COMPLIMENTS OF THE AUTHOR. 
PATHOLOGY AND TREATMENT 
OF 
ALOPECIA AREATA. 
BY 
A. R. ROBINSON, M. 8., L. R. 0. P. and S. (Edin.), 
Professor of Dermatology at the New York Polyclinic ; Professor of Histology and Pathological Anatomy and Der- 
matology at the Woman's Medical College of the New York Infirmary ; Member of the American 
Dermatological Association, of the New York Dermatological Society ; President of 
the Section for Dermatology and Syphilography of the Ninth Inter- . - 
national Medical Congress, Washington, 1887, etc. 
[Reprinted from the “ Transactions of the Ninth International Medical Congress,’’ Yol. IV.] 
WM. r. FEU. A CO., PBS.. 1280-24 6ANSOM BT. SECTION XIY DERMATOLOGY AND SYPHILOGRAPHY. 
241 
FIFTH DAY. 
Dr. Thin, London, presiding. 
THE PATHOLOGY AND TREATMENT OF ALOPECIA AREATA. 
LA PATIIOLOGIE ET LE TRAITEMENT DE L’ALOPECIE PAR PLAQUES. 
USER DIE PATHOLOGIE UND BEHANDLUNG PER ALOPECIA AREATA. 
A. R. ROBINSON, M.8., L.R.C.P. & S., EDIN. 
Of New York. 
In attempting to open a general discussion on alopecia areata I am not unaware of 
the difficulty of the task; for perhaps no subject in dermatology has given rise to more 
scientific discussion, or upon which such opposite views exist, than that of the aetiology 
of this disease. The believers in the parasitic origin have advanced many arguments 
founded upon microscopical study of the hairs and epidermis of the affected parts, as 
well as deductions and analogies from the clinical symptoms and result of methods of 
treatment, to prove either the positive presence of organisms or the almost certainty of 
their existence as the setiological factor of the disease; at the same time they have 
endeavored to show that there is no real basis, either in the clinical symptoms or other- 
wise, for the trophoneurotic theory. And, on the other hand, those who regard the 
disease as a neurosis—and they are at present greatly in the majority—maintain, with 
equal positiveness, that the clinical symptoms are not those of a parasitic disease, and 
that microscopical examination has failed to show any organism having a proven setio- 
logical relationship to the affection ; but that all of the symptoms of the disease, even 
the peculiar manner of extension of the patches at the periphery, are not only not 
opposed, but are in favor of its having a neurotic origin. As an impartial, even if a 
somewhat incompetent, judge of the value of the statements and views of the advocates 
of the two theories, I will now endeavor to briefly review and criticise the arguments 
of both sides as given us by their advocates up to the present time, and thus attempt 
to find out whether we are justified from the facts obtained concerning its aetiology—the 
result of a study of the symptoms, natural history, results of treatment, and micro- 
scopical examinations, in forming definite conclusions as to the cause of the disease. 
Before accepting the parasitic theory it must be shown that a definite organism is 
always present at the commencement of the disease—an organism not found under 
normal states or concerned with other pathological conditions; that the pathologico- 
anatomical changes in the affected part are the result, directly or indirectly, of their 
presence, or, finally, that the disease is contagious. Cultures with inoculations would, 
if successful, naturally confirm the view of their positive setiological significance, but 
this is not absolutely necessary. I say an organism must always be present at the 
commencement of the disease, but if the eruption is not spreading their absence in that 
case wTould not be proof against their existence in an earlier stage, as the continued 
existence of an area of the skin devoid of normal hair could be the result of anatomical 
conditions of the part arising from their previous presence, just as we may have a per- 242 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
manent alopecia produced by the favus fungus and continuing long after the organisms 
have ceased being present. 
So, also, if we find organisms which are not met with on or within the shin in any 
other condition, and their situation, number, etc., would clearly explain any patho- 
logico-auatomical changes of the part in which they are situated, and no other explana- 
tion of these changes would be at all probable, then I think we would be justified in 
accepting them as the cause until the opposite was proven, as is the case, for instance, 
in tinea versicolor. If the disease is contagions—and I mean by that positive, indis- 
putable proof of its occurrence, and not a possible coincidence of the same disease 
occurring in persons who associate together—a contagious power—such, for instance, as 
we have in measles—then, with our present knowledge of bacteria, it would not be 
necessary to demonstrate the organism to prove the origin of the disease. 
Before accepting the neurotic theory, the clinical history should point very strongly 
in that direction, or the microscopical examination should show changes in the nerve 
tissue or in the skin somewhat similar to those occurring in well-known neuroses, or, 
finally, one should be able to produce the disease at will by producing certain injuries 
to certain portions of the nervous system. The upholders of this theory must show 
that the almost invariably circular shape of the patches, their manner of spreading at 
the periphery, as well as many other characters, are consistent with their view; that 
anatomical changes, if any, are such as are known to result from trophic disturbances 
of nutrition; and, finally, that if an alopecia, the result of certain experiments, be 
produced, all the spots must have the characters, in every respect, of ordinary alopecia 
areata. 
Any criticism I shall attempt upon the views of gentlemen who have written upon 
the subject will be based upon the foregoing conditions for prool of causation, using the 
clinical symptoms of the disease, the anatomical changes of the part, as they have 
hitherto been described, and the results of modes of treatment, as evidence for or 
against the two theories, as the case may be. 
Let us first consider the value of the arguments advanced by those who believe in 
the parasitic origin. And here I wish to state that, in my mind, no good grounds have 
as yet been given for the division of alopecia areata into forms depending upon the 
extent of area affected; for, apparently, at least, the aetiology, method of extension and 
condition of the parts affected, judging from the clinical history, are similar, whether 
the disease remains confined to a single small spot, or whether there are several circum- 
scribed patches of various size, or, finally, whether the entire body becomes hairless. 
Gruby, Malassez, Eichhorst, Thin, Buchner, Lassar and Von Sehlen may be regarded 
as the principal observers who have endeavored by their studies and arguments to prove 
its origin from organisms. 
As it has long been decided by subsequent observers that the fungus described by 
Gruby * is the trichophyton tonsurans, and that by Malassez f is an organism acci- 
dentally but not very infrequently found on the skin, with no relation whatever to the 
disease, alopecia areata, I will pass on to a consideration of the observations and deduc- 
tions of the other observers mentioned. 
Eichhorst X found spores in diseased hairs once in nine cases. They were situated 
between the hair and root sheath, did not color in Bismarck brown, and consisted of 
round elements of a yellowish-brown color, variable in size, the smallest appearing as 
* Gruby. “ Recherches sur la Nature, le Si6ge, et le Developpement du Porrigo Decalvans ou 
Phytoalopecie.” Oompt. rend, de V Acad, des Sc., 1843. 
f Malassez. “Note sur le Champignon de la Pelade.” Arch, de Phys. Norm., et Path., 1874, 
I, 203. 
j; Eiehhorst. “ Beobachtungen liber Area Celsi.” Virch. Arch., Bd. 78, vrn, p. 197-209. SECTION XIV—DERMATOLOGY AND SYPHILOGRAPHY. 
243 
shining, homogeneous bodies, and the larger ones somewhat like red blood corpuscles, 
with light double contour. In the latter, a small, shining, transparent body was often 
seen. The usual seat of the spores was between the hair and inner root sheath, hut an 
occasional one was observed between the epithelial cells of the root sheath. Spores 
were found on the hair as far as the root sheath remained connected with the shaft, that 
is, in the upper two-thirds of the hair follicle. Mycelia were not found. He thought 
that the fungus was related to that of tinea versicolor. 
Buchner (H.) * believes that the disease is parasitic, although he was unable to 
detect a special fungus. He suggests the small size of the organism or imperfect lenses 
as possible cause for the rarity of detection by observers of the fungus; and adds the 
fact that it is possible that single celled, non-col onized organisms can be present, yet 
indistinguishable from lifeless granules, or be hidden from observation by the tissues. 
He tried cultivation in one case, and in eight experiments always found the same 
fungus, a form of organism never observed by him as accidentally occurring in the hair* 
It consisted of small, shining, sharply-limited granules, with two line, thread-like pro- 
jections in opposite directions. He does not, however, maintain that this fungus is with 
certainty the one causing alopecia. Regarding the symptoms, he thinks that the method 
of spreading of the disease is a sufficient proof that it is parasitic in its nature. 
Dr. Thin (Geo.) f found small, shining bodies, which from their arrangement and 
other qualities he believes to be organisms, in the hair shaft and between the shaft and 
the hair sheaths. He believes that the fungus enters the hair follicle between the 
internal root sheath and the shaft, and toward the root of the hair penetrates the hair 
substance, and as it multiplies, ascends upward in the hair, breaking it up and loosen- 
ing it. 
Yon Sehlen J colored his preparations by a special method, and also made cultures 
of certain organisms which he saw. He found micrococci, especially in the outer part 
of the follicle, above the sebaceous gland opening, but also as low down as the papilla 
in some cases. They were not found in all hairs, but mostly in those with retained 
root sheaths. His drawings show the presence of micrococci without doubt, and in 
colonies. He made cultures and inoculations, but although a falling out of hair was 
observed to follow the inoculations, the course of the disease thus experimentally pro- 
duced did not very closely resemble that of alopecia areata. 
Other observers have written upon the subject and described organisms in the hair 
follicles, but as their observations give us no more proof than those already quoted, it 
is not necessary to refer to them, as the same arguments to be used against the above 
observations will hold good for these also. 
Before considering the value of these observations, it will be necessary to bear in 
mind the symptoms and clinical history of the disease, and to these I will how briefly 
draw your attention. 
As a rule, no subjective symptoms of any kind mark its onset; sometimes it is pre- 
ceded by neuralgic pains or a sense of slight burning or itching of the part from which 
the hair is about to fall out. The patient may notice for several days that his hair is 
falling out, and soon a bald spot is observed; or a large spot may form very quickly. 
* Buchner. Ueber Pilze bei Area Celsi : Sitzung d. arztl. Vereins in Miinchen. Kritisehe 
Bemerkungen zur Aetiologie der Area Celsi. Archiv f. pathol. Anatom., 1878, Bd. 74, p. 527. 
f Thin. “On Bacterium Decalvans; an organism associated with the Destruction of the Hair 
in Alopecia Areata.” Proceedings of the Royal Soc., Lond., xxxin, 1881, No. 217. “Alopecia 
Areata and Bacterium Decalvans.” Monatsch. f. prakt. Fermat., 1885, 8, p. 241. 
j; Von Sehlen. “ Zur Aetiologie der Alopecia Areata.” Virch. Arch., Bd. 99, p. 327. “ Mikro- 
kokken bei Area Celsi.” Fortsch. d. Medic., 1883, 23, p. 763. “ Zur Aetiologie der Alopecia 
Areata.” Aerzt. Intelligbl., No. 28, p. 317. 244 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The bald spots are more or less circular in outline, are usually at first quite small, 
but may gradually increase until a large surface is covered. They increase in size by 
extension at the periphery, and may remain small or cover a very large area. The 
patch devoid of hair, whether large or small, is smooth, shining, pale, sunken beneath 
the general surface; the hair at the margin of the patch is thinner than normal and 
comes out with a very moderate amount of traction. A certain number of broken-off 
hairs are frequently present. There is no redness or scaling to be observed, and usually 
all the hairs within the bald area fall out. There may be only one spot or many; when 
the latter is the case, they arise successively, and even some spots may heal while new 
ones arise. After existing for a variable time, usually several months, the disease 
frequently disappears spontaneously; in other cases permanent alopecia results, without 
giving rise to any change in the existing characters of the patch. The hairs which fall 
out show signs of interference with the nutrition of the whole hair, and not a local 
interference, as in ringworm. 
Sections of the skin have been examined by Schultze,* E. Wagner, f and Duckworth 
and Harris. J The two former found no changes whatever. The latter, in sections 
stained with hsematoxylon, found atrophy of the hair follicles, these appearing as long, 
fibrous cords ; considerable increase in the connective tissue in the neighborhood of the 
atrophied follicles, but not elsewhere ; almost entire absence of the sebaceous glands ; 
sweat glands normal ; infiltration of the hair follicles, especially of their outer sheath, 
with a new round-celled growth. In some instances remains of hair papillae were seen ; 
but the papillary loops were infiltrated with the round cell growth. No parasitic ele- 
ments were found ; but as they stained the sections with hsematoxylon only, their nega- 
tive observation is of no value whatever. The absence of any statement as to the 
duration of the disease, and as to the previous treatment, detracts much from the value 
of the case studied by them ; but from the absence of the sebaceous glands, and the 
new connective tissue formation, it was very likely one of long standing. 
The portions of the clinical history to which I wish especially to refer, are the 
manner of origin and spreading of the patches, the absence of superficial inflammatory 
symptoms in almost every case, the almost complete falling out of hair in a given area, 
the rarity of signs of local interference with nutrition of the hair shaft, the irregular 
duration of existence of the spots, the size of different patches, and the usually finally 
complete restoration to a normal condition. 
As the upholders of the parasitic theory all describe the fungus as situated either in 
the hair follicle, hair shaft, or corneous layer, we must first consider what effects are 
produced by organisms present upon or within the living or dead tissues. 
As shown by Bizzozero | and others, many organisms are constantly present on the 
normal skin, not acting upon the living tissues or taking their nourishment from them, 
but living upon the dead material, the product of secretion and desquamation. As this 
latter is inert matter it is incapable of reacting from the presence of these fungi, con- 
sequently there are no signs of interference with nutrition. In the living tissues fungi 
can produce tissue growth or degeneration, or cause inflammatory action, varying in 
intensity from a slight nutritive change to suppuration or necrosis ; or can act injuriously 
upon the normal nutritive processes of the part by abstracting nourishment from the 
'*■ Schultze. “Die Theorien iiber Area Ceisi.” Virch. Arch., 1880, Bd. 80, p. 193. 
•f Wagner. Arch. f. phys. Heilkunde, 1859. 
J Duckworth and Harris. “Case of Area Ceisi, in which the parts were examined after death.” 
Transactions Path. Soc., Lond., 1882, p. 386. 
$ Bizzozero. “Ueberdie Microphyten der normalen Oberhaut des Menschen.” Virch. Arch,, 
Bd. 98, p. 451. SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
245 
tissues, either directly or by the plugging of vessels, or hy the organisms or the produc- 
tion of a fibrinous coagulum within the latter. 
The upholders of the parasitic theory claim that the manner of spreading of the 
eruption, the occasional redness or slight scaling observed, the presence of broken hairs, 
the presence of organisms, the occasional contagious character, as apparently shown by 
reported cases, and the results of treatment, fairly prove the correctness of their view, 
at the same time that they disprove the theory of a neurotic origin. 
First as regards the manner of spreading. Every one will admit that the manner in 
which the patches increase in area, viz., hy contiguity of tissue, thus producing more 
or less circular areas of baldness, is such as to lead us to strongly suspect a parasitic 
affection, even if a fungus be not found, as this manner of spreading is the rule with 
local parasitic affections. Buchner even declares that it is absurd to suppose that an 
affection of the nerves or blood vessels can give rise to such spreading areas as occur in 
alopecia areata. As will he shown later on, however, Schultze endeavors to show that 
it is compatible with the neurotic theory, and the recent experiments of Joseph, to 
which I will presently refer, seem to confirm his statements. Nevertheless, the fact 
that all the spots spread in the same manner, although not conclusive, is a strong point 
in favor of the parasitic theory, on the grounds already mentioned, and should have its 
value as rather favorable evidence. 
As regards the method of falling out of the hairs, it seems to point rather against 
than for the cause consisting in organisms, existing either on the general surface or in 
the hair follicles. Thus not infrequently a patient finds that quite a large patch of 
baldness has evidently formed in a very short period of time, waking up in the morning, 
as they say, to find a bald spot, the first intimation they have had of their having any 
disease of the scalp. If the disease depends upon such organisms as have been described, 
organisms so difficult to find on account of their small number rather than their diminu- 
tive size, one would not expect such rapidly forming areas of baldness, certainly not 
without being accompanied by more inflammatory symptoms than are observed. So 
also the usually complete falling out of hairs in the affected area is to my mind opposed 
to the view of the fungus having its seat in the hair follicles alone, for then, as the disease 
spreads, many hairs would probably escape invasion, and there would merely be thinning 
of hair. If the fungus lived in hair follicles, and on dead epidermis of the corneous layer, 
as in ringworm, then we could have all the hairs affected as the fungus invaded contiguous 
elements. Butin this case what would we discover ? No doubt just what is seen in 
ringworm, viz., signs of inflammation or interference with nutrition, or else no change 
in the hair, as in tinea versicolor ; that is, there would be a large number of broken off 
hairs caused by a fungus at the seat of fracture, and signs of inflammation, or there 
would be no interference with the nutrition of the part invaded. We find, however, in 
alopecia, that the majority of the hairs fall out entire, accompanied frequently with the 
root sheaths, the shafts showing signs of atrophy, which I need not here describe, as 
they are not those which bear any resemblance to what would be expected from the local 
action of an organism. If the organisms were situated at the base of the follicle, they 
could, of course, possibly deprive the hair of its proper nourishment, if present in great 
numbers, by abstracting it from the follicle sheath region for themselves ; but then they 
would be in living tissue and would probably give rise to inflammatory changes, and 
should be easily detected by microscopical examination. According to Duckworth and 
Harris, already quoted, inflammatory changes were observed in sections from their case, 
but they found no fungus. I have already drawn attention to the incompleteness of the 
history of that case, and consequent difficulty of properly estimating the value of the 
histological changes observed, as the inflammation may have been produced by external 
applications for the cure of the disease. 246 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Then as regards the broken off hairs to be observed in greater or less number, 
although the number is frequently very small, in the majority of cases no fungi are to 
be detected at the seat of fracture. Furthermore, the condition of the hair in its imme- 
diate neighborhood is not such as to suggest the disintegration of fibres from organisms, 
neither, as far as lam aware, have organisms been found at that part. While, there- 
fore, the method of spreading of the patches favors the parasitic theory, the manner of 
falling out of the hairs and their anatomical condition, oppose the idea of the presence 
of a fungus within them and acting injuriously upon their structures. The possibility 
of a fungus existing in the living tissue at the base of the follicle is not, however, 
excluded; but that is not the situation which has been given by any one, except Dr. 
Thin, as the seat of the organism, but rather the part of the follicle above the place 
where the sebaceous gland duct enters it. The above criticism is, therefore, especially 
opposed to the conclusions of Yon Sehlen, and those who think the fungus is situated 
upon the general surface or within the upper part of the follicle. 
That occasionally, even if very rarely, there is some redness or slight itching or 
scaliness observed at the commencement of the disease, would show some inflammation 
with a probable local cause; but as this redness is an exceptional condition, and further- 
more, does not persist with the continuance of extension of the eruption, it can scarcely 
be considered to be the result of organisms such as have been described, even if we do 
not forget that a patch of ringworm sometimes shows no signs of inflammation. 
We will now consider the situation of the organisms, as described by the authors 
already mentioned, and the proof of their setiological connection with alopecia. 
Gruby found them surrounding the hair shafts, but his cases were evidently exam- 
ples of ringworm. Malassez found them only in the most superficial layers of the 
epidermis, and never in the hair follicles. The organisms described by him are con- 
sidered, probably by all who have worked upon the subject, as accidental organisms, 
having no pathological significance for the tissues of the scalp. Buchner found no 
fungus for certain except after cultivation of hairs. Eichhorst found once in nine cases 
a fungus between hair and root sheath, having some resemblance, according to him, 
to the fungus of tinea versicolor. These four observers all describe a different organ- 
ism, and all have failed to show the slightest relationship between the fungus and the 
alopecia. As regards Eichhorst’s fungus, on account of its size there should have been 
no difficulty in detecting it in every case of the disease, if it was a constant element 
and the cause of the disease. As he found it only once in nine cases, we can dismiss 
the observation as being valueless in the question of aetiology. 
Dr. Thin found the elements which he considered to be bacteria, in the situations 
already described, and attributed to the growing organisms the loosening and falling 
out of the hairs. He did not stain the bodies he saw, or make cultures and inocula- 
tions. The objections to the conclusions are that the hairs, as a rule, do not show signs 
of breaking up and disintegration, such as would be produced by a fungus growing 
within them. It is not necessary to repeat the observations of Hutchinson* (J.), 
Michelson, Rindfleisch,t Kaposi, J Schultze,| and others, all of which tend to show 
that the splitting up or fibrillation of the hair shafts, which sometimes occurs, is the 
result of an atrophy from interference with the factors engaged in hair production, and 
not from direct action of an agent upon the hair structure, after its formation is com- 
There remain still for consideration the studies of Dr. Thin and Yon Sehlen. 
*J. Hutchinson’s “Report on the Natural History, Diagnosis and Treatment of Alopecia 
Circumscripta.” London Medical Times and Gazette, 1852, I, page 165. 
•f Michelson, Rindfleisch. “ Area Celsi.” Arch. f. Dermatol, und Syph., Prag, 1869, i, p. 
483. 
X Kaposi. “ Pathologic und Therapie der Hautkrankheiten,” 1880. $ Schultze, Ibid. SECTION XIV—DERMATOLOGY AND SYPHInOGRAPHY. 
247 
pleted. It can be argued that the deductions from these observations are not correct, 
and that the fatty degeneration, the longitudinal fibrillation, or transverse fractures 
observed, are the result of interference with the hair struct ure. As these nutritive 
changes are found in only a small proportion of the hairs of an affected area, and organ- 
isms have not been invariably found at the seat of fracture, while the majority of the 
hairs have an unchanged consistence and show none of these breaking-up changes, the 
loose hairs, accompanied with or without their root sheaths, having the hair root usually 
thin and pointed and pale in color, while the upper part of the hair is larger and darker, 
and the free end fibrous or brush-like in character, these deductions may be considered 
justifiable. Schultze found that the splitting up of ripe hairs appears only on certain 
parts of the shaft, the best examples occurring in dry atrophic hairs, poor in pigment, 
and in a stage of “Schalt” or “ Beeth ” hair condition. In these cases a frequent 
absence of the root sheath and of the normal hair cuticula favors splitting of the shaft. 
The medulla is frequently absent. These, together with the other changes which have 
been described by observers, make the seat of origin of the nutrition changes not 
within, but outside of the follicle, i. e., in the factors concerned in hair production. 
Still, as already mentioned, organisms might be situated within the follicle, and, by 
abstracting or taking up the nourishment intended for the hair growth, produce the 
falliug out of the hair. They are, however, not found in the ordinary atrophied hairs, 
or in hairs not yet loose; and other observers have very rarely found organisms in the 
lower part of the follicle; and, furthermore, if they were confined exclusively to the 
lower part of the follicle, not existing upon ordinary dead epidermis, the patches would 
not be round in form, since for this to occur the organisms, if on the exterior of the 
body, must be able to exist on the general surface—the corneous layer, to produce a 
regular spreading patch. On these grounds we must conclude that no connection has 
been shown, from a clinical or histological standpoint, to exist between the elements 
described by Dr. Thin and the disease alopecia areata, although some of the changes 
observed in the broken hairs may be caused by the organisms described by him. 
Yon Sehlen,* whose work drew renewed attention to the aetiology of this disease, dis- 
covered micrococci organisms in considerable numbers, situated principally in the hair 
follicles, above the place where the sebaceous gland duct enters the follicle. They were 
not found in all hairs, but mostly in those with retained root sheaths after epilation, 
and possessed sufficient distinctive characters for other observers to substantiate his 
observations. He also made cultures and inoculations, with the result of causing a loss 
of hair in the part subjected to the experiment, although the hair did not fall out in 
the manner peculiar to alopecia areata. 
From these observations, then, we learn that a certain organism is very generally 
present, but, as already shown, organisms upon the general surface, or at the openings 
of hair follicles, cannot produce the symptoms of this disease. That inoculations fail 
is to my mind no proof against its parasitic nature, for the tissues in the animals 
experimented on may not have been favorable for their growth. The fatal objection, 
however, to these organisms having any setiological connection with alopecia is that 
Bizzozero,f Bordoni-TJfifeduzzi, j: Michelson \ and others maintain that they have found 
a similar fungus under normal conditions, that they have cultivated this fungus and 
*lbid. 
fßizzozero. Ibid. 
X Bordoni-Uffreduzzi. “Ueber die biologischen Eigenscbaften der normalen Hautmikrophy- 
ten.” Fortschr. d. Mediz, 1886, No. 5. 
g Michelson. Fortschritte d, Med., 1886, No. 7, p. 230. “Ueber die sogen. Area. Kokken.” 
Virchow’s Archiv, 1885, Bd. 99, p. 572. Bemerkung zu don Arbeiten des Herrn. Dr. von Sehlen 
“ fiber die Aetiologie der Alopecia Areata. Zur Discussion fiber die Aetiologie der area eelsi.5’ 
Virch. Arch., 1880, Bd. 80. 248 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
made inoculations, with the result that, if much material was used, signs of inflamma- 
tion were produced. 
Bender * found similar organisms to Yon Sehlen’s in all his seven cases hut one, and 
also in the normal scalp, and made cultures and inoculations, but with negative 
results. 
Bordoni-Utfreduzzi thinks these organisms are normal to the part. He made inocu- 
lations after cultivation, and if many organisms were used the scalp was irritated, 
while if there were only a few no signs of inflammation appeared. He examined 
hairs from the normal scalp of himself and others, and found microcochi colonies of 
similar appearance as those described by Yon Sehlen. 
These observations and experiments by inoculation strengthen the arguments which 
I used against the cause of the disease being any organism on the general surface, or 
within the hair follicle, on account of the absence of signs of inflammation. 
Yon Sehlen denies the correctness of the observations of his opponents, and I think 
we should not forget that previous to the time Von Sehlen described these organisms, 
organisms present in considerable numbers, some of these observers stoutly denied the 
existence of fungi of any kind on the scalp in Alopecia areata, showing surely that they 
were not very careful observers. 
If the disease is parasitic and the organism situated in the parts described by Von 
Sehlen, anti-parasitic remedies should almost invariably and quickly control the disease. 
As the inoculation experiments were unsuccessful; as similar organisms have been 
found in normal skin; as the situation of the fungus is such that the production of hair 
would not be interfered with; as inflammatory symptoms are absent, and anti-parasitic 
treatment frequently unsuccessful, we cannot admit that Yon Sehlen has proven his 
view, or even made it probably a correct one. 
As regards the contagiousness of the disease, although some cases have been reported 
which would suggest its contagious nature, yet the disease may be regarded as non-con- 
tagious in the ordinary sense of the word. In Hutchinson’s forty-two cases no two 
occurred in members of the same family or playmates. Experiments by inoculation 
from head to head, and upon places of a scalp of a person already affected, have always 
given negative results, so that the upholders of the parasitic theory receive no support 
on this point, but rather the opposite. I believe, however, that we should not lay much 
stress upon the absence of proved contagion. Alopecia is a rare disease, and conse- 
quently if it is parasitic, the ground is rarely in a favorable condition for the 
growth of the organism ; hence failure of inoculation is no proof of its non-parasitic 
nature. We know how numerous the organisms are in tinea versicolor, and that fur- 
thermore they live upon the very surface, a situation most favorable for contagion, yet 
the disease is not a contagious one clinically speaking. The same is true of tubercu- 
losis, and even in such a severe disease as osteo-myelitis organisms injected into the sys- 
tem have failed to induce the disease until the bones were previously injured. All this 
goes to show that absence of frequent examples of contagion is no proof of a disease 
not being parasitic in its nature. At the same time, the few cases of alopecia reported 
as showing its contagiousness should not be regarded as of much value when the non- 
contagious character is generally so evident. 
When we come to study the treatment recommended, it is to be observed that reme- 
dies that are anti-parasitic in their action are the only ones recommended; and, according 
to the latest views, such remedies as corrosive sublimate and sulphur are positive in 
their effects That the disease has a tendency to disappear spontaneously and at very 
uncertain periods of its existence, interferes considerably with our ability to judge of 
* Bender. “ Ueber die Aetiologie der Alopecia Areata.” Deutsch. Med. Wochemchrift, Berlin, 
1886, xn, p. 817. SECTION XIY DERMATOLOGY AND SYPHILOGRAPHY, 
249 
the results of treatment in single cases ; but when a large number have been treated 
by anti-parasitic remedies with uniform success, as in the fifteen cases reported by Dr. 
Thin,* we are justified in attributing the result to the remedy. It has been maintained 
that all these remedies are more or less irritant in their action also, and that, perhaps, 
it is to this quality that any beneficial effect is due. Irritating applications, as blister- 
ing, or croton oil of a strength sufficient to produce marked dermatitis, have been em- 
ployed exclusively by some, and these applications continued for weeks if necessary. 
Those who have treated cases in this manner must have observed very often favorable 
results; but such results do not show the disease to be non-parasitic; for do we not use 
the same means sometimes to cure inveterate cases of tinea tonsurans ? So, also, the 
fact that many cases resist the use of anti-parasitic remedies is not a proof that organ- 
isms do not cause the disease. How many cases of ringworm resist treatment for 
months and months, although the fungus is situated in not very inaccessible regions; 
and if the organisms are deeper seated, as in lupus vulgaris, anti-parasitic applications 
are of but little value, indeed. Then, further, it does not follow that if an organism 
is the cause of the disease, it is still present in old, non-spreading areas, no more 
than the fungus of favus, for instance, is present, because we see the results of its action 
in permanent alopecia. It may have been present and produced directly or indirectly 
the changes which led to the alopecia areata; and the nutritive disturbances continue 
indefinitely, although the organism has long ceased to be present. In that case, anti- 
parasitic remedies as such could have no effect. To judge of their value, then, they 
should be used in an early stage of the disease, or while the alopecia spot is increasing 
in size; and in these cases they have been found to be very frequently of benefit by 
many observers, while, according to Lassarf and Thin, their action is prompt, positive 
and decided. 
To sum up the results of treatment, we find that remedies anti-parasitic in their 
action are the most certain means we possess at present for the treatment of alopecia 
areata, although they are not always to be relied upon. 
We have thus seen that the absence of signs of superficial inflammation, the char- 
acter of the falling out hairs, the negative results of inoculation of the cultured organ- 
isms observed, the apparently non-contagious nature of the disease, and the frequent 
failure in treatment of anti-parasitic remedies, render it fairly certain that the disease 
does not depend upon organisms situated either upon the general surface or within the 
hair follicles. The finding of organisms in these situations is of itself no proof what- 
ever of an etiological relationship to the disease, for Bizzozero and others have shown 
that many forms exist upon the normal scalp. 
The upholders of the neurotic theory have, until lately, depended principally upon 
the clinical symptoms, and the failure of observers to show an organism having an setio- 
logical relation to the disease. 
The clinical symptoms which they believe point to a neurosis are Ist, changed sen- 
sibility of the part; 2d, neuralgic symptoms appearing before or during the disease; 
3d, heredity. They further support their view of the significance of these symptoms, 
by inferences from comparisons with other diseases of a known neurotic character, in 
which there is falling out of hair, and from experiments which show that alopecia can 
be produced at will by injury to certain parts of the nervous system. 
We will pass rapidly over the arguments for the neurotic origin, with the exception 
of the experiments of Joseph; for, as Michelson justifiably wrote before these experi- 
* Thin. “Alopecia Areata.” Br. Med. Jour., 1882, n, 783. “ A further contribution to the 
Treatment of Alopecia Areata.” Brit. Med. Journ., 1882, n, 828. 
f Lassar. “ Die Uebertragbarkeit der Alopecia praematura.” Monatschr. f. pr. Derm., 1882, 
p. 131. Deut. Med. Wochenschft., 1885, p. 531. 250 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
merits were made, “dass auch dieser Theorie (der neurotischeu) bei dem derzeitigen 
Stand der Wissenschaft eine solide Basis nocb durcbaus fehlt.” 
Micbelson* found tactile sensation, electro cutaneous sensibility, pressure and tem- 
perature sense unchanged, sometimes even increased. The absence of perverted sensi- 
bility, however, is not against a nervous origin, as in Joseph’s experiments there was 
no change in the sensibility of the part. Hence, the argument of a changed sensibility 
in the part has no decided value. 
That neuralgia frequently precedes or accompanies the disease is an accepted fact; 
but alopecia areata also frequently occurs without antecedent or present nervous symp- 
toms. Collier f reports a case of a boy who was struck with the fist over the left ear, 
causing intense neuralgia, lasting two weeks; it then ceased and was followed by alopecia 
areata of the left parietal region. In Mr. Hutchinson’s forty-two cases only four com- 
plained of severe headaches. Cases have been reported of the headache ceasing when 
the hair had fallen out. But the number of cases accompanied or preceded by neural- 
gic symptoms is too few to justify us in attaching any special importance to the condi- 
tion, at least in the sense of cause and effect. 
The argument of deduction from analogy by observation of certain nervous dis- 
turbances producing alopecia is of more value. A few examples will suffice. 
Dr. Crocker reports a case of a boy who fell upon his head, and soon became com- 
pletely and permanently hairless. Kinney J reports a case of general alopecia six to 
eight days after a shock caused by lightning striking a tree near the patient. Unna $ 
reports a case in which epilepsy, hemicrania, Graves’ disease and alopecia areata all 
appeared simultaneously after a severe fright. 
Fredet || reports a case of a female, age seventeen, of previous good health, who was 
sitting at a window when the floor fell in. She caught hold of the window frame, and 
held on till released. No loss of consciousness or nervousness followed. On the follow- 
ing night she had headache, chilliness and disturbed sleep, and on the following morning 
weakness of the legs, nervous excitement, convulsive movements of the fingers and 
great itching of the scalp. Two days later the hair began to fall out on the scalp, and 
in a few days there was general alopecia. One month later the scalp was pale, smooth, 
with normal sensibility, no itching and no lanugo hairs. After two years’ treatment 
there was no return of growth of the hair. 
Schiitz (Jos.) reports a case of alopecia from peripheral lesion. The bald spot, 
however, was not round, but triangular in shape, was not sharply limited, and there 
was general thinning of the hair. The bald spot corresponded to the area of the occipi • 
talis magnus nerve. 
Many cases could be reported of somewhat similar character, all of which show us 
that alopecia can be the result of a neurosis. They have not shown, however, sufficient 
similarity in the clinical symptoms with alopecia areata as to justify us in regarding 
the latter as depending on similar conditions. Furthermore, the shape of the bald 
patch in Schlitz’s case suggests a different cause from that producing ordinary alopecia 
areata. 
Nevertheless, all these observations only allowed theoretical deductions and ana- 
* Michelson. “ Ueber Herpes Tonsurans und Area Celsi.” Volkmann’s Sammlg., 1877, No. 
120; also Virch, Arch,, Bd. 80 and 99. 
f Collier. Lancet, London, 1881, i, p. 951. 
j; Kinney. Virginia Med. Monthly, 1881, vn, p. 937. 
| Unna. Vierteljahrsch. f. Dermat. und Syph., Bd. xiv, p. 138. 
(| Fredet. Archiv. General, 1878. 
•j[ Jos. Sohiitz. “ Beitrag zur Aetiologie und Symptomatologie der Alopecia Areata.” Monatsch. 
f. Prakt, Dermat., 1887, p. 97. SECTION XIV—DERMATOLOGY AND SYPHILOGRAPHY. 
251 
logical conclusions of doubtful justification, without giving a positive proof that alo- 
pecia areata depends upon some abnormal condition of the nervous system. 
The experiments of Max Joseph* are entitled to much more consideration, even if 
all will not agree with him, that they justify us in considering alopecia areata as a tro- 
phoneurosis, a disease depending upon an affection of trophic nerves. 
He removed the spinal ganglia of the second cervical nerves, and observed between 
the fifth and twenty-seventh day following the operation, falling out of the hairs in the 
region supplied by the injured nerve. On one or more circumscribed, twenty-pfennig- 
piece-sized places, with normal-looking skin, the hair became thinner in round, oval, or 
longish areas, and, later, complete baldness occurred. The spots also afterward increased 
in size to a fifty-pfennig or mark piece. The falling out of the hair was not accompa- 
nied by any marked change in the sensibility of the part. Microscopical examination 
showed atrophy of the hair papillae, with complete absence of hair, the root sheaths 
lying close together or separated by a small vacant space. The sweat and sebaceous 
glands were unaffected, and there were no symptoms whatever of inflammation present, 
the characters of the tissues being those of the purest simple atrophy. As he was able 
to exclude traumatic influences and vasomotor nerve action as factors in the production 
of the alopecia, he believes that he has proved the existence of pure trophic nerves, and 
that alopecia is the result of injury to them. In contradistinction to alopecia, as has 
Fig. 1. 
been observed after injury to the nervous system, in which the form of the spots has 
been triangular, longish, irregular, with thinning of the hair, the spots were roundish 
and rather sharply limited. He endeavors to explain why the spots may be round, and 
also why they present this form as they spread peripherally and occupy new nerve ter- 
ritory; but his explanation will hardly convince those who have seen immense areas 
deprived of hair by peripheral spreading of the disease from a small, round spot. 
While it is true that the spots of alopecia areata generally retain the rounded form 
as they continue to increase in size, and have this form even when occupying a large 
area of the skin, yet it not infrequently occurs that the disease ceases to spread at one 
part of the circle while it extends by contiguity of tissue at other parts, in the manner 
so frequently observed in a serpiginous tubercular syphilide or a lupus vulgaris of the 
extremities. Thus, a patch which was previously round may assume the form shown 
in Fig. 1, where the parts at 6 continue to spread, while at ait is stationary. Now, if 
Joseph’s explanation is correct, the extension at the periphery must be equal at all 
parts; that is, such a method of spreading of a patch as I have described above could 
not occur as the result of an injury to the trophic nerves. 
* “ Experimentelle Untersuohungen iibsr die Aetiologie der Alopecia Areata.” Monat.f. 
Prakt. Dermat., 1886, v. 483. 252 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
It is not necessary to relate the objections—evident to every one—to this theory, for 
the explanation of the occurrence of widely separated and irregularly distributed sec- 
ondary spots of alopecia, or of the disappearance of some spots with the simultaneous 
appearance of new ones, or of the manner of spreading when general alopecia results 
from gradual invasion of all parts of the cutaneous surface, from peripheral spreading, 
bald spots. 
The symptoms in the case reported by "Wagner, of measles in a patient with alo- 
pecia, in whom the eruption did not appear upon the bald spots, as being one support- 
ing the neurotic theory, can be much easier explained by deficient blood supply in the 
part, in consequence of which the inflammatory symptoms of measles could not well 
show themselves. 
Joseph’s experiments prove the presence of trophic nerves, and the dependence of a 
form of alopecia upon a neurotic affection. Whether this alopecia is similar to the 
usual form observed we will endeavor, later on, to consider and decide. 
Joseph’s experiments have been confirmed by Mibelli.* In the latter’s experiments 
the bald places appeared not only after excision of the spinal ganglion of the second 
cervical nerve, but also after simple interruption of continuity of this ganglion, and of 
the nerve bundle passing from it. Also the bilateral and symmetrical appearance of 
spots tar removed from the region supplied by the trigeminus was observed. 
That alopecia is sometimes observed in persons with lowered nutrition, that it is 
sometimes hereditary, or that relapses occur, as in Hardaway’s case,f in which there 
was a return for four successive years of alopecia, always in the Spring, and always 
upon the same spot—all these facts have no weight for or against the parasitic or 
neurotic theory. 
Against the neurotic theory is the usual absence of nervous symptoms, the manner of 
spreading of the patches, the results of treatment based on this theory, and the tendency 
of the disease to spontaneous recovery with restitution of the part to a normal con- 
dition ; for atrophic processes of neurotic origin show a tendency to progressive loss of 
tissue. 
While, therefore, the upholders of the parasitic theory have not definitely proven 
anything, although the course of the disease and the results of treatment favor this 
view, the defenders of the neurotic theory have shown that hair can fall out from 
injury to cutaneous nerves, and that the manner of falling out and the shape of the 
bald patches may resemble very much that of alopecia areata as ordinarily encountered. 
My own observations on the setiology and histology of alopecia areata comprise the 
microscopical examination of portions of affected skin removed from the scalp of seven 
different individuals. The duration of the disease in these different cases varied from 
one week to several years, and the clinical characters from a rapidly disappearing to a 
permanent alopecia. These observations have been carried on at intervals during the 
last eight years—at intervals, because it is difficult to obtain the consent of persons to 
the removal of a portion of skin from their scalp for purposes of study only. Some 
of the excised pieces were hardened in Miller’s liquid and alcohol, and afterward cut 
into sections and stained for the anatomical changes ; while others were immediately 
put into alcohol and afterward cut and stained for examination for organisms and ana- 
tomical changes. The majority of the pieces excised were removed from the peripheral 
portion of a bald spot in process of extension, and included a portion of skin from which 
the hairs had not yet all fallen out. In three patients, including recent and old cases, 
pieces were also removed from the centre of a bald area in order to study late changes. 
*'Mibelli (V). “Riserohe sperimentale sulla etiologia dell’ alopecia areata.” 8011. d. sez. d. 
cult. sc. med. n. r. Accad. d. fisiocrit. di Siena, 1887, v. 636-68. 
■{■Hardaway. Journ. Cutan. and Vener. Diseases, 1884, p. 260.. SECTION XIY—DERMATOLOGY AND SYPHILOGRAPHY. 
253 
In four of the cases more than one piece was excised, and in one patient four pieces 
were removed at different periods of the disease. 
I -will first describe the tissue changes observed in a case of about one week’s dura- 
tion. the size of the patch being about two-fifths of an inch in diameter, round, sunken 
beneath the general surface and devoid of hair. The excised portion included some of 
the hairy margin. When I say the spot was of one week duration, that refers to the 
length of time since falling out of the hair was observed; the cause of the alopecia must 
have been acting for a considerably longer period to produce the atrophied condition of 
the hairs present. This patient, a boy fourteen years of age, had another spot of two 
years’ and one of several months’ duration. His physical condition and general health 
were excellent, and he had never suffered from headache or neuralgic symptoms in any 
part of the body. The alopecia disappeared in two spots in a few weeks, and in all 
within four months. 
Fig. 2. 
a, epidermis ; b, embryonic cell collection around bloodvessels; c, corium ; d, external root sheath of 
hair; e, space previously occupied by hair shaft. 
After hardening in alcohol and sections made, the microscopical examination showed 
the following anatomical changes : The epidermis, including both the corneous layer 
and rete, were normal. The papillary layer of the corium was but very slightly changed; 
in some papilla} there were signs of slight inflammation, as shown by the collection in 
limited numbers of embryonic corpuscles (white blood corpuscles?), while others 
appeared to be normal. In the corium proper, especially in its upper portion, beneath 
the papillary layer, signs of inflammation were very evident, especially in the peri- 
vascular regions, as shown by a marked embryonic cell infiltration and dilated blood 
vessels, as shown in Fig. 2. 
This cell infiltration was not general throughout the corium, but limited to areas; 
that is, there were parts of the section which appeared to be in a normal condition, 
while others showed varying degrees of inflammation. There were no signs of special 
serous exudation, the changes being more like those observed in a small-celled iufiltra- 254 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
tion, such, for instance, as occurs in a chronic interstitial nephritis. Neither did the 
inflammation appear in the perifollicular region more than in other parts, although in 
some sections a marked perifolliculitis was observed. 
The connective tissue corpuscles were much more distinct than normal, and it 
seemed that in many places there must have been an active proliferation of them—a 
formative inflammation. 
The subcutaneous tissue was normal. The blood vessels were dilated where the 
embryonic corpuscle infiltration existed to any extent, and some of the smaller arteries 
contained a fibrinous coagulum. 
Some of the lymph vessels in the corium and subcutaneous tissue were greatly 
dilated, and in some situations contained a fibrinous coagulum similar to that already 
mentioned as being present in the blood vessels. 
With the exception of this coagulum the subcutaneous tissues were normal. 
The sebaceous and sweat glands were normal in appearance. 
The hair follicles were either empty or contained normal or languo hairs. In Fig. 2 
is shown a hair follicle from which the hair has fallen out; the external root sheath, as 
far as shown, is normal in appearance and the internal root sheath is also to be seen. 
In some cases no papilla was to be found, the lower part of the contents of the follicles 
consisting of epithelial cells devoid of pigment, these cells forming a small hair shaft— 
a lanugo hair further up in the follicle. 
In other hairs and hair follicles nothing abnormal was to be detected. Some of the 
hair shafts showed signs of interference with nutrition, there was splitting up and 
fibrillation of the shaft in a few cases and an occasional stubbed hair. 
The anatomical changes, then, in this case were, a mild inflammatory condition of 
the corium, especially of the upper part, and occasionally of the papillary portion, a 
small-celled perivascular infiltration and connective tissue corpuscle proliferation, a 
falling out of the hairs and their replacement by lanugo ones, and finally coagulation 
within some of the blood vessels and lymph channels. In another case, in which the 
disease lasted only a few weeks, the hair rapidly growing again after using an oleate of 
mercury application, similar conditions were found. 
The next case from which sections were studied, was that of a man who in six 
months’ time had lost fully one-half of the entire hair of the scalp. The loss he 
attributed to mental despondency in consequence of the death of a child just previous 
to the appearance of the alopecia. 
In Figs. 3, 4, 5, 6, 7, 8, 9 the anatomical changes are shown. There were the same 
signs of inflammation as in the first case, only they were more marked in all parts of 
the corium, including the papillary layer. The embryonic cell collection in perivascular 
areas was quite considerable, and beyond that region not a few were also observed. 
The inflammatory changes are very evident by examination of a part of a section 
shown in Fig. 3. 
Fibrinous coagula within the blood and lymph vessels were very distinct, and in Figs. 
4 and 5 it is shown within a lymph vessel at the commencement of the subcutaneous 
tissue; in Fig. 4 the extent and situation of this coagulum are shown under a low 
power, and in Fig. 5 a part of the coagulum is drawn under a higher power. As the 
drawing, Fig. 4, was made by means of a camera lucida, the proportions are correct, 
and the lymph vessel at h is seen to be much dilated and the coagulum to be a long 
one. 
Some of the arteries also contained a fibrinous coagulum, not only the vessels of the 
corium but also of the subcutaneous tissue. This coagulum completely or only par- 
tially filled the lumen of the vessel. 
In Fig. 6, is shown a transverse section of such a vessel. 
The sweat glands were normal. Fig. 8. 
a. Corneous layer; 6. rete mucosum ; c. papillary part of corium ; d. upper part of corium ; e. deep part 
of corium; /. blood vessel with round cell infiltration around it; g. micrococci. 
Fig. 4. 
Section under a low power, a. Epidermis; b. corium ;c. subcutaneous tissue ; d. hair-follicle orifice; 
e. unstriped muscle; /. sebaceous gland; g. sweat gland; h. lymph vessel. 
Fig. 5. 
Fig. 6. 
Fibrinous coagulum in lymph vessel of upper part of subcu- 
taneous tissue; a. lumen of lymph vessel; b. fibrinous 
coagulum ; c. subcutaneous connective tissue. 
Transverse section of an artery ; a. 
fibrinous coagulum in lumen of 
vessel. 256 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
In one or two instances there were signs of commencing degeneration of a part of a 
sebaceous gland, but beyond that they appeared to be normal. 
The hairs had either fallen out of their follicles or showed characters pointing to 
such a process. The root of the hair showed atrophic changes—the external root 
sheath was becoming separated from the follicle sheath preparatory to being cast off 
with the hair, or remained united, and the hair without the sheaths falls out. 
In Fig. 7, at e, the separation between the follicle and hair-root sheath is shown, 
and can be compared with the normal condition present at c. 
The round-cell collection is shown under a higher power, and also its limitation to a 
small area. In this drawing two hair follicles are cut across—in the one the external 
root sheath is seen to be separated from the follicle sheath while in the other it is con- 
nected with it, as in normal conditions. 
Fio. 7. 
Fig. 8. 
Transverse section of a hair follicle, a. sweat gland ; 
b. round-celled infiltration ; c. first row of cells of 
external root sheaths united to follicle sheath ; d. 
section of hair - e. abnormal space between follicle 
sheath and hair-root sheath. 
Lanugo hair; a. hair 
shaft; b. external 
root sheath. 
None of these three patients had used any local applications previous to removal 
of the portions of skin, yet in all the inflammatory symptoms in the corium were 
distinct, while the epidermis appeared to be normal. Where lanugo hairs existed 
the hair papilla was absent or only an indication of its existence could be detected; the 
lower part of the follicle being filled with epithelial cells corresponding to those of the 
external root sheaths and the slight hair shaft commenced to be formed high up in the 
follicle. 
All the lanugo hairs which I have studied in this disease had their origin in this 
manner, and probably continue to be produced as long as the external root sheath is 
composed of well-formed epithelial cells. If that view is correct, then an absence, for 
any length of time, of hair of any description would indicate atrophy or destruction of 
the hair follicle and consequent permanent alopecia. SECTION XIV—DERMATOLOGY AND SYPHILOGRAPHY. 
257 
In Fig. 9 is shown the upper part of a hair follicle with a lanugo hair and the 
inflammatory round-cell infiltration in the perivascular tissue of the corium. 
The external root sheath very frequently shows irregularity of contour from hyper- 
plasia of the epithelium, the increase in growth occurring at any part of the follicle, 
although most frequent in the lowest portion. 
In Fig. 10 is shown such a hyperplasia, and the occurrence of similar conditions in 
this disease is altogether too frequent to he regarded otherwise than pathological, and 
signifies increased nutrition to the structures affected. 
The next two cases, from whom portions of skin were removed, had had the disease 
for years, and one still has it; the hair of the scalp, eyebrows and beard of the latter has 
all fallen out, and in the former the hair grew in after several months’ treatment, in all 
the situations affected, except the lower part of the occiput, and here not even lanugo hairs 
Fig. 9. 
Fig. 10. 
Fig. 11. 
Transverse sec- 
tion of artery 
showing 
thickened 
walls, a. lu- 
men of vessel. 
Section in lanugo hair area. 
a. hair-follicle orifice; ft. 
perifollicular round-cell 
infiltration. 
Hair follicle filled with epithelial cells and 
having irregular outline, from increase 
in cells of external root sheath, 
were to he observed when he first came under my observation seven or eight years ago, 
and none have appeared since, consequently the spot will he permanently bald. In 
removing pieces of the skin I always took some from the spreading periphery. In these 
two patients the same inflammatory changes already described were observed, but in 
addition there was thickening of the walls of many of the blood vessels, as shown in 
Fig. 11, and atrophy of others. 
In some vessels the lumen seemed almost closed, while the walls were several times 
thicker than normal. In both cases there was thinning of the epidermis and diminu- 
tion in the size of the epidermic cells. In the case of subsequent recovery the sebaceous 
glands were particularly well developed, as a rule ; in the other patient more or less 
degeneration was frequently observed in some glands, while others were unaffected. 
The hair follicles were either devoid of hair or contained a lanugo hair, or a hair in 
process of being cast off. In this case the hair showed the nutrition changes already 
described by observers, and which do not differ much from those seen in normally fall- 258 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ing out hairs. These changes will be fully described in a more complete paper on this 
subject, and they are not necessary for the purpose of the present discussion. 
The fat tissue was normal in both cases, as also the subcutaneous tissue, which was 
present in normal amount, the fat cells being well developed. 
Fig. 13. 
Fig. 12. 
Portion of a sebaceous gland in a case of chronic per- 
manent alopecia areata, a. degenerated gland 
epithelium; b. connective tissue framework; c. 
unstriped muscle bundle. 
Lower part of hair follicle in case 
of chronic alopecia areata, a. 
hair papilla; 6. empty space 
between papilla and follicle 
epithelium; c. space, probably 
artificial, from hardening in 
M tiller liquid ; d. pigment col- 
lection. 
The appearances I am now about to describe were observed in a case that I saw only 
once, about eight years ago. The disease at that time had existed several years and 
occupied almost the entire scalp, and I have lately learned that it still continues in as 
severe a form as at that time. Sections of the skin removed showed more or less atrophy 
of all the structures except the blood vessel walls. The epidermis was thinner, the 
corium also somewhat thinner ; there was considerable atrophy of the fat tissue, the 
sebaceous glands in some cases were normal, but in many instances were degenerating 
and disappearing. Sometimes only the remains of the glands were to be observed. In 
Fig. 12 is represented a part of a sebaceous gland, the structure of which is already 
broken down in the greater part and the rest undergoing degeneration. SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
259 
The fat tissue showed the ordinary appearances observed in simple atrophy, but, as 
in the case of the sebaceous glands, there was considerable fat tissue but slightly, if 
any, affected. 
The hair follicles showed signs observed in normal falling of hair, or marked signs 
of atrophy and disappearance of papilla and follicle. 
Depending upon the extent of these changes lanugo hairs were present, or only an 
empty space within the hair follicle previously occupied by a hair. The anomalous dis- 
tribution of pigment was very striking in several instances. Instead of being in the 
usual situation, it was distributed in clusters irregularly within the hair papilla, among 
the epithelial cells of the hair follicle and in the perifollicular connective tissue. In 
Fig. 12 this anomalous pigment deposition is shown. 
In Fig. 13, however, very different anatomical changes are seen. The follicle 
sheaths are atrophied and shrunken, the basement membrane is greatly thickened, show- 
Fig. 14. 
Section of hair follicle in advanced permanent alopecia areata, a. root of hair •6. basement membrane; 
c. follicle sheaths. 
ing the teeth-like strise, the hair papilla has disappeared, and the hair itself is being 
cast out. 
Here it is seen that the process does not resemble the normal one, for there are no 
structures left behind from which a new hair could arise. Fig. 13 represents, no doubt, 
an earlier stage of a similar process. In it the entire follicle has lost its usual form, the 
papilla is still normal as regards shape, and pigment is deposited in it in irregular 
masses. The condition shows interference with hair growth from disturbance in the 
circulation apparatus. 
This patient was sent to me for consultation, and from the above changes in struc- 
ture, I gave the opinion that the alopecia would be permanent. 
The hairs were either absent from the atrophied hair follicles, or, if present, were of 
the lanugo variety almost without exception. In the rare example of papilla hairs the 
shaft showed longitudinal splitting up, fibrillation and easy transverse fracture. 260 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
In Fig. 15 is shown the degeneration of a sebaceous gland and fibrillation of a hair. 
The base of the follicle is filled with round cells and the follicle sheaths are indistinct. 
The section did not color well, and the transverse fracture observed in the shaft is, no 
doubt, mostly artificial, consequent on the hardening of the section, the normal coher- 
ence of the cells with each other having become much interfered with, from atrophy. 
The blood vessels in some places were atrophied while the arteries showed thickened 
walls, from increase in the connective tissue, with diminution in the size of the lumen 
of the vessel, a condition similar to that shown in Fig. 11. 
Such were the anatomical characters observed in these different cases of alopecia 
areata; in all of them inflammatory changes were present, a round-celled infiltration of 
limited extent, confined, in great part, .to the perivascular regions, with increase in the 
Fig. 15. 
a. sebaceous gland ; b. broken-down external root sheath; c. hair shaft; d. root of hair; e. follicle sheaths, 
connective-tissue corpuscles of the parts. This inflammation was not specially peri- 
follicular, only as the glandular structures have.a richer supply of blood vessels than the 
corium tissue, the inflammation was often well-marked around these structures; there 
was also coagulation of lymph in a number of lymph vessels in the more recent cases, 
with consequent stoppage of the current in that part; there was, further, coagulated 
fibrine in some of the arteries, large and small, and, finally, a thickening of the blood 
vessel walls in the more advanced cases. As regards the glandular structures, only the 
hair follicles were affected in recent cases; in more advanced ones the sebaceous glands 
also, and in the worst case there was a partial, but only a partial, atrophy of the sub- 
cutaneous fat tissue. The seat of the inflammatory changes pointed to the causative 
agent as one not acting specially upon the hair follicles, but in a more general manner SECTION XIY DERMATOLOGY AND SYPHILOGRAPHY 
261 
throughout the corium; and the coagulation within the lymph and blood vessels 
denoted that the agent had not a central hut a local seat. 
The changes observed in the recent cases show that the depression of the patches 
observed in this disease depends at its commencement upon the absence of the hair, as 
already suggested by Hutchinson, and not upon a primary disappearance of the subcu- 
taneous fat tissue and atrophy of the cutis, as maintained by Michelson. 
From these observations, that question is no longer one of doubt; the sections show 
anything but an atrophy of the connective or fat tissues in the early stages of the 
disease. Afterward, in the very severe cases, the secondary disappearance of the seba- 
ceous glands and hair follicles are additional factors in the production of the depression 
of the skin. This disappearance of the glands and apparatus, however, as we have 
seen, occurs only rarely, and probably never occurs in these cases of temporary alo- 
pecia. When it does occur, as is shown by the absence for a length of time of even 
lanugo hairs, there is no possibility of the hair growing again. These changes in the 
glandular apparatus depend evidently upon an atrophy, the result of interference with 
their proper nutrition from inflammatory changes and thickening of the blood vessel 
walls and consequent narrowing of their lumen. A temporary narrowing is observed 
in all cases, and in the worst case observed by me, new connective tissue was present 
in considerable amount, and the muscular layer also appeared to be thicker than 
normal. The interference to the growth of the hair -would seem to depend, partly at 
least, upon the thickened blood vessel walls, and in the recent cases, also upon the pre- 
sence of coagula in the arteries and lymph vessels, interfering with the nutrition supply. 
If an artery should be closed, the hair could fall out very suddenly in an area of con- 
siderable size, namely, the area supplied by that vessel; or a considerable extent of 
lymph vessels could be clogged, as shown in Fig. 4, and the same result could follow. 
Thus, I would explain the falling out of the hairs suddenly at the commencement 
of the disease, and why sometimes a larger area is affected than at other times. The 
paleness of the skin and absence of all inflammatory symptoms depends upon the 
deficient blood supply to the part and the fact that the inflammatory changes occur 
principally in the sub-papillary layer, and that the process is a small-celled infiltration. 
Perhaps, from a clinical standpoint, it could be questioned that there is an inflamma- 
tion present; the section, however, from even the most recent case, cannot leave any 
doubt upon the subject, for the inflammatory changes are easily recognized. In the 
most advanced and severest case studied there was some atrophy of the subcutaneous 
fat tissue, so that this can aid in making the depression of the affected part, but as 
already mentioned, it does not occur in recent cases. 
The process, then, is an inflammatory one; a small-celled infiltration leading to per- 
manent or temporary nutrition changes; to permanent or temporary alopecia; an inflam- 
matory affection of the corium, and not a disease primarily of the hair structures. 
In Joseph’s experiments, it will be remembered that he produced a falling out of the 
hair, the result of a pure atrophy of the hair structures, and that there were no signs 
whatever of an inflammatory character in the sections studied by him. If these micro- 
scopical examinations of sections were correct, and we have no reason to doubt their 
correctness, then the process in the six patients studied by me were not examples of the 
disease produced experimentally by him, that is, the disease was not a trophoneurosis. 
That being admitted, we must seek for some other cause than a trophoneurotic one. 
As a vasomotor disturbance of central origin, I think no one would consider it for a 
moment, so we must look for a local cause. 
As regards its dependence upon organisms, I have studied sections after staining 
them in the manner recommended by Yon Sehlen, as well as after the usual methods 
for their detection, and will briefly give the results of my observations. On the surface 
of the skin, around hairs and sometimes around the shaft, I found organisms resembling 262 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the tinea trichophytina and tinea versicolor fungus occasionally. In one case I saw 
organisms apparently like those described by Yon Sehlen. 
Staining sections from the most recent case, that of a week’s duration, by Gram’s 
method and by the different aniline dyes, decolorizing with alcohol, and examining with 
the microscope, showed in the lymph spaces of the corium and in the walls of some of 
the small blood vessels small round bodies arranged in groups and deeply stained. They 
were about the same size, were arranged in groups and zooglea masses, and were unaf- 
fected by acetic acid or alkalies. The majority were to be found in the lymph spaces 
of the middle part of the corium; a few were present in some of the papilla, and occa- 
sionally they were found deep down in the corium. They were shown to be micrococci 
by the staining and the action of the acids and alkalies. They were present in tissue 
which often showed no signs of inflammation in the area of their location, and fre- 
quently one could trace a long row of these organisms from the zooglea mass into the 
surrounding tissue, along the course of the lymph capillaries. When these rows of 
Fig. 16. 
Section showing organisms in lymph vessels and walls and lumen of blood vessels, a. corneous layer 
6. rete; c. corium; d. blood vessel; e. micrococci. 
organisms were studied by high powers it could be seen that diplococci are quite 
frequent. In a case of several months’ duration, similar organisms were found in simi- 
lar situations but were more numerous. 
In Fig. 16 their situation in the lymph vessels and blood vessels is shown. As the 
specimens were decolorized with alcohol, the inflammatory round-cell infiltration is not 
seen, but it was slight. 
The organisms were present in larger numbers, both in inflamed and normal tissue, 
and were especially to be observed in the corium, occupying the lymph spaces and 
extending by traveling through these channels. In Fig. 17 is shown large masses in 
these lymph channels, the immediately surrounding connective tissue appearing normal. 
In Fig. 18 organisms from the same patient as those of Fig. 17 are shown, under a 
higher power. The number of the organisms and their grouping are marked. Their 
presence around blood vessels is also shown in Fig. 3 and Fig. 16. SECTION XIV DERMATOLOGY AND SYPHILOGRAPHY. 
263 
In the two cases of several years’ duration they were also found, but in much less 
number. In the most severe case of all I did not examine for them, as the specimen 
had been hardened in Muller’s liquid, and, consequently, was unfit for such studies. 
The specimens of the other ones had been hardened with alcohol alone. 
I have already given you the histological characters of the shin, and endeavored to 
explain the cause of the falling out of the hair, the depression in the skin at the alfected 
part, etc. Now, I wish to inquire if these organisms are accidental, or essential to the 
anatomical changes described. You will note the large number present in the tissues, 
Fig. 17. 
Micrococci in the lymph vessels, a. micrococci; h. connective tissue of corium. 
the almost, if not entirely, normal condition of the skin in many places, and the 
inflammatory changes in other parts—a condition suggestive of a local agent acting in 
different places. Organisms in such quantity, and with such anatomical characters of 
the habitation, do not, I believe, occur in any other condition, as far as known at 
present. 
Their number and situation explain, without argument, the condition of the lymph 
vessels, and also of the blood vessels. It is true that micrococci are present in other 
pathological conditions, but then the tissues show marked changes in nutrition in such 
Fig. 18. 
Micrococci in lymph vessels, a. micrococci. 
cases, while in alopecia the changes are slight at first, or perhaps not appreciable, 
although organisms are present. 
The manner of spreading of the disease is furthermore easily comprehended when 
vre consider how these organisms travel in the lymph vessels, just as in erysipelas, and 
in no other way, do I think, can we explain satisfactorily the manner in which the bald 
patches spread. 
The deep seat of the organisms also explains why contagion occurs so rarely, if ever 
it occurs, and the absence of marked contagious power is no longer an argument against 
the parasitic nature of the disease. 264 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Finally, the frequent failure of anti-parasiticides in the treatment of the disease is 
easily understood; for the organisms are too deeply seated to be destroyed with ordi- 
nary anti-parasitic remedies. To insure success a remedy must be chosen that will 
penetrate deeply from without, or the organisms must he destroyed by internally acting 
agents, as white blood corpuscles, or the ground must be made unfavorable for their 
growth and multiplication. 
Treatment.—As alopecia areata is a disease which generally tends to disappear spon- 
taneously and at no definite period of existence, sometimes after having existed only a 
few weeks, and, again, only after many months, or even years, it is very difficult to 
judge of the positive results of any special method of treatment, even when a consider- 
able number of cases have been under observation, and it is absolutely impossible if 
only two or three have been treated. 
I have treated about thirty cases during the last eight years, and, in a number of 
these cases, have experimented with different remedies upon the same person, either 
upon a single patch at different times, or, when the patient had more than one bald 
spot, upon the different ones at the same time, using different substances on different 
places, with the object of observing their comparative value. I have used electricity, 
stimulating or irritating applications, as capsicum, cantharides, etc., different mercurial 
preparations, chrysarobin and croton oil. The sulphur preparations were not made use 
of, as the observations of Dr. Thin on fifteen cases made any experiment on my part 
unnecessary for the present study. 
Unna reports a case cured by electricity, that had resisted all the usual methods of 
treatment, hut this must have been a case of long standing, and the result due to the 
effect of the agent producing the changes, for I have never seen any benefit whatever 
from its use, in any form, upon recent cases of the disease. That it can be of benefit in 
restoring the part to a normal condition after the active (progressive) stage is passed, is 
not difficult to understand, and it could or should he used in chronic cases. Stimu- 
lating or mildly irritating (inflammation-producing) preparations, as capsicum, ammonia, 
cantharides, etc., I have not found to be of any value, if their action is limited to the pro- 
duction of hyperaemia or slight superficial catarrhal condition of the skin ; but if their 
application be prolonged or sufficiently often repeated to produce a deeper dermatitis, 
and this inflammation be kept in existence for a length of time, and in a somewhat 
intense form, in order that emigration of corpuscles be greater than takes place in a 
simple serous inflammation, then I think we are generally, if not always, able to con- 
trol the spreading of the disease. The explanation I have for this result will appear 
directly. Of the mercurial preparations, I have used the oleate in two, four, six and 
ten per cent, solutions, and while some cases have been cured rapidly by this remedy, 
others have not been benefited. A four or six per cent, solution is strong enough, 
unless the object be to inflame the skin, and this can be better accomplished by other 
means. The cases which have been most benefited have been recent ones, but the 
remedy is an unreliable one, not only in this disease, but in those which all admit to be 
parasitic, as ringworm, for instance ; consequently the failure to cure every case of 
alopecia areata with it is no argument against the parasitic nature of the disease, while 
its prompt cure of some cases of recent origin favors the parasitic theory. White pre- 
cipitate ointment has never seemed to me to be of any value, although I have made 
frequent use of it. The same unfavorable results were observed when the mercurial 
preparation was mixed with lanolin or agnine. The bichloride of mercury was of value 
in some cases, and in others no beneficial effect was observed. As I did not follow the 
method for its application recommended by Lassar, that is, perhaps, the reason for the 
difference in the results obtained by us. My own observations from the use of the 
mercurial preparations, especially of the bichloride, lead me to the conviction that any 
organisms existing on the surface of the skin are not the cause of the disease. 265 
SECTION XIV—DERMATOLOGY AND SYPHILOGRAPHY. 
Chrysarobin of the strength of 15 to 20 grains to an ounce of lanolin has given me 
the best results among the remedies properly called directly anti-parasitic. It will not 
cure every case ; but I have often seen spots rapidly cured and the spreading process 
stopped, by the use of this remedy. As an example of its comparative value, I treated 
| a boy last year who had several large areas of alopecia areata of over one year’s duration, 
with either oleate of mercury, bichloride of mercury, white precipitate ointment or 
chrysarobin applied to the spots, the chrysarobin being applied to the largest of the 
bald areas. Within two weeks’ time an increase in the growth of the hair in the area 
treated by the chrysarobin was observed, with subsequent rapid return to a normal 
condition, while the other places remained unchanged. 
The results obtained by the mercurial preparations and chrysarobin, point to the 
disease being parasitic in its origin, for surely these remedies can have no beneficial 
effect in neurotic conditions, unless their action be traced to a stimulating effect, a view 
hardly correct, at least as regards chrysarobin. If to these results we add those obtained 
by Dr. Thin with sulphur ointment, and by Lassar with corrosive sublimate, I do not 
see how any one can doubt the parasitic origin, unless they doubt the results obtained, 
or at least described. The failure of the anti-parasitic remedies in some cases, can be 
best explained by the view of the deep seat of the organisms, as I have already 
pointed out, comparing the results with those obtained in lupus vulgaris when treated 
by anti-parasitic agents. 
Croton oil has given the best results in the treatment of this disease, when used in 
the proper strength to accomplish the object in view viz : the production of a dermatitis 
in which the exudation or rather infiltration will contain a considerable number of 
white blood corpuscles. If pure croton oil is used a very intense inflammation of a 
suppurative character is almost certain to be produced around the hair follicles, a 
suppurative perifolliculitis by which there is danger of destruction of the hair follicle. 
A fifty per cent, preparation, the croton oil being mixed with olive oil or some other 
suitable substance, should be used at first, and this made stronger or weaker afterward, 
according to the vulnerability of the tissue, that is, according to the intensity of the 
inflammation produced. As intensity of inflammation in any case depends upon 
the vulnerability of the tissue being acted upon, upon the agent acting, and the 
duration of action of the agent, so we can with a weak preparation of the croton oil 
accomplish, by frequent application or long duration of action, without danger, the 
same results as by a stronger preparation. An inflammation of the character I have 
described should be produced and maintained for perhaps a few weeks, and the result 
studied, observing whether the disease is spreading or the alopecia disappearing. The 
application should be made not only to the bald area but also to the hairy margin. 
With this agent I have often seen the disease stop spreading in the region treated 
while it spread at other parts. If it was a neurosis surely such an effect would not be 
produced, nay, I would say could not be produced. The result is the same as can be 
obtained in treating a portion of a serpiginous syphilide by a mercurial ointment ; the 
Part treated becomes free of the disease while the remainder of the lesion continues to 
spread; and syphilis is an infectious disease, with organisms, no doubt, in the corium, 
even if they have not been cultivated or successfully inoculated in the lower animals. 
The beneficial results of the croton oil depend, I believe, upon the inflammation 
produced; the white blood corpuscles passing ont of the vessels into the lymph channels, 
the situation of the microccoci already described, act as anti-parasiticides, and destroying 
the organisms remove the agent producing the disease. As this emigration of corpus- 
cles occurs especially in chronic inflammations of some intensity, the necessity of main- 
taining for some time the dermatitis produced by the action of the croton oil is apparent. 
Any agent, of course which will produce such a dermatitis, will act as well as croton 266 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
oil; the reason I recommend this substance is because as yet it has given me the best 
results.* 
From what we have already learned of the histological characters of alopecia, it is 
evident that there are some cases in which treatment cannot be of any service what- 
ever. When the hair follicles are destroyed the alopecia must be permanent, and there 
are some cases where lanugo hairs are still being produced, hut the blood vessel walls 
are too much changed to admit of restoration to a normal condition. If, however, we 
treat recent cases in the manner I have described, regarding the disease as parasitic and 
the location of the organisms as seated in the corium, I believe the results will he 
entirely different from the treatment based on the neurotic theory. 
As the nature of the ground is an important factor, perhaps the most important, in 
most parasitic diseases, it follows that everything should he done that is necessary to bring 
the general system into a normal physiological condition. It is not necessary to enter 
into a discussion of this subject, for each case must be treated according to the special 
condition present. A cure of the alopecia by internal medication which corrects the 
nutrition of the tissues, is no proof that the disease is not parasitic, for the changes 
produced in the skin about the period of puberty, for instance, will usually cause a 
ringworm to disappear without local treatment. 
As an additional argument for the parasitic theory I might mention the tendency to 
invasion of certain tissues, viz., those parts specially provided with well developed hair, 
as scalp, beard, axilla, etc., the capillary production being the result not of the nervous 
system but of hereditary influences. The selection of certain tissues by certain organ- 
isms is a well established fact, and should be considered in a discussion of the aetiology 
of alopecia. If the disease were a neurosis this selection of certain areas covered with 
hair would not occur. 
The results of my observations would tend to show, then, that alopecia areata is a 
parasitic disease; that the organisms are microccoci and have their seat specially in the 
lymph vessels; that they give rise to inflammatory changes in the corium, and frequent 
coagulation of fibrine in the lymph and blood vessels; that the depression of bald areas, 
in recent cases, depends upon the loss of hair and diminished blood supply in the part, 
and in old cases, in addition to these changes, the destruction of the sebaceous glands 
and an atrophy of the corium and epidermis; and finally that in anti-parasitic remedies, 
in the widest sense of that term, we have the only means which have any effect upon 
recent cases of the disease. 
I have further endeavored to show, by the clinical symptoms, the histological 
changes and the effects of certain local agents to the parts, that ordinary alopecia areata 
cannot depend upon a disturbance of the nervous system for its cause. 
DISCUSSION. 
In the discussion, Dr. Unna said that just as summer changes to winter and 
back again, so do the views upon the aetiology of alopecia first favor the neurotic then 
the parasitic theory. 
He himself might he said to hold both views. One must, however, have his mind 
•directed to the possibility of a parasitic origin when one sees, as he has, a father and 
daughters in one family simultaneously affected. On the other hand, an alopecia 
following an injury to the scalp, as from a needle broken off in the tissues, rather 
favors the opposite view, and one must recognize a neurotic origin for cases of general 
alopecia following shock, etc. He could only offer his congratulations to Dr. Robin- 
son on the scrupulous original work which he had done, and the admirable manner 
in which he had presented the result of his investigations. The two theories rise 
* Since reading this paper I have used Chrysarobin in several cases, with excellent results. SECTION XIV—DERMATOLOGY AND SYPHILOGRAPHY. 
267 
side by side, each having points of strength and weakness. He thought it would be 
a long time before either became the recognized one for all cases of alopecia areata. 
To prove the parasitic theory, isolation, cultivation, and transmission were neces- 
sary. 
Dr. Thin, after a careful examination of Dr. Robinson’s specimens, satisfied 
himself as to the undoubted presence of cocci, as described by Dr. Robinson, in the 
lymphatic vessels and in the arteries, and of the presence of fibrinous coagula in the 
vessels. He considered that these cocci were identical in form and size with the 
cocci described by himself some years ago as being present in the hairs in alopecia 
areata, and named by him bacterium decalvans. 
Dr. Thin had, by repeated investigations, after the publication of Yon Sehlen’s 
paper, confirmed his previous views as to the presence of these cocci in the interior 
of the hairs, but the demonstration was by no means easy. The same aniline dyes 
that are used in staining cocci also stain the hair substance proper. In the various 
manipulations that are necessary to differentiate the hair and the cocci, as recom- 
mended by Yon Sehlen, the cocci that are lying free on the split surfaces are very 
apt to be washed away. The more manipulation the hair undergoes in staining the 
less chance of the cocci being left. Still, if these manipulations are carefully per- 
formed, cocci can be found lying on the surface of the fibres which are formed by 
the splitting of the hair. 
As regards the pathogenic value of this bacterium, Dr. Thin considered himself 
entitled to criticise with severity some of the German writers, particularly Dr. Michel- 
son, the author of the chapter on Alopecia areata in Yon Ziemssen’s “Handbook.” 
He considered it somewhat remarkable that the editors of the book allowed an obser- 
vation of Dr. Michelson’s to appear in which that gentleman expresses his belief that 
the objects described by Dr. Thin, and figured by him in a paper accepted for publi- 
cation in the Royal Society, were only air bubbles. 
As regards the value of Dr. Michelson’s opinion Dr. Thin is ignorant, but in 
regard to the German criticisms on recent researches on alopecia areata, he would 
remark that the same gentleman, who, when his paper appeared, could not accept 
the fact that bacteria were present in alopecia areata, as soon as Yon Sehlen’s paper 
appeared, jumped incontinently to the other extreme and said that bacteria were pre- 
sent in all hairs. 
In regard to the existence of organisms in healthy hairs, Dr. Thin differs from 
the German critics. He has made many observations (which he hopes shortly to be 
able to publish) which show that no such organisms are present in ordinary hairs as 
he has described in hairs in alopecia areata. If proper precautions are taken in 
purifying the scalp and in extracting the hairs, it can be shown, he believes, that 
normal hairs are free from bacteria in that part of the shaft which is in the corium. 
As regards the value of Dr. Robinson’s observations, which Dr. Thin believes 
constitute a great discovery as regards this disease, opinions will vary according to 
the bias of different observers on the important point of what constitutes sufiicient 
evidence that an organism is pathogenic. Those who hold that we are not entitled 
to consider an organism pathogenic until we have reproduced the disease by cul- 
tivated organisms will consider that the point is not proven as regards this organism, 
but he would call to mind the fact that this canon is not held in universal respect. 
Many observers, like himself, have no doubt that the bacillus of leprosy is a patho- 
genic organism, although not only has the disease not been produced by the cul- 
tivated organism, but the organism has not yet been cultivated. 
He would remind them that for more than forty years trichophyton tonsurans was 268 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
almost universally accepted as the cause of Ringworm, although the fungus had never 
been cultivated at all. Even now he is not aware that authentic observations are to 
be found in literature that show that ringworm of the head or of the body has been 
produced by cultivations of trichophyton. No one doubts that tinea versicolor is pro- 
duced by the fungus that is always found among the scales of that eruption, but the 
fungus has never been cultivated, far less has the disease been reproduced by the 
cultivated fungus. 
Dr. Robinson has shown that, in a series of cases, in the diseased areas of alo- 
pecia areata one and the same coccus is always present, leading to obstruction of the 
lymphatic vessels and blood vessels, and causing changes which explain hitherto 
unexplained features of the disease. Those who believe that the bacillus of leprosy 
is pathogenic, and that the fungi of favus, ringworm and tinea versicolor are respec- 
tively pathogenic in these diseases, are, he contended, logically bound to accept Dr. 
Robinson’s conclusions. 
The paper he considered to be one of enormous interest, and to mark the begin- 
ning of a new epoch in the study of this important malady, and he congratulated the 
author and the Section on the fact that they had had a paper of such great value 
brought before them. A MANUAL OF 
DERMATOLOGY. 
By A. R. ROBINSON, M. B, LR. C. P. and S. (Edin.), 
Professor of Dermatology at the New York Polyclinic; Professor of Histology and Patho- 
logical Anatomy and Dermatology at the Woman’s Medical College of the New York 
Infirmary ; Member of the American Dermatological Association, of the New 
York Dermatological Society; President of the Section for Dermatology 
and Syphilography of the Ninth International Medical Congress, 
Washington, 1887, etc. 
Bvo vol., 647 pages. Cloth, $5.00. 
D. APPLETON & CO., Publishers, 1, 3, & 5 Bond Street, New York. PRESS NOTICES. 
“Dr. Robinson has long been known to the profession of this country by his valu- 
able contributions to dermatological subjects, made from time to time in the columns 
of the medical press. Almost without exception these papers have been characterized 
by a merit due to original and laborious pathological research. As a consequence, few 
of the later contributions to dermatological literature, of any pretension to a systematic 
exposition of the entire field, can he compared with the volume before us. In merely 
glancing over its pages, one is struck with not only the number of illustrations, most 
of them drawn from microscopical preparations made by the author’s hand, but also by 
the number of subjects to which he has by his own writings made the latest, and in 
many senses the largest, contributions. Thus, for example, the brilliant discovery, 
quite his own, of the existence of both afferent and efferent nerve-fibers in the tactile 
corpuscles, and of the double axis-cylinders in the Pacinian bodies; his well-known 
establishment of the real relation of several of the derangements of the sweat-secretion 
to the anatomical seat of the disorder; his clear demonstration of the difference between 
lichen planus and lichen ruber, . . . these results of his untiring industry serve to em- 
bellish his pages with a luster which only too few modern authors can hope to enjoy. 
. . . His style is terse and effective, his descriptions clear, his suggestions always prac- 
tical and unbiased by prejudices. His chapter on syphilis is particularly good. . . . 
The work before us is an admirable text-book. . . .”—Professor James JVevins Hyde, 
in Chicago Medical Journal and Examiner. 
“The amount of originality that is to be found in this book is surprising. It is 
most conspicuous in the matter of pathological anatomy, and is well exemplified by the 
fact that sixty-five of the eighty-eight illustrations represent the results of the author’s 
own researches, as well as by his marked personal views of sycosis, pompholyx, tricho- 
phytosis, lichen ruber, lichen planus, sudamina, comedo, milium, herpes, pemphigus, 
and a number of other diseases, and of the nerve terminations in the tactile corpuscles. 
. . . Turning from pathology to etiology, diagnosis, and treatment, we find them treated 
of in an equally satisfactory manner. Principles and indications are thoroughly incul- 
cated. . . . The work is a complete text-book. . . . While it is likely to prove of great 
value to the professed dermatologist, it is eminently a book for general practitioners 
and students, and its points of excellence are so many and so pronounced that we look 
to see it become a general favorite.”—New York Medical Journal. 
“ The author has already earned the reputation of being a sound pathologist, and 
the memoirs from his pen on dermatological subjects are invariably referred to by Euro- 
pean writers, who discuss the questions to which they refer. The part that he has 
taken in discussions regarding the so-called dysidrosis, and the pathology of psoriasis 
and sycosis, has marked him out as a writer of force, and an observer of considerable 
originality. His name is sufficient to call attention to any work on dermatology of 
which he is the author. The book before us is characterized by conciseness, clearness; 
. . . it is remarkable for an entire absence of repetition—a feature alone which distin- 
guishes it from many other similar works. This special quality renders the book use- 
ful to the general practitioner, who will find the chapters on treatment clear, precise, 
and short. . . . There is so much original work in the book that it is impossible to do 
more than indicate a few points which are of special interest from the pathological 
side. . . . The book will take its place permanently among standard works.”—The 
British Medical Journal. 
“Dr. Robinson has long been known as one of the most original investigators in 
the field of dermatological inquiry. His contributions to our knowledge of the histol- 
ogy and pathology of the skin have been accepted as authoritative by the most distin- PRESS NOTlCES.—(Continued.) 
guished European dermatologists. . . . This volume will add to his reputation, and 
take its place at once as a standard treatise. . . —Medical Bulletin. 
“ It is with great pleasure we give a review of this the most recent work on skin- 
diseases. . . . The work which Dr. Robinson has already given to the world is of the 
most solid character, many of his short articles having been the result of enormous 
labor. It is gratifying also to know that the views of no pathologist in skin-diseases 
in America are received with more respect in Europe than those of Dr. Robinson. 
The work before us is about the proper size for a student’s text-book. As might be 
expected, the pathology of the various diseases is dealt with in a clear and exhaustive 
manner. ’ ’—Canadian Practitioner. 
“The descriptions of the diseases are excellent. . . . Altogether it is an excellent 
work, helpful to every one who consults its pages for aid in the study of skin-diseases. 
. . . Medical students, also, will find no better aid to their study of skin-diseases.”— 
Detroit Lancet. 
“The work will prove interesting to the general practitioner, since the author is 
free of illustrations, clear in his statement of points bearing upon diagnosis, and simple, 
sensible, and scientific in his suggestions for treatment. The pathology of the work 
can not fail to interest the specialist. In this department the author is most happy, 
proving himself to be indeed a master of the subject.”—Louisville Medical News. 
“In this work we see how much original work has been made by a single laborer 
in this domain. ... It would be impossible to review this work in detail. In general 
appearance it is similar to Duhring’s excellent book, more valuable, however, in that 
it contains much later views, and also on account of the excellence of the anatomical 
description accompanying the microscopical appearances of the diseases spoken of. . . . 
We are sure it will have a large sale, as it is certain to become popular with the general 
practitioner and students of medicine. To the latter, especially, it can not fail to prove 
of the highest value, and it is written in a manner to interest the student of medicine 
and induce him to take a little more than ordinary interest in the subject of skin-dis- 
eases.”—St. Louis Medical and Surgical Journal. 
“The author is Professor of Dermatology in the New York Polyclinic, and has 
successfully accomplished his intention to present the study of dermatology in its 
modern aspects. His individual experience has been ample, his methods of observa- 
tion excellent, and his general presentation of the subject in everyway commendable.” 
—College Clinical Record. 
“The foregoing extract from the preface gives the author’s views of the scope and 
raison d'etre of the book, and his well-known and excellent work in the normal and 
pathological histology of the skin renders the portions of the book devoted to these 
subjects of more than ordinary value. . . . This is the only treatise on dermatology, 
however, in which we have seen stated, with the fullness which they deserve, the char- 
acteristics of syphilitic eruptions as selected and arranged by Kaposi, there being 
nothing which so facilitates the diagnosis of cutaneous syphilis as an intelligent appre- 
ciation and application of the rules laid down by the eminent Professor of Dermatology 
in Vienna.”—Boston Medical and Surgical Journal. 
“. . . His researches in the field of the morbid anatomy of the skin would, of 
themselves, render any book of his worthy of attention. . . . kinder the anatomy of 
the skin, which is comprehensively dealt with, there will be found a full account of the 
tactile and Pacinian corpuscles, illustrated from the author’s own observations. , . . PRESS NOTICES.—(Continued.) 
The characters peculiar to these eruptions met with in syphilis are well described, and 
the special course which the lesions pursue, from their first appearance to their involu- 
tion, will be found to be well told. . . . Sycosis is one of the skin affections to the 
elucidation of the anatomy of which Robinson early devoted himself. And this article 
is not only the best we know on the srrbject, but is thoroughly worthy of the author. 
. . . Psoriasis is another disease in which the views of Robinson have been almost 
universally and without reservation accepted. His description of the morbid changes 
in the skin have been confirmed, but have scarcely been modified.”—Edinburgh Medi- 
cal Journal. 
“As would have been predicted by any one familiar with the professional career of 
Dr. Robinson, he has produced an exceptionally meritorious work in the one before 
us. . . . The sections devoted to etiology and treatment throughout the book are, as a 
rule, extremely satisfactory. The balance is judiciously held between the constitutional 
and the local origin of the diseases and local and general treatment, undue prominence 
being given to neither. In discussing the treatment of eczema, the chronic and acute 
forms are considered under separate headings, a distinction which will at once strike 
the eye of the general practitioner seeking aid from the book, and impress this very 
important matter indelibly upon his mind. . . . The most striking feature of the book 
is, however, the prominence given to the pathological histology of the different diseases. 
About sixty of the large number of woodcuts are evidently original drawings from spe- 
cimens made by the author. ... As a rule, they illustrate in an extremely lucid manner 
the views advanced in the text, and force upon the reader the conviction that what the 
author says upon the subject is absolutely true.”—Journal oj Cutaneous and Venereal 
Diseases.