j Reprinted from the Tri-State Medical Journal, St. I.oui.s, March, 1S96. | NONSPECIFIC SYMPTOMATIC ALOPECIA. By A. H. Ohmann-Dumesnil, Professor of Dermatology and Syphilology in the Marion-Sims College of Medicine, St. Louis. ALOPECIA, calvities or baldness is a condition which is much more prevalent than is generally supposed. It is embraced under the general class of atrophic diseases of the skin and may be either idio- pathic or symptomatic, local or general. The idiopathic form is that which is most ordinarily encountered as one of the accompaniments of senile changes in the integument. A more or less sclerosed condition of the corium and overlying layers takes place, and this results in a shrinkage pressure upon the papillae of the hair-bulbs. This action naturally reduces the calibre of thd papillary vascular loops and brings about their final disap- pearance by absorption. As this is going on the hairs gradually fall out and the result is a glabrous area of integument entirely devoid of any hair. The progress of this variety is almost imperceptible and unnoticed at first. It, however, continues until a comparatively large portion of cranium is denuded of hair. Upon examination of the scalp it will be found that the openings of the hair follicles have completely disappeared, and when such is the case it may be safely laid down as a rule that it is an impossibility for hair to appear in those places which are bald. In the symptomatic forms of alo- pecia, on the other hand, we have a condition which, whilst it is described as a disease, is, in reality, merely a symptom of some deep, underlying cause which has, amongst other manifestations, that of falling out of the hair to a greater or less degree and, as a general rule, not of permanent nature. In a consideration of alopecia it would certainly be an omission to neg- lect mentioning that form which is symptomatic of syphilis, as well as that encountered in tinea capitis. I do not intend dwelling upon these, as they are essentially of specific nature, as well as all the other forms due to micro- organisms or parasites. It may perhaps not be superfluous to mention that in these forms the hairs become dry, brittle, harsh, and lack lustre. They are either easily broken off or fall out in small, circumscribed patches, a modus which differs radically from the forms which will be taken into con- sideration later on. Furthermore, it is not unusual, in some of the specific varieties, for a total destruction of the hair papillae to take place and lead thus to a permanent baldness. Whereas, in symptomatic alopecia a spon- taneous return of the hair takes place in the majority of cases very often with an increased abundance of growth. In non-specific alopecia we have three principal methods in which the hair falls out, and they are pretty nearly characteristic of the diseases which cause them. But, before taking up this part of the subject, it may be as well to consider the various modes of distribution which are most com- monly met with in the cases which present themselves. There may be a symmetrical loss of hair, like portions of the surface being affected and with a faithfulness to distribution which is as singular as it is interesting. On the other hand the process may be unilateral and this distribution, in some cases, ceases abruptly at the median line in quite a sharply-defined manner. Again, in some cases there is a marked assymmetry and an irreg- ularity which differs with each case observed, so that no general description would be found applicable to all cases. In some of the cases observed a more or less serpiginous form will be observed, whereas in others a linear conformation is observable. In the majority, however, the bald spots con- sist of irregularly-shaped areas of greater or less extent. A point of some interest is in regard to the varieties of hairs which are implicated as well as the amount of pilous surface which is involved. It will be remembered that there are three principal varieties, of hair: the long and fine such as we find on the scalp, the short and coarse like the eyelashes and the short and fine like the lanugo hairs. In some forms of non-specific symptomatic alopecia it is the hair of the head only which suf- fers, in others the scalp not only loses its hair, but the eyebrows and eye- lashes share in this process. In men it is not unusual to find the beapd and moustache involved, and occasionally in both sexes the axillae and pudenda. Finally, cases are encountered in which the lanugo hairs par- ticipate in the affection. Any one of these forms alone or combined may 3 occur and each one is always possessed of points of interest, both from an etiological and therapeutical point of view. A factor which increases this interest is that which concerns the manner in which the hair falls out. Thus we find that there may be a sudden and complete loss of hair, a veri- Fig. i. Symptomatic Alopecia following F.rysipelas. table defluvium, such as may be observed after an attack of typhoid fever. In other cases the falling out of the hair is in bunches, and patients will speak of the trouble by saying that their hair “fell out in handfulls.” The 4 denuded areas are not necessarily contiguous, but may have intervening portions which are supplied with hairs. In the third manner of evolution of symptomatic alopecia there is a gradual “ thinning” of the hair, which is progressive and steady and so insidious, that the subject is unaware of the fact until some day he suddenly awakens to the fact that he has lost a con- siderable amount, and finds out that it is perhaps impossible to cause a new growth. On the other hand, when the hair falls out suddenly and in large quantity, we have a condition which has a tendency to recover spontane- ously. These points should always be borne in mind in making a progno- sis, as the possibility of a recovery is always an important matter to a patient, more especially when he is solicitous concerning the cosmetic appearance presented. There are two forms of non-specific symptomatic alopecia which may be said to be permanent and incurable—that due to senile changes in the skin and universal alopecia. In the other forms there is always hope and a good share of success may be expected under effective treatment. This latter should always be of a more or less stimulating character, and it must not be forgotten that remedies which would prove irritating to the ordinary integument are not more than merely stimulating to the scalp or hairy parts. This is no doubt due to the fact that such parts are so amply pro- vided with rather large sebaceous glands and a rather thick epidermis. However it may not be uninteresting to give short histories of one or two cases which are rather typical of the conditions which they represent. Case 1.—X., single, aged 34, whose occupation was that of a photog- rapher, had an attack of facial erysipelas. This trouble was of an ordina- rily severe character, but he rallied nicely and was soon convalescent. All symptoms of an inflammatory character had disappeared and he was gain- ing strength rapidly. The case was practically cured when the patient was alarmed when a marked defluvium took place suddenly. This falling out occurred in masses from time to time until his scalp presented the ap- pearance shown in Figure 1. As will be seen the occiput was completely denuded with the exception of a wisp of hair at a point near the juncture of the scalp; and neck. The temporal regions were also visited with a marked loss, that on the left side having but a few scattered hairs and that on the right perhaps a few more. Normally the hair was of a brown color and apparently strong. It will be noted that the eyebrows, eyelashes and beard did not participate in the trouble. After the alopecia had fully de- clared itself, as shown in Figure 1, a condition was observed which is not unusual in such cases. A growth of new hairs began and it was exceed- ingly slow, to such a degree that the patient was in despair from the fear that he would never have a full growth of hair. This was, however, groundless, as eventually it all returned, more abundant and better in ap- pearance than it had ever been. 5 Case 2.—This patient was at the St. Louis City Hospital and gave a history of having suffered at one time from a marked case of acute rheuma- tism. This was followed by valvular disease of the heart. This illness was the only possible adequate cause which could be assigned for the alopecia which occurred. The falling out of the hair was a very gradual process, and the patient could not give a clear history of its progress. He stated, Fig. 2. Universal Alopecia. however, that it had gone on for years and had apparently invaded every portion of his body simultaneously. Upon a careful examination it was found that he was entirely bereft of hair, and he presented the appearance shown in Figure 2. The lanugo hairs had all disappeared and, so far as any hirsute appendages of the skin were concerned, he presented as thor- 6 oughly a naked individual as could well be imagined. This should be qualified, for he had one single hair still remaining which arose from the right side, a little above the line of the natural growth of the hair on the scalp. This is not shown in the engraving, but may be distinctly made out in the photograph. No hopes of restoration of the hair could be held out. There have been cases similar to this one reported from time to time and a history of some acute general condition has been elicited or observed. But, beyond this, nothing more definite can be offered. These conditions have been so different and various that the only safe conclusion which can be drawn is that the cause or origin is of a very deep nature and that the changes produced are of so marked an organic character as to have pro- duced complete destruction. It is for this reason that it may be safely asserted that the loss is irreparable and irremediable, local and internal measures of all natures having always failed in producing any favorable results. In the other forms of symptomatic alopecia, as has already been stated, spontaneous recovery takes place, but it is so slow, at times, that treat- ment will be found of benefit and rather advantageous. Not only should this treatment be local, but general measures are to be adopted which tend to place the patient in the best possible condition, and especial attention should be paid to the circulatory and nervous systems. This will be found of marked benefit. The local treatment is essentially stimulating in nature and should never be made irritating except in extreme cases. On the other hand, the stimulation should be of a degree sufficient to make an impres- sion imparting a glowing sensation of warmth to the part to which it is applied. It should certainly not be limited to such mild agents as alcohol or bay rum, but should have a strength equal to that of the trichogenous solutions recommended by dermatologists. It should not be oil nor in ointment form, as such preparations are neither as pleasant or as cleanly as many lotions whose efficiency is just as great. The following may be given as examples of such preparations, and should be applied thoroughly, taking care that the liquid is not permitted to run over the face or in the eyes: It Resorciui resublimat., 3 j Spts. vini rectificat., g iv M. Sig. Apply morning and night. Beta naphthol, 3 ss Spts. myrciae, g iv M. Sig. Apply twice a day. Resorcini, 3 i Beta naphthol, 3 ss Tinct. cinchonae co., 3 iij Spts. myrciae, g vi M. Sig. Apply twice a day. 7 Tinct. cantharidis, 3 i Ol. rosmarini, m x Spts. vini rectificat., § iv M. Sig. Apply to scalp twice daily. 01. gaultheriae, Spts. etheris sulphurici, t aa § i M. Sig. Apply twice daily, carefully. These are a few which are efficient. The proportions given are, of course, not inflexible, and should be varied according to the requirements of the case, and especially the sensitiveness of the skin to which applied. The last one is the strongest, and it may be necessary to reduce the quan- tity of oil of gaultheria. To get rid of the strong odor of wintergreen, it is only necessary to spray a little perfume after having made the application. A comparatively rapid return of the hair will follow the regular application of any one of the above lotions.