a distance, and cannot be gotten at without a puncture of the overlying cuticle. In these cases it is often very difficult to reach and destroy the whole of the follicle, but it can be accom- plished with care,” and the author should have added, with the production of additional cicatrices. Other quite possible and probable results, under the same circnm- stances, would be the formation of small abscesses or cysts with the hairs in them. Now, where is the necessity for incurring such undesirable accidents ? It certainly does not appear in the article that the sealing up process had an object. The instrument used by the author, apart from its objectionable three sharp sides, is defective in a most 24 Michel.—Trichiasis and Distichiasis, important point, namely: the extremity which comes in contact with the papilla; this part is extremely fine, its cutting corners scarcely perceptible, and not calculated to lacerate, or rather cut and drill away the papilla. Now, the one which I employed was an ordinary, fine, hypodermic syringe point, the upper edges of which are blunted. If this is examined, it will be seen to very nearly fulfill every requi- site indication; the stem is smooth, and the slanting point presents two sharp and rather broad edges, admirably adapted to laceration or cutting away when it is rapidly rotated. I used a convex lens to assist in accurately plac- ing the needle-point at the orifice of the follicle, and dem- onstrated that I virtually entered the follicle (from one side, at least), notwithstanding the presence of the hair, by bringing it out attached to my needle in a fair percentage of applications ; I had fairly dug it out. Yet, with these advantages in my favor, I can agree with the author, who expresses himself thus : “ I am safe in saying that not 50 per cent, of the hairs removed at an operation will be per- manently extirpated.” Nay, I still feel very safe in plac- ing the successful results at less than 15 per cent. The reverse, however, is the case when we come to consider my electrolytic method; for, although concerning it, Bulkley says : “I have tried this in combination with my own method, but did not find that any advantage was gained over that with the needle alone,” etc. I claim that by it, fully 90 per cent, of the larger hairs are at once and per- manently destroyed, and of the downy and almost invisible hairs, about 50 per cent.