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 A PRACTICAL TREATISE 
 
 3453 
 
 The Diseases OF THE Haik AH ^GALP 
 
 GEORGE THOMAS JACKSON, M.D. 
 
 Professor of Dermatology, Woman's Medical College, N, Y. Infirraarj'; Chief of Clinic 
 
 and Instructor iu Dermatology, College of Physicians and Surgeons; CgusuU- 
 
 iug Dermatologist, Presbyterian Hospital ; Visiting Dermatologist, 
 
 Randall's Island Hospital; Member of the American 
 
 Dermatological Association, etc 
 
 NEW, REVISED, AND ENLARGED EDITION 
 
 NEW YORK: 
 
 E. B. TREAT & COMPANY, 
 
 241-243 WEST 23D STREET. 
 CHICAGO: R. C. TREAT, 199 Clark Street. 
 
 $2.00, net.
 
 COPYRIGHT r,V 
 
 GEORGE) THOMAS JACKSON 
 
 1887-1803 
 
 PHiSS iF iTtrriNER, LAKHERT .. CO. . tt, t4 A 26 HE*0£ ST., NEW YORK.
 
 Library 
 
 PREFACE, 
 
 In this edition of this book it is hoped that the 
 reader will find all the knowledge about the hair that 
 has been gained during the years that have gone since 
 the appearance of the first edition of this book in 
 March, 1887, During this time alopecia areata, the 
 parasitic diseases, and seborrhoea have been studied 
 with great care by many investigators. 
 
 Every page of the old edition has been revised and 
 corrected ; new articles upon folliculitis decalvans, 
 lepothrix, and aplasia pilorum propria, and many 
 new sections to the old chapters, have been added. 
 The bibliography has been brought down to January, 
 ^ 1893, and nine new illustrations have been inserted in 
 K the text. 
 
 \ The author hopes that the present edition of the 
 >^ book will meet with as good a reception as the first 
 ^ edition did, and that it may prove useful to his pro 
 fessional brethren. 
 14 East 31st street, New York, 
 
 624323
 
 PREFACE TO FIRST EDITION. 
 
 Five years ago, the author of this work was in need 
 of some complete treatise upon the diseases of the hair; 
 and finding none of recent date, excepting such as 
 were rather of a popular than a scientific character, he 
 began those studies which have resulted in the present 
 volume. 
 
 The aim of this book is to present to the medical pro- 
 fession a concise statement of what is known of the 
 diseases of the hair and scalp; special attention being 
 given to their diagnosis and treatment. To this end 
 a great number of medical journals have been con- 
 sulted, and all available books upon the hair have been 
 read. 
 
 The chapter upon the anatomy of the hair is drawn 
 chiefly from Waldeyer's '^ Atlas der Menschlichen 
 und Tierischen Haare,^^ Lahr, 1884; and from Unna's 
 article upon the anatomy of the skin in the last num- 
 ber of Ziemssen's '' Ilandbuch der speciellen Pathologie 
 und Therapies Leipzig, 1883. Those diseases of 
 the scalp which occur as part of a general disease of 
 the integument have been described briefly, since all 
 text books on dermatology treat fully of them. 
 
 In the Journal Literature there will be found but 
 few references to papers which have appeared prior to
 
 18(30. lu the last tweuty-five years our kiiowledge of 
 the diseases of the hair has so advanced that many 
 of the views held by writers of an earher date are 
 no longer of practical value. Where experience has 
 shown that the older writers were right, their princi- 
 ples and practice have been absorbed into the general 
 sum of our knowledge, and are to be found in all sys- 
 tematic treatises upon the skin. For these reasons the 
 year 1860 has been chosen arbitrarily as a dividing line, 
 and the Hterature of the following years only has 
 been consulted. The Bibliography contains the titles 
 of books ^vhich deal solely with the hair, and also of 
 general treatises upon the skin which have been con- 
 sulted. Such references as have not been accessible 
 to the author he has indicated by grouping them to- 
 gether and having them printed in smaller type. 
 
 The author takes gi-eat pleasure in acknowledging 
 in this place his obligations and expressing his thanks 
 to his friends Dr. George Henry Fox and Dr. Edw^ard 
 B. Bronson, and to his brother Eev. S. M. Jackson, for 
 valuable suggestions and kindly criticisms during the 
 composition of this book. The gi'eater number of the 
 illustrations which add so much to the value of the 
 work are from the large collection of photogi^aphs be- 
 longing to Dr. George Henry Fox, who placed them 
 most generously at the author's disposal 
 
 No. 14 East 81st St., New York, 
 March Ut, 1887.
 
 CONTENTS. 
 
 PART I. 
 
 General Considerations. 
 
 CHAP. PAGE 
 
 I. Anatomy of the Hair, 21 
 
 II. Physiology of the Hair, .... 32 
 
 III. Hygiene of the Scalp and Hair. . . .51 
 
 PART II. 
 Essential Diseases of the Hair. 
 
 IV. Canities, 63 
 
 V. Changes in the Color of the Hair other 
 
 than turning Gray, . . . .74 
 
 VI. Alopecia, 80 
 
 VII. Alopecia Areata, 115 
 
 VIII. Atrophia Pilorum Propria, . . . 140 
 
 IX. Hypertrophia Pilorum,or Hypertrichosis, . 158 
 
 X. Trichiasis and Distichiasis, . . .180 
 
 XI. Sycosis 182
 
 PART III. 
 Parasitic Diseases of the Hair. 
 
 CHAP. PAGE 
 
 XII. Trichophytosis Capitis, .... 205 
 
 XIII. Kerion, 239 
 
 XIV. Trichophytosis Barbae, .... 245 
 XV. Favus, . .256 
 
 XVI. Pediculosis Capitis, . . . . 275 
 
 XVII. '' Pubis, 283 
 
 XVIII. Beigel's Disease, and other unusual para- 
 sitic Diseases. .... 290 
 
 PART IV. 
 
 Diseases of the Hair secondary to Diseases 
 OF THE Skin. 
 
 XIX. Dandruff, ' . .299 
 
 XX. Keratosis Pilaris, 310 
 
 XXI. Eczema Capitis et Barbae, . . .314 
 
 XXII. PUca Polonica, 339 
 
 XXIII. Dermatitis Papillaris CapiUitii, . . 344 
 
 XXIV. Naevus Pilosus, 350 
 
 XXV. Syphihs. Lupus. Vitihgo. . . .354 
 
 Bibhography and Journal Literature, . . 365 
 Index, i09
 
 CHAPTER I. 
 
 ANATOMY OF THE HAIR. 
 
 Before we can understand the diseases which affect 
 the hair, it is necessary for us to have some knowledge 
 of its anatomy and physiology. The close connection 
 of the sebaceous glands with the hair foUicles, and the 
 fact that disease of the former is very commonly asso- 
 ciated with that of the latter, render it essential for us 
 to devote a little time to the anatomy and functions of 
 these glands. It is true that histologists are not yet 
 in perfect accord in regard to some points in the micro- 
 scopical anatomy of the hair, and that there are yet 
 some unanswered questions in the phenomena of its 
 development J growth, fall and regeneration; but, nev- 
 ertheless, we know enough to aid us materially in our 
 study of its diseases. 
 
 General Description. — The hair is an epidermic 
 structure consisting of a root, which is seated in the 
 skin and expanded below to form the hulh; and of a 
 shaft, which projects beyond the surface of the skin 
 and terminates in Si point. Its form may be described 
 as spindle-shaped, or as a slender cone gradually taper- 
 ing to its apex. Its contour is circular, oval or flat- 
 tened; and it is either straight, or more or less curled. 
 It presents three main varieties: 1. Long, soft hair, 
 such as is met with on the head, in the beard, on the 
 pubis and in the axillae. 2. Short, stiff hair, such as 
 is found in the eyebrows and eyelashes. 3. Lanugo, 
 or soft, downy, colorless hair, such as is scattered all over 
 the surface of the body, where the other varieties are 
 absent. Each hair grows from a small nipple-shaped
 
 22 DISEASES OF THE HAIR AND SCALP. 
 
 connective-tissue projection, the hair papilla, situated 
 at the bottom of a deep slender pocket or sac-like de- 
 pression in the skin which is called the hair follicle. 
 To each hair foUicle there is attached one or more se- 
 baceous glands, which empty by their ducts into its 
 upper third. 
 
 The Hair. — The hair is composed of three layers, 
 which from within outwards are : 1. The medulla. 
 2. The cortex. 3. The cuticle. These are distin- 
 guishable even in the deepest part of the hair root, 
 and become yet more distinct as we proceed upwards. 
 The hail's, excepting those called lanugo, are hollow 
 cylinders, the central cavity being filled, in fully formed 
 healthy hair, with the medulla, and called the medul- 
 lary canal. This canal begins below at the papilla, and 
 extends to T\ithin a short distance of the point of un- 
 cut hairs. In the lanugo hairs it is generally wanting. 
 The upper extremity or tip of the hair is pointed, if 
 the hair has not been cut; if it has been cut it is flat- 
 tened, or more or less rounded, depending upon the 
 length of time that has intervened between the time 
 of cutting and of examination; if a sufficient time has 
 elapsed it may even become again pointed. The lower 
 extremity of the hair, the root, is expanded to form the 
 bulb, which is hollou'ed out so as to fit accurately hke a 
 cap over the nipple -shaped papilla upon which it rests. 
 
 The jMedulla. — The medulla consists of a column 
 of superimposed cells which occupies the cavity of the 
 medullary canal. It begins immediately upon the 
 upper rounded top of the hair papiUa as a layer of ir- 
 regular cubical epithelial cells, each ceU containing one 
 or two masses of keratohyalin, which appear as dark 
 round drops. Waldeyer (S3) thinks it. probable 
 that keratohyahn, the ''eleidin" of Raxvier, is 
 identical with the " hyahn '' of Von Eecklinghausen, 
 wliich is found in many different kinds of cells. As
 
 ANATOMY OF THE HAIR. 23 
 
 we trace the medulla higher up in the hair we see that 
 the cells, which were dispersed at first irregularly in 
 layers, form themselves into a stratified column, like 
 a roll of coins, with three or four cells in each horizon- 
 tal layer. According to Waldeyer (83) the cells are 
 held together by means of delicate projections, and 
 when isolated appear hke the prickle cells of the skin. 
 The lower cells alone have nuclei. As the medulla 
 ascends in the hair the cells become more and more 
 flattened, the keratohyalin melts into the cell plasma, 
 and the nucleus shrivels up and disappears. Then the 
 cells themselves shrivel and leave spaces between them, 
 which in the middle follicle region are filled with air, so 
 that the cells are surrounded by a system of air canals. 
 The air does not penetrate the cells. Towards the point 
 of the hair the medulla is reduced to a column of single 
 cells laid one upon the other. Then the column be- 
 comes broken up, gi^eater or smaller spaces forming 
 between the cells, till finally it ends. The medulla cells 
 sometimes contain pigment. The delicate foetal hairs 
 are without a medulla, as are also most of the lanugo 
 hairs. As a rule, the greater the diameter of the hair, 
 the greater will be the diameter of the medulla. Nev- 
 ertheless strong hairs will often be found with propor- 
 tionately thin medull^e, as is frequently the case in the 
 hairs of the human beard. Still more common is it to 
 find thin hairs with stout meduUae. Towards the close 
 of the life limit of a hair no more medulla cells are pro- 
 duced, and in such hairs there is a wide space between 
 the bottom of the medulla and the end of the root. 
 
 The Cortex. — The second layer of the hair is the 
 cortical substance. This is the substance proper of the 
 hair, and consists of long spindle-shaped epithelial cells 
 which are flattened out into fine bands, and run in the 
 long axis of the hair. They are completely cornified 
 and contain a shrunken nucleus, which appears as if
 
 24 DISEASES OF THE HAIR A>T) SCALP. 
 
 pulled out length^^^se; it is wanting entirely towards 
 the point of the hair, and is plainly seen only in the 
 root. The first cells of the cortex in the neighborhood 
 of the papilla are cube-shaped, but under pressure from 
 without inwards they become as described above. The 
 cortical cells are, hke those of the medulla, provided 
 with prickles. In the cortex are found pigment and 
 air. The pigment occurs either in the form of 
 gTanules, or diffused. The granular pigment is 
 found heaped up in the cells of the cortex, especially 
 in those Mug i^eripherally, and sometimes the gran- 
 ules are crowded so closely together as to render the 
 individual ones indistinguishable. In the upper part 
 of the cortex pigment granules may be fomid lying 
 between the cells. The diffused pigment is the essen- 
 tial coloring matter of the hau\ The air gains entrance 
 to the cortex on account of a separation taking place 
 between its cells, and is fomid either in the form of 
 rounded, discrete air-globules, or in groups of them, or 
 in long streaks. 
 
 The Cuticle. — The third and last layer of the hair 
 is the cuticle. It corresponds to the epidermis of the 
 skin in location and function. It consists of flattened, 
 non-nucleated, fully cornified cells which cover the hair 
 like scales and are arranged hke shingles on a roof with 
 their free ends du^ected towards the ix)int of the hair. 
 In the lower part of the hair root these ceUs are cyhn- 
 drical and contain nuclei; but they gTadually becojne 
 flattened and lose their nuclei. In the deej^est part 
 of the shaft of old hairs the cuticle is wanting. 
 
 Hair-Eoot. — The root of the hak, with its bulb or 
 expanded part, contains aU the elements of the hair. 
 As the hair shaft descends towards the lower part of 
 the hair-folhcle it widens more rapidly, and then swells 
 out to form the bulb Avhich covers like a cap the papilla, 
 excepting at its naiTOwest part. It results from this
 
 ,1 
 
 
 mk 
 
 oh 
 
 h 
 
 
 Longitudinal Section of Hair Root from Beard. 
 
 OS = External sheath of hair-follicle. i& = Internal sheath of hair-follicle, gt 
 — Vitreous membrane, aw = External root sheath, iw = Internal root-sheath, 
 fce = Henle's layer. Aw = Huxley ''s layer, ow = Cuticle of root-sheath, oh =• 
 Cuticle of hair, h = Cortex of hair, ink = Medulla, p = Papilla, viiw, mo, mh^ 
 mm =• Matrices of iw, aw, oh, mk, and h. ph = Neck of papilla.
 
 26 DISEASES OF THE HAIR AND SCALP. 
 
 that the bulb is hollow below and indented like the 
 bottom of a champagne bottle. The lower part of the 
 bulb contains the matrices of the three layer-s of the 
 hair. The matrix of the medulla occupies the part 
 coiTesponding to the top of the papilla, and consists of 
 irregular cubic cells. That of the cortical substance 
 begins at the side of the body of the papilla, in a layer 
 of cyhndrical cells; while that of the cuticle springs 
 from the neck of the papilla, and is hkewise composed 
 of cyhndrical cells. The matrix cells soon begin to 
 take on the characteristics of the cells of the different 
 layers as we have already learned to know them. The 
 sheaths which suiTound the hair at its root are two 
 in number, the hair-foUicle and the root-sheath. The 
 hair-foUicle is derived from the cutis, while the root- 
 sheath is formed from the epidermis. We may rep- 
 resent the arrangement of the hair and its sheaths by 
 picturing to oui'selves the effect of thrusting, let us say, 
 a dull needle into the skin. First there will take place 
 a depression of the whole skin, and then the epider- 
 mis will be punctured at the lower paii; of the depres- 
 sion and the point ^ill come in contact \^ith the cutis 
 below. The cutis wiU be to the outside and represent 
 the hair-foUicle, the epidermis vdU. be in the middle 
 and represent the root-sheath, while the blunt point 
 of the needle vdR represent the hair-root. 
 
 Hair-Follicle. — The hair foUicle is always placed 
 at an angle to the skin excepting in the eyelashes, 
 where it is perpendicular to the tarsal edge. It is 
 foimd in the upper half of the cutis when it is con- 
 nected with lanugo hairs; deeper placed ^^ith stronger 
 hairs; and in the subcutaneous connective tissue in 
 comiection vrith. some very coarse hairs; and is from 
 one-twelfth to one-foui-th of an inch deep. It is a per- 
 manent structui'e, and does not leave its place when a 
 hair is plucked from the skin. It begins above at the
 
 ANATOMY OF THE HAlH. 27 
 
 opening of the sebaceous gland, passes down alongside 
 of the hair, and surrounds its lower end forming a 
 closed pouch, while some of its fibres enter the hair- 
 root from below to form the papilla. It consists of 
 three layers; 1. An outer longitudinal fibrous layer of 
 ordinary connective tissue. 2. A middle layer of cir- 
 cular fibres which are richly studded with long nuclei 
 resembling those of smooth muscular fibres; but no 
 muscular fibres are present. This layer is the true 
 foundation of the follicle, and is the only one that en- 
 ters into the formation of the papilla. 3. The vitre- 
 ous membrane which is inside of all. It is a thin, 
 smooth and homogeneous membrane, which, accord- 
 ing to Unna (82 a), is merely a thickening of the inner 
 coat of the middle layer of the follicle, and is only 
 found in its lower one third. The older the hair is, the 
 more prominent does this membrane become. The 
 inside of this membrane, especially in old hairs, is 
 thrown into circular or semi-circular projections or 
 ridges, which protrude into the prickle -cell layer of the 
 outer root sheath in the form of variously sized, duU or 
 sharp-pointed teeth. It does not reach to the papiUa. 
 
 Eoot-Sheath. — The root-sheath consists, as usually 
 described, of two parts, namely: 1. An external root- 
 sheath. 2. An internal root-sheath. Unna (82 a) 
 teaches that the external root-sheath should be desig- 
 nated as the prickle-cell layer of the hair-follicle, as it 
 is genetically different from the internal root- sheath, 
 being continuous with the epidermis; while the inter- 
 nal root- sheath springs from the hair papiUa. The ex- 
 ternal root-sheath is continuous above with the epider- 
 mis. As it reaches the mouth of the sebaceous gland 
 the granular and corneous layers of the epidermis 
 cease, and the prickle and cylindrical cell layers proceed 
 in full width to near the papilla, where they suddenly 
 grow smaller; and finally at the neck of the papiUa they
 
 28 DISEASES OF THE HAIR AND SCALP. 
 
 form a narrow stratum. It is composed of three layers : 
 1. An external cylindrical cell layer which is continuous 
 with the cylindrical cell layer of the epidermis, and 
 like it is composed of a single row of cells, which pre- 
 sent their narrow ends to the vitreous membrane of the 
 hair-follicle. 2. A middle prickle cell layer, a continu- 
 ation of the same layer of the epidermis. This is the 
 thickest of all the layers of the root -sheath. 3. A sin- 
 gle layer of flat cells lying next to the outer layer of 
 the internal root-sheath. The internal root-sheath 
 begins below at the neck of the papilla, and passing 
 upwards ends abruptly, as if cut off, at the neck of the 
 hair-follicle, where the sebaceous gland empties into it. 
 It consists of three layers, according to most anato- 
 mists: 1. An external or Henle's layer. 2. A middle 
 or Huxley's layer. 3. An internal or cuticular layer. 
 The external or Henle's layer is composed of only a 
 single row of flat ceUs. The middle or Huxley's layer 
 is usually formed of a single row of short cylindrical 
 cells; but when connected with the thick hairs of the 
 beard it at times has a second row of cells. The inter- 
 nal or cuticular layer is similar in formation to that of 
 the hair cuticle, being composed of a single layer of 
 flat cells which rest one above the other hke scales. In 
 the upper regions of the hair- root they are cornified. 
 The cuticle of the sheath differs from that of the hair, 
 in its cells standing oblique to the long axis of the hair 
 and pointing downwards; while those of the hair have 
 their long diameter parallel with it and point upwards. 
 There thus results an inteilocking between them, and 
 a fast union, esx)ecially in the middle third of the folli- 
 cle, so that when a hair is plucked from the skin it 
 usually brings with it a part of the internal root sheath. 
 The internal root -sheath can readily be divided into 
 two divisions, a lower and an upper. The lower one 
 corresponds to the region of the papiUa. All its cells
 
 ANATOMY OF THE HAIR. 
 
 29 
 
 are nucleated. In the upper region the cells of the 
 cuticle are cornified, and those of the Henle layer have 
 lost their nuclei. The cells of Huxley's layer preserve 
 their nuclei longer, but they become shrunken, and 
 finally disappear. Unna (82 a) proposes to do away 
 with the terms Henle's and Huxley's layer, as he re- 
 gards them as artificially prepared layers, and to speak 
 of the whole as the 
 root-she a t h . As 
 noted already he 
 has dropped the 
 term *^ outer root- 
 sheath," regarding 
 it simply as a part 
 of the hair-follicle. 
 
 The Papilla.— 
 The hair-papilla is 
 situated at the bot- 
 tom of the hair-fol- 
 licle in connection 
 with its circular 
 fibrous layer. It is 
 a wart or nipple- 
 shaped connective- 
 tissue projection, 
 which penetrates 
 the hair bulb from 
 below. It has a 
 narrow neck, a 
 strongly developed, wide middle pai't or body, and a 
 fine point. Upon it the hair rests ; and it contains 
 the. blood' vessels for the chief supply of its nutriment. 
 
 Twin Hairs. — Giovannini {Siy ap.) has described a 
 curious anomaly of hair-growth, where two hairs grow 
 inside of a single follicle, surrounded by a common in- 
 ternal root-sheath. At the bottom of the f olhcle there 
 
 Twin Hair after Giovannini.
 
 30 DISEASES OF THE HAIR AND SCALP 
 
 were two separate papillae, one for each hair. At 
 their bases by transverse section they were of irregular 
 shape, with their greater diameter in the same direc- 
 tion. The hairs were of a more or less regular oval 
 form. Above the root they were somewhat kidney- 
 shaped, and only occasionally oval or round. In the 
 region of the matrix the hairs were about parallel ; at 
 the neck of the follicle they were divergent ; in the 
 shaft they were sometimes divergent, sometimes par- 
 allel. In the neighborhood of the follicle-ground the 
 matrices of the hair were entirely separated. About 
 the middle of the neck they were joined, to become 
 separated and again joined higher up. The juncture 
 was made sometimes by a melting together of the 
 cuticle, sometimes by a bridge formed partly of cuti- 
 cle, partly of cortex. Sometimes they were joined 
 at the front, sometimes at the side. 
 
 Blood-\t:ssels. — The blood supply of the hair is de- 
 rived from arterial branches which surround the hair 
 folhcles in the form of a capillary net-work between 
 their middle and external layers ; and from small arte- 
 ries which penetrate the papilla from below. These ar- 
 terial branches are derived from the sub-papillary arte- 
 rial anastomosis of the skin. According to Unna (82 a) 
 the arteries of the follicles alone are derived from this 
 source and enter the f oUicle in its middle region, while 
 the arteries of the papillae spring from the deeper cir- 
 culation of the cutis. The veins follow the same di- 
 rection. 
 
 Nerves and Lymphatics. — Nerves have been traced 
 to the hair-folhcles, but not to the hair-papillse in the 
 human subject. Some histologists have followed them 
 to the vitreous membrane of the foUicle; and Unna' 
 (82 a) has demonstrated that the prickle-cell layer of 
 the external root- sheath is supplied with sensitive 
 nerves. He describes tlie nerve trunks as entering the
 
 ANATOMY OF THE HAIR. 31 
 
 follicles immediately beneath the sebaceous glands, los- 
 ing their medulla when they reach the vitreous mem- 
 brane through which they pass, and then breaking 
 up into branches, which end within the cells with 
 double-ended extremities. No lymphatics have yet 
 been demonstrated in connection with the hair. 
 
 Arrectores Pilorum. — The muscles of the hair are 
 comjiosed of smooth muscialar fibres and are named ' 'ar- 
 rectores pilorum/' They arise from the lower part of the 
 papillary layer, pass downwards beneath the sebaceous 
 glands, and are attached with many ends to the middle 
 part of many iieighboring hair-follicles upon the side 
 which makes an acute angle with the skin. 
 
 Sebaceous Glands. — The sebaceous glands are of 
 the racemose variety, and are found in close connection 
 with the hairs of the body, from two to six glands 
 emptying into each hair-foUicle in its upper third. In 
 structure they consist of a number of acini which 
 empty by a common duct. They are composed of a 
 delicate, structureless capsule, the memhrana propria, 
 which continues into the duct, and then merges into 
 the vitreous membrane of the hair-foUicle; and of hn- 
 ing cells, which are large, though short, cubical or cy- 
 lindrical epithelial cells, arranged in one or two layers. 
 These pass through the duct, and are continuous with 
 the cylindrical cells of the outer root-sheath and of the 
 skin. The interior of the gland is filled with the fatty 
 secretion. The size of the glands varies in different 
 regions, the largest of those connected with the hair, 
 being on the nose, measure 2 mm. in diameter in some 
 places, and may have as many as twenty acini. Some 
 glands are but ^^ of an inch in diameter. Their length 
 varies in different regions, the longest being on the 
 nose. As these glands are offshoots of the hair-folli- 
 cles, the external layer of the hair-follicles passes 
 around them and supports their membrana propria.
 
 CHAPTEE 11. 
 
 PHYSIOLOGY. 
 
 We have now to consider the phenomena of the de- 
 velopment, degeneration, fall and regeneration of the 
 hair; its pecuharities of form and constitution; and tht 
 pai-t it plays in the Hfe history of the human being 
 whom it clothes. 
 
 Development. — Fcetal Hair. — The germs of the 
 future hair appear first upon the face (forehead) and 
 eyebi'ows in the tenth to the twelfth week of foetal life; 
 on the Hps in the fomteenth week; on the r^st of the 
 head in the sixteenth week; soon after upon the tiiink; 
 a few weeks later upon the arms and legs; and at last, 
 in the seventh month, upon the backs of the hands and 
 feet. The hair itself forms about one month later and 
 follows the same order, first coming on the eyebrows, 
 and so on. These germs of the future hair are short 
 peg-Hke elevations of the outer embryonal skin. 
 Reissner and Gotte considered them sweUings of the 
 '".orium; but Waldeyer (83) and Unna (82 a) are in 
 accoi-d in teaching that only the stratum Malpighii of 
 the epidermis takes part in their formation, the corne- 
 ous layer passing smoothly over them. These germ?- 
 are at first separated only by a fine seam of connective 
 tissue. An increase and heaping up of round and spin- 
 dle-shaped cells then slowly takes place in the cutis 
 connective-tissue at the fundus of the germs. At first 
 these cells surround each germ like a basket; but soon 
 a prominence forms by tlie cells crowding together at 
 one part, and this indents the bottom of the hair germ.
 
 PHYSIOLOGY. 3^ 
 
 Thus are formed the primitive hair-f oUicle and the prim- 
 itive hair-papilla. According to Waldeyer (83), while 
 these changes are taking place in the connective tis- 
 sue, the hair-germ sends a sHghtly knob-shaped pro- 
 jection down into the underlying cutis, and the original 
 elevation disappears The outer cells of the hair-germ 
 now become cylindrical, place themselves crosswise, 
 and appear as a continuation of the basal cells of the 
 stratum Malpighii of the skin, while those in the long 
 axis of the hair-germ place themselves vertically, grow 
 longer and appear, if the papilla has already pene- 
 trated from below, as a delicate cone-shaped body rest- 
 ing on the top of the papilla. This is the primitive 
 hair-cone (Haarkegel) of Unna (82 a). 
 
 The cornification of the cells of the primitive hair- 
 cone begins at its point, and proceeds rapidly down- 
 wards on its external layer till to the point of the hair 
 papilla. The lower end of the hair-cone embraces the 
 papilla more and more as the upper end grows nearer 
 to the outer surface of the skin. Where the hairs 
 stand almost perpendicularly to the skin, the grow- 
 ing hair-cone drives the corneous layer of the skin be- 
 fore it, forming a rounded elevation. This at last 
 gives way, and the point of the hair protrudes. Where 
 tlie hair is placed more at an angle to the skin, it some- 
 times runs for some distance under the epidermis in a 
 spiral manner before piercing it. The middle part of 
 the hair-cone grows more rapidly than tlie outer part, 
 and soon breaks through the protecting cell layer of 
 the primitive hair-cone as a formed hair, though only 
 consisting of cortical substance. The outer layer of 
 cells becomes the inner root -sheath and crumbles grad- 
 ually away to end at the mouth of the sebaceous gland. 
 The remaining cells of the liair-germ, which are still 
 to the outside of the external layer of the primitive 
 hair-cone, become the outer root- sheath, which is con-
 
 34 DISEASES OF THE HAIR AND SCALP. 
 
 tinuous above with the prickle -cell layer of the skin, 
 and ends below in a point in the neighborhood of the 
 papilla. This is the formation of the primary or foetal 
 hairs. The vibrissae, and the hairs of the eyehds, outer 
 nose and lips, are placed almost perpendicularly to the 
 surface of the skin. In other situations the hairs stand 
 at an oblique angle to the surface of the skin, the ob- 
 hquity increasing with the size of the hair, so as to afford 
 more space for the lodgement of the hair-f olhcle. The 
 more obhquely the hairs stand, the more plainly do the 
 arrectores pili muscles appear, servmg to bridge over 
 the obtuse angle which the hairs form with the sur- 
 face, and to sustain them in position. Where the hairs 
 are perpendicular to the skin these muscles do not ex- 
 ist. The body of the foetus at the seventh month is 
 almost entirely covered with hair, and sometimes this 
 condition persists till birth. 
 
 Embryoxal Hair Change. — It is no unusual thing to 
 see a child born with long, colored hair upon the head, 
 and long, light, or colorless hair upon the rest of the 
 body as well as on the face. Normally, however, in the 
 sixth month of foetal life, or at the beginning of the 
 seventh, the embryonal hair change takes place, com- 
 mencing on the lip. The primitive hair is raised from 
 the papiUa, and its root end becomes knob-shaped in- 
 stead of cap-shaped. It mounts up in the follicle till it 
 reaches its middle third, where it remains for a time, 
 and continues growing, gaining its nourishment from 
 the epithelial cells of the part. For a time the lower 
 part of the f olhcle remains open, but slowly its epithe- 
 lial lining disappears, it shortens, and the papilla atro- 
 phies and vanishes. Now a new epithelial process is 
 sent out from the lower part of the old hair, passes 
 downwards, enters the lower part of the follicle, mak- 
 ing it pervious again, and becomes indented from below 
 by a new papilla. Then there is a new growth of hair^
 
 PHYSIOLOGY. . 35 
 
 upon the same principle as in the embryonal hair. 
 This process takes place at about the eighth month, 
 and is coincident with the fall of the primary hair. 
 The fall of the old hair, and the growth of the new, fol- 
 lows in the same order as in the first appearance of the 
 hair. Even if the child is born with a good deal of 
 hair it falls soon, showing that the prim ary hairs were 
 already loosened from their papillae. This change from 
 embryonal to permanent hair is a change in type, for 
 the new hair is soon furnished with a medulla. After 
 this there is no change in type, excepting in the devel- 
 opment of new hair at puberty, though the old hairs 
 constantly fall out and are replaced by new hairs.^ 
 As the child grows older, its head, which at birth is 
 usually sparsely supplied with fine hairs, becomes well 
 covered with long, colored, dark hairs, and its eyebrows 
 and eyelashes become more pronounced. 
 
 Change of Hair at Puberty.— At puberty an- 
 other change in the hair growth takes place, consist- 
 ing in the appearance of hair upon the pubes and in 
 the axillae of both sexes, and about the anus and on 
 the face of males. Still later strong hairs grow in the 
 nostrils and in the ears, though this growth may be 
 long deferred. It is notable that there are usually no 
 hairs about the anus of a woman. In women, also, the 
 axiUary hairs are generally less developed than in men, 
 and often they are entirely wanting. By some ob- 
 servers, indeed, it is stated that the absence of axillary 
 hairs in women is the rule. As far as my observation 
 extends they have almost always been present. 
 
 Varieties of Hair Growth. — In fuUy developed 
 adults most of the body, excepting in the regions just 
 mentioned, is supphed only with colorless, fine lanugo 
 hairs, but in most men and in a few women a more or 
 less luxuriant growth of hair will be found upon the 
 chest and extremities. In the male the pubic hair is
 
 o(3 DISEASES OF THE HAIR AND SCALP. 
 
 often continuous al)ove with a pyramidal growth of 
 hair upon the middle Une of the abdomen. In women 
 this is never the case, the pubic hair ending by a 
 sharp horizontal line. Hair is always absent from the 
 glans penis and the prepuce; from the vermilion bor- 
 der of the hps: from the labia minora; from the last 
 plialanges of the fingers and toes; and from the palms 
 and soles. The hair of women grows to a greater 
 lengih than does that of men, even if the latter is un- 
 cut. The hair of the scalp grows in groups, two or 
 three hairs in each gToup, seldom as many as four. 
 The hairs of each gi^oup are, according to Pincus (71), 
 not all of the same lengih, because they are not all of 
 the same age. 
 
 Hair Centres. — The hairs are not only placed at an 
 angle to the skin, but they grow from a number of 
 well-defined centres. Wilson (S4) has studied these 
 and carefully described them as follows: " The hairs 
 of the head radiate from the croT\Ti with a gentle 
 sweep l:)ehind towards the left and in front towards 
 the right. The centre for the forehead is a median 
 vertical line from wliich the hair passes to the right 
 and left, the loAver border of the growth forming the 
 upper half of the eyebrows. This centre is distinctly 
 visible in its whole length in many newborn children. 
 At the inner angle of each eye is another centre from 
 which the hair radiates, the upper and inner rays as- 
 cending to the hue between the eyebrows, where tliey 
 often meet those from the opposite side and form with 
 them a line across the root of the nose; and the upper 
 and outer rays curve along the brow and form the 
 lower half of tlie eyebrow. The lower and outer rays 
 ^Wth those of the nose, mouth and chin make a sweep 
 over the cheek and side of the face. On the upper lip 
 the hair gi'ows from the nostrils outwards, and forms 
 the mustache; on the lower Hp there is a middle line
 
 PHYSIOLOGY. 37 
 
 for a centre. The beard is formed by the convergence 
 of two side currents which meet at the middle Hne. 
 On the trmik there is a centre of radiation from each 
 armpit and two lines of divergence, one of the latter 
 proceeding from this point horizontally to the middle 
 of the front of the chest, the other vertically alone;- 
 the side of the trunk, across the front of the hip, and 
 down the inside of the thigh to the bend of the knee. 
 From the armpit centre, and from the upper side of 
 the hoi'izontal line, a broad and curved current sweeps 
 upward over the upper part of the front of the chest 
 and around the neck to the back. From the lower side 
 of the horizontal line and from the vertical hne the set 
 of the current is downwards and inwards, with a gen- 
 tle undulation to the middle hne in front, and back- 
 wards to the spine. 
 
 '' From the armpit centre there proceeds another line 
 of divergence which encircles the arm like a bracelet 
 immediately below the shoulder. From the upper 
 margin of this hne the direction of the current is up- 
 wards over the shoulder, and then backwards to the 
 mid-line of the body. Another line commences at this 
 ring on the front of the arm, and runs in a pretty 
 straight course to the cleft between the index finger 
 and thumb on the back of the hand. This is the line 
 of divergence of the arm. From it and from the ring, 
 the stream sets at first with a curve forwards, and then 
 with a curve backwards to the point of the elbow. In 
 the forearm the currents sweep downwards in front, 
 and upwards behind towards the point of the elbow, 
 which is thus the centre of convergence. On the back 
 of the hand and fingers there is an outward sweep with 
 the concavity upwards. On the lower hmb there are 
 two vertical lines of divergence, the one being the con- 
 tinuation of that of the side of the trunk, proceeding 
 around the inner side of the thigh to the bend of the
 
 38 
 
 DISEASES OF THE HAIR AND SCALP. 
 
 knee ; the other, an undulating hue, beginning at about 
 the middle of the hip, and running down the outer side 
 of the thigh and leg, and across the instep to the cleft 
 between the great and second toes. A short oblique 
 line connects the two vertical lines at the bend of the 
 knee On the front of the thigh the streams from 
 the two lines converge and descend towards the knee. 
 On the back they converge also at the middle hue, but 
 ascend toward the trunk of the body On the leg, 
 where there is but one line, the diverging currents 
 sweep round the limb, and meet upon the shin, while 
 on the foot they diverge with a sweep, as upon the 
 back of the hand. The hair centres are called whorls. 
 
 Shedding of Hair.— At certain 
 times of the year animals ' ' shed 
 their coat, '' that is, a rapid fall of 
 hair takes place and the animal's 
 coat is thinned. At the same 
 time with the fall of the old hair 
 there is a growth of new hair and 
 soon the coat is as thick as ever. 
 In the human species there is, 
 instead of a periodic shedding, a 
 constant fall and new gro^^i^h of 
 hair, though at certain seasons it 
 may proceed more rapidly than 
 at other seasons. This is accom- 
 plished in the same way as we 
 learned when describing the em- 
 bryonal hair change, namely: the 
 hair loosens from its papilla and 
 mounts up to the middle foUicle 
 region, where it remains for a 
 time attached to the prickle-cell 
 lajev of the foUicle, and grows 
 The lower part of the follicle collapses, and the 
 
 Section of hair follicle show- 
 ing beprinning separation of 
 hair from papilla ^.Unna.) 
 
 there.
 
 PHYSIOLOGY. 39 
 
 papilla grows smaller. The lower end of the old hair 
 becomes broom-like and knob -shaped. This appearance 
 is due to new cornified cells being constantly attached 
 to the root as it mounts up in the folhcle. 
 
 Bed-hair. — The hair in this position is called by 
 Unna (82 a) a ^' bed-hair " (Beethaar), to distinguish it 
 from the hair seated upon its papilla, or ^'papillary 
 hair.^^ The part of the follicle from which it grows, 
 he names the ''Haarbeet," or ''hair-bed." The ''bed- 
 hair " is always secondary to a papillary haii-, and all 
 hairs go through this stage before they fall They are 
 distinguished from papillary hairs by absence of root- 
 sheath, want of cuticle and medulla in their roots, and 
 by having their pigment distributed in stripes and heaps. 
 
 The cause of the loosening and shedding of hair, 
 whether at the close of its normal length of life, or on. 
 account of some disease, as eczema, typhus fever and the 
 like, is to be sought for, according to Unna (82 a), in the 
 character of the blood supply of the hair. As we have 
 learned, the middle region of the hair f oUicle is supphed 
 by arterial twigs from the sub-papillary circulation, 
 and the papilla of the hair is nourished from little ar- 
 teries from the deeper arterial circulation of the cutis. 
 Therefore the middle follicle region must participate in 
 the disturbances of the sub-papillary circulation, while 
 the papilla is relatively free from this influence. Thus 
 any lessening of the nutritive supply to the papilla, or 
 any increase in that from the sub-papillary circidation 
 to the middle follicle region must cause a preponder- 
 ance of nutrition in the middle over the lower follicle 
 region. This would necessarily cause an increased 
 growth of the prickle-cell layer of the middle follicle 
 region, and an increased pressure upon the hair. Then 
 either the circumference of the hair cylinder would be 
 lessened, or the hair itself w^ould be pressed out of the 
 f oUicle and raised from the papilla. The latter is what
 
 40 
 
 DISEASES OF THE HAIR AND SCALP. 
 
 actually takes i)lace. The bed-hair is shoved higher 
 and higher up, so long as it remains in the middle third 
 of the follicle, but when it reaches the unproductive 
 part of the foUicle, that is, just below the mouth of the 
 sebaceous gland, the circulation becomes again equal- 
 ized, and the hair ceasing to grow, falls out. The final 
 fall of the hair is hastened both by the pressure of the 
 new hair from below, and by traction exerted upon it 
 from above by brushing, combing, and the like. The 
 loosening of the hair from its papilla 
 begins at the cuticle, and proceeds 
 from without inwards. 
 
 According to Giovannini (87 ap.), 
 when a coarse hair is plucked from 
 its follicle, the latter shrinks up and 
 its cavity completely disappears. 
 -M The papilla diminishes slightly in 
 illi--M ^^olume, and approaches to the lower 
 edge of the derma, while from below 
 it gives off a connective-tissue pel- 
 ^-■^ hcle containing blood-vessels. In the 
 intra-dcrmic portion of the follicle 
 the shrinkage goes on more i-apidly 
 in the upper and lower than in the 
 middle portion of the follicle. The 
 widest portion is where the arrectores 
 pilorum muscles are attached. A 
 new hair begins to form in from 
 forty-one to seventy-two days after 
 Section of hair follicle epilation, aud is fully formed in from 
 
 skow mg liair in beet- ^ ^ ' ^ -^ 
 
 haar ^' stage, and growth thirty to sixty days afterwards. 
 tr^trUZ;,^ Regeneration of HAiR.-While 
 hb = hair bed, from the bed-liair IS still in the middle 
 
 .hieh6/.grows(Unna.) ^^^-^j^ ^.^^.j^^^ ^j^^ fomiatioU of the 
 
 new hair is under way. From the lower end of the 
 old hair down to the papilla there stretches an ei^ithe-
 
 PHYSIOLOGY. 41 
 
 lial process composed of the old, collapsed, and greatly- 
 atrophied root-sheath. This enlarges, its cells increase, 
 it grows downwards into the old hair follicle, wiiich 
 again becomes open, and shoves the old papilla before 
 it. Out of this a new hair is formed, seated upon the 
 old papilla which takes on new activity. The whole 
 process is analogous to that which occurs in the foetus. 
 The new hair mounts up in the old follicle and grows 
 sometimes alongside the bed-hair, but more often it 
 pushes it out ahead of it. This new hair lives its ap- 
 pointed time and then undergoes the same fate as its 
 predecessor, and thus is constantly repeated the regu- 
 lar normal fall and regeneration of the hair. It is 
 possible that new papillae may be formed, producing 
 new hairs, but the above is the usual course . 
 
 Appearances of Hair. — The microscopical appear- 
 ances of the hair will vary according to whether it is a 
 lanugo hair, bed-hair, or papillary hair ; or whether 
 it has been plucked from the head, or has fallen of 
 itself. The lanugo hairs are very fine and downy, 
 colorless or very slightly colored, and contain no me- 
 dulla. Their roots are small. The bed-hair has 
 neither root-sheath, cuticle nor medulla in its root, and 
 the root itself, instead of being hollow, is rounded off 
 and shaped somewhat like an old-fashioned broom of 
 twigs, or, it may be likened to a fir tree in shape, as 
 Unna suggests. Sometimes the medulla is entirely 
 absent throughout its length. These appearances are 
 those commonly seen in fallen hairs. This we should 
 expect from what we have already learned of their na- 
 ture. The papillary hair has a long, pliable, soft root- 
 end, which is bulb-shaped and hollowed out for the re 
 ception of the papilla. All the component parts of the 
 hair are present in it, and the medulla can be followed 
 from its root to near its point. When such a hair is 
 phicked, it presents for observation in addition to the
 
 42 DISEASES OF THE HAIR AND SCALP. 
 
 above, an attached piece of the root-sheath which 
 makes its lower paii look swollen. These are the typ- 
 ical forms of hair. If the microscoj^e is focused upon 
 the surface of a hair, the edges of the cuticle cells will 
 be seen as dark lines like the edges of the slates in a 
 slate roof. If it is focused carefully upon the edge of 
 the hair, the latter \\dll look hke the edge of a fine saw 
 blade, as the edges of the cuticle cells overlap one an- 
 other. If now the tube of the microscope be lowered, 
 the cortical substance wiU come into view. It ap- 
 pears like a solid body marked by short stripes of a 
 darker color, which gives it the appearance of being 
 composed of fibres. The fibres are in reahty long 
 spindle- formed cells, as is learned by tracing the hair 
 toward the root, when their ceU form \vi]l be more 
 apparent. Fine black granules are scattered about or 
 gathered in heaps in its substance. These are the 
 pigment granules. Lastly Ave meet with long, oval, 
 irregularly shaped, or small, round, dark bodies lying 
 between the fibres. These are air -globules. The small 
 ones may be grouped and mistaken for pigment, a mis- 
 take easily rectified by altering the focus, wiien they 
 wiU present the changes of color dependent upon their 
 optical properties, becoming lighter as we raise the tube 
 of the microscope. The medulla runs through the 
 centre of the hair as a dark streak. In hmnan hair, 
 Avhen examined in water alone, the sepai'ate ceUs of 
 which the medulla is composed, are not \asible, as a 
 rule. This is owang to the presence of a large amount 
 of pigment and air between the ceUs, both of which 
 have the effect of rendering the medulla dark colored 
 by transmitted light. If the hair be laid in glycerine, 
 the au'-giobules wiU be driven out, and the ceUs wiU 
 become more apparent. The form of the medulla ceUs 
 has been given in the chapter on the anatomy of the 
 hair.
 
 PHYSIOLOGY. 43 
 
 Technique. — A word must be said as to the proper 
 methods of examining hair. For most examinations of 
 the hair, an ordinary microscope, magnifying, say, 250 
 diameters, is sufficient. If you have higher powers so 
 much the better The hair should be examined at first 
 under a covering glass alone. Then water should be 
 added and the hair again examined. To render the 
 hair transparent, it should be placed in liquor potassae 
 alone, or in liquor potassae and glycerine. The per- 
 oxide of hydrogen acts even better than liquor potassae 
 as a bleaching agent, as it bleaches the pigment and 
 does not destroy the hair. Unfortunately it soon loses 
 its virtues by keeping. Waldeyer (83) recommends 
 a twenty per cent, solution of nitric acid for rendering 
 the hair transparent. If there be much foreign mat- 
 ter adherent to the hair, place the latter in a small test 
 tube containing ether and shake it for some time, or 
 put it in a corked bottle with ether and let it stand. 
 These methods are sufficient for the proper examination 
 of both healthy and diseased hair. 
 
 Color. — The color of the hair depends upon four fac- 
 tors, namely: 1. Diffused pigment. 2. Granular pig- 
 ment. 3. Air contents; and I. The superficial charac- 
 ter of the hair. The cortex plays the chief part in de- 
 termining the color of the hair. 1. The diffused 
 pigment or essential color of the hair gives it a light - 
 brv3wn to a dark-red hue, according to its intensity. 
 2. The granular pigment lies in, (Waldeyer, 83) or 
 between (Unna, 82 a) the cells or fibres of the cortex, 
 and, in some cases, in the cells of the medulla. It is 
 found chiefly in the peripheral portion of the cortex, 
 and occurs either scattered or grouped. Sometimes it 
 is heaped up so thickly that the individual granules are 
 indistinguishable. Its color is a shade of brown, any- 
 where from a light -brown to ebony. The combinations 
 of the diffused and granular pigment makes the vari-
 
 44 DISEASES OF THE HAIR AM) SCALP. 
 
 ous shades of color met ^\ith. The darker the hair is the 
 more granular pigment it contains, but even the hghtest 
 of blonde hair will be found to contain some granular 
 pigment. 3. The air-globules are generally in the outer 
 layers of the cortex. Viewed by direct hght they ap- 
 pear under the microscope as briUiant points; by trans- 
 mitted hght they appear black. 4. By the supei-ficial 
 character of the hair is meant whether it is smooth or 
 rough. These two last factors influence the color of 
 the hair on account of a law in optics, namely: Every 
 body appears white in wliite daylight if it reflects the 
 white light to all sides. If the surface of the hair be 
 uneven, and there are many httle particles of air in the 
 cortex and medulla, the hght will be thus reflected 
 and the color of the hair will be, therefore, more or 
 less white, the tone being modified by the amount of 
 pigment present in the cortex. A hair containing pig- 
 ment never appears quite white, even if air be present, 
 but some shade of gray. If there be no air present, or 
 the pigment is m excess, the hair will be more or less 
 purely of the color of the pigment. The most univer- 
 sal color of hair is dark brown or black. 
 
 Pigment. — The somxe of the pigment is not yet sat^ 
 isfactorily settled. It is derived, without doubt, from 
 the coloring matter of the blood, as is all the pigment 
 of the body. Ehrmann (100 and 101) of Viemia, 
 pubhshed, in the years 1SS4, 1>185 and 1SS6, some ex- 
 ceedingly interesting and valuable obsei^vations upon 
 the formation of pigment in tlie skin and hau\ His 
 studies were made in the beghming upon frogs and 
 salamander; later upon the skin of dogs and men. 
 He has found that the pigment is produced only in the 
 corium, in parts innnediately surrounding the blood- 
 vessels, and that ceU acti^^ty is absolutely essential 
 thereto. From the corium it reaches the epidermis 
 through protoplasmic movement. The pigment ceUs
 
 PHYSIOLOGY. 45 
 
 in men are round or oval, with short or few branches 
 or prolongations. They are in the basal cells of the 
 epidermis and send their prolongations downwards into 
 the corium, to connect with the pigment -carrying cells 
 of that part. The latter are not a pecuHar species of 
 cells, but true connective- tissue cells. 
 
 But, we are interested now more especially with the 
 l)igment of the hair. Pigment-carrying cells are found 
 in the hair pajiilla, which are large in its neck and 
 lower parts, and small in its top. As yet no Ijranches 
 have been observed to these cells. The ])igment cells 
 proper lie for the most part in the bases of the mat- 
 rices, entirely included in them, and touch the boundary 
 of the papilla only with one side of their circumfer- 
 ence. Their branches pass only upwards between the 
 cells of the matrix of the cortex up to the point where 
 these begin to undergo cornification. The cells them- 
 selves of the cortex are devoid of pigment. Further 
 up in the hair matrix, the branches of the pigment 
 cells form a net-woi'k, and the cortical cells of the third 
 or fourth row are in close connection with this net- 
 work, and themselves contain pigment. 
 
 Life Phenomena. — The length of life of the hair 
 varies with the age, sex, character of hair, and indivi- 
 dual peculiarity. Each hair has its determined length 
 of life, and this is not the same for every hair of the 
 same sort. What may be the circumstances that de- 
 termine the period of its existence is not known. The 
 lifetime of the eyelashes has been determined by 
 Mahly as one hundred and thirty five days. PiNCUS 
 (71) says that the period of hair growth on the human 
 head is from two to six years. Hair is said to grow 
 faster by day than by night, and in the warm weather 
 rather than in the cold. Shaving and cutting the hair 
 certainly make it coarser, and, may be, stimulate its 
 growth. The average length of the hair of the head
 
 40 DISEASES OF THE HAIR AND SCALP. 
 
 in women of the Anglo-Saxon race is from eighteen to 
 twenty-four inches, when left uncut. Exceptionally 
 it may grow to thirty-six or even fifty inches or more 
 in length. The hair of men of the same race has an 
 average length of six to eight inches; hut custom de- 
 manding that it be cut from time to time, it is rarely 
 seen of this length. The hair of each individual 
 has its own detei-minate length, and the hair of men, 
 even if left uncut, will not grow as long as that of 
 women. The rate of growth, specially in yoruig women, 
 is from 2 to 5 mm. during each ten days after first 
 piercing the skin. When it reaches a length of ten to 
 fourteen inches its rate of groTd^h is reduced one half; 
 and later towards the end of its normal life its increase 
 is hardly perceptible. The short, stiff hairs, as of the 
 eyebrows, are from i to 1 inch long. 
 
 Hairs, ^^athout their papillae, have been transplanted 
 and become fixed on granulating wound surfaces and 
 on the iris. I do not know that they have actually 
 taken root and grown there. 
 
 The average number of hairs to the square inch 
 is given by Wilson (SI) as, on the scalp, l,OuO. 
 WiTHOF (83) found on a man in one quarter of a 
 square inch of the crown of the head, 293 hairs; 
 occiput, 225; anterior part of the head, 211; chin, 39; 
 pubes, 34; forearm, 23; back of the hand, 19; anterior 
 surface of the thigh, 13. Wilson (84) calculates that 
 there are 120,000 hairs upon the head of an adult. As 
 a rule the finer the hairs, the thicker they will stand on 
 the head. 
 
 The dJameter of the hair varies \\Tith its color and 
 location, and with the age and sex of the individual. 
 Wilson (84) found that fiaxen hair was the finest, and 
 black hair the coarsest; that the hairs of the beard 
 and whiskers were coarser than those of the breast and 
 eyebrows, and then in order of decreasing diameter came
 
 PHYSIOLOGY. 4 1 
 
 those of the eyelashes and armpit, of the head, of the 
 thigh, and of the leg, the latter being finest. The finest 
 hairs of the scalp in the Anglo-Saxon race are from 
 TTFo to swo in., while the coarsest are from 4^0 to yio 
 in. in diameter. The head hair of a woman is some- 
 what coarser than that of a man, the diameter of the 
 former being from ^Jo to 2+0 hi. ; that of the lattei' 
 from yj-j to 3^ in. As a general rule, the hair of chil 
 dren is finer than that of adults, ranging from -j|y to 
 4^0 in. in diameter. Even on the same head there is a 
 great diversity in the diameter of different hairs, and 
 individual hairs are not of the same thickness through- 
 out. As stated in the first chapter (p. 21) the contour 
 of the hair is circular, oval or flattened. Whether a 
 hair is to be curly or straight is largely dependent upon 
 its contour; the more oval or flattened it is, the more it 
 will be curled. The curliness is influenced, also, by 
 the condition of the atmosphei-e; naturally curled hair 
 becomes more curled when the air is surcharged with 
 moisture, and less so in dry weather. But artificially 
 curled hair always loses its curi in damp weather. 
 
 Race Differences. — Ethnographical classifications 
 have been founded upon the evident differences exist- 
 ing in the hair of different races of men. We are all 
 familiar with differences of color, as between the black 
 hair of the Negro, and the flaxen hair of the Saxon race; 
 and of form, as between the close curled hair of the 
 Negro, and the long straight hair of the American In- 
 dian. As marked differences between races exist in 
 the contour of the hair, in the manner of its grouping, 
 etc. But a discussion of these matters of classification 
 is foreign to our purpose, and we will content ourselves 
 with the mere statement of the fact. 
 
 Physical Peculiarities. — It has already been stated 
 that the curliness of the hair is influenced by the 
 moisture of the atmosphere. This is because the hair
 
 4.^ DISEASES OF THE HAIR AND SCALP. 
 
 is ]iYgiT)ScopiCj absorbs moisture very i^adily from the 
 atmosphere, and becomes lengthened, as well as more 
 rounded. Hair is also elastic, and is capable of being 
 stretched from one-fifth to one-third of its normal 
 length. When the tension is renioved it will retract 
 to« nearly but not quite its original length. It possesses a 
 considerable amount of strengih, a good healthy adult 
 hair being capable of sustaining a weight of from two 
 to four ounces without breaking. The qualities of elas- 
 ticity and resistance are mainly located in the fibrous 
 portion or cortex of the hair. Hair is strongly electric 
 hj friction, particularly in cold and dry weather. Its 
 electricity may readily be shown by passing a rubber 
 comb through the long hair of a woman, when a slight 
 crackling sound will be heard In peculiarly susceptible 
 individuals the hairT\iU stand almost straight out from 
 the head under this electrical stimulus. The electricity 
 of the hair is negative. 
 
 Chemical Constitution.— The chemical constitu- 
 tion of the hair, as given by Waldeyer (83) from sev- 
 eral recent analyses, is as foUows: One hundred parts 
 of dry hair contain from yV to -i\ part of incombustible 
 material. This contains 28 per cent, of alkaline sul- 
 phates, 2 to 10 per cent, oxide of iron, and -40 per cent, 
 silica. Dark hair contains somewhat more iron. The 
 analysis of the hair substance shows it to be composed 
 of carbon, 50; hydrogen, 6.30; nitrogen, 17.14; oxygen, 
 20.85; sulphur, 5. The hair is said to contain a cer- 
 tain proportion of an oily substance, the color of which 
 varies with that of the hair. The proportions of the 
 chemical constituents vary with the color of the hair. 
 Thus, fair hair contains least carbon and hydrogen and 
 most oxygen and sulphur; brown hair gives the lar- 
 gest proportion of carbon and the smallest quantity of 
 oxygen and sulphur; white hair of the aged contains 
 a considerable amount of bone earth or phosphate of
 
 PHYSIOLOGY. 49 
 
 lime. The quantity of nitrogen remains the same in 
 all. 
 
 Uses of Hair. — The uses of the hair are fom^f old: 1. 
 As a preservative of heat. 2 As a protective agency. 
 3. As an organ of touch. 4. As a promoter of beauty. 
 (1.) As the hair is a bad conductor it serves to preserve 
 the heat of the body. When one is exposed either to ex- 
 cessive heat or cold the hair is apt to grow more luxuri- 
 antly. (2.) The hair of the head forms a thick elastic 
 cushion, and is thus an admirable defence to the skull 
 against blows and falls. The pubic hair in like manner 
 acts as a cushion during coitus. The eyebrows are a de- 
 fence to the eye against ])lows,and turn the perspiration 
 to the outside of the eye-socket, thus preventing its gain- 
 ing access to the eye. The eyelashes catch flying par- 
 ticles of dust; the hairs of the nostrils and ears prevent 
 insects from crawling into the cavities which they pro- 
 tect, as well as guard against the entrance of other for- 
 eign substances; the mustache acts as a respirator; and 
 the beard protects the larynx from the action of cold. 
 (3.) Parts furnished with hair are more sensitive than 
 are those without it. This is because the hair, being 
 planted at an angle to the skin, acts as a lever on l)eing 
 touched, shoves to one side the hair- follicle, and thus 
 causes a slight irritation of the neighboring cutaneous 
 nerves. This sense of touch in man is but little develop- 
 ed. (4.) Of the hair as a promoter of beauty, little need 
 be said, as it will be conceded by all that the hair is 
 an adornment. 
 
 Uses of the Sebaceous Glands.— The sebaceous 
 glands furnish an oily secretion to the hair which ren- 
 ders it pliable and soft, and gives it lustre. This secre- 
 tion is a constant one in health, and is the result of a 
 fatty degeneration of the lining cells of the glands, 
 which slowly fill up with the oily matter, burst, and 
 discharge their contents. As the sebaceous glands
 
 50 mSEASES- OF THE HAIR AND SCALP. 
 
 empty into the hair-follicles in their upper third, they 
 are admirably located for lubricating the hair just be- 
 fore its exit into the outer air. The oil is upon the out- 
 side of the hair and also within it. It reaches the in- 
 terior of the hair b}' capillary attraction, as Avill be 
 readily understood by referring to the anatomy of the 
 hair, and noting its fibrillar construction and the spaces 
 between its fibres. Pincus believes that the capillary 
 attraction is, to a certain extent, assisted by the pres- 
 sure exei-ted upon the hair in the part of the follicle, 
 just above the entrance of the sebaceous gland, its nar- 
 rowest part or neck, the diameter not being large 
 enough to admit of the escape of the hair and the se- 
 baceous matter at the same time, without considerable 
 squeezing, so that the sebaceous matter is pressed into 
 the hair. It is probable that the hair, besides being 
 supplied with oil by the sebaceous glands, secretes a 
 cholesterine fat. This is shown by the investigations 
 of Liebreich in regard to lanoline. 
 
 Muscles. — The arrectores pilorinn muscles pass 
 under and around the sebaceous glands, to be inserted 
 into the hair-follicle. By their contraction they 
 straighten the direction of the hair bulb, and, in conse- 
 quence, erect the point of the hair, literally causing the 
 hair to stand on end. This function is observed in 
 man chiefly in the occurrence of ^' goose flesh," from 
 the action of cold. The contraction of these muscles 
 further aids, though to a sHght extent, the emptying 
 of the sebaceous glands.
 
 CHAPTEE III. 
 
 THE HYGIENE OF THE HAIR. 
 
 Attention to the care of the hair and the hairy 
 scalp is of special importance to those who belong to 
 families in which premature baldness is hereditary, 
 and it can not be given too early. We should, there- 
 fore, instruct the parents as to the importance of giv- 
 ing attention to their children's heads, so that the 
 matter may not be delayed too long, and the hair fall 
 out when it is too late to stop it. Dandruff is regarded 
 by most people as merely an annoyance, and, if not 
 excessive, is neglected. If we could convince the laity 
 that dandruff is the chief cause of baldness, they would 
 eagerly seek relief, the disease could be early checked, 
 and the day of hair-fall very much delayed, The care 
 of the hair is important, not only to those with an in- 
 herited tendency to baldness, but to all who wish to 
 preserve their hair in good condition, and, if properly 
 attended to, it will be a prophylactic, not only to dis- 
 eases of the hair proper, but also to parasitic troubles 
 of all sorts. It is true that this demands the expendi- 
 ture of a certain amount of time, but it is time well 
 expended, though, I must confess, often greatly be- 
 grudged by male patients. 
 
 The hygiene of the hair and scalp consists in the 
 proper use of the shampoo; in brushing and comb- 
 ing; in arranging the hair; in the exposure of the 
 hair to air and light; in cutting and shaving it; and 
 in the use of pomades. We should watch over the 
 hair from earliest infancy, and instruct our patients as 
 carefully in regard to its hygiene as we should do in 
 regard to matters of general hygiene.
 
 52 DISEASES OF THE HAIR AND SCALP. 
 
 Shampoo. — The first attention that the hair demands 
 is the ridding of the scalp of the newborn child of the 
 vernix caseosa. This is the fh'st shampoo, and should 
 be more carefully performed than any subsequent one. 
 Improper management at this time may entail endless 
 worry to the mother and a great deal of suffering to 
 the child, as it is exceedingly likely to set up an in- 
 flammation of the scalp. The child is born covered 
 ^Wth a fatty matter called the vernix caseosa^ which 
 is often very thick upon the scalp. Steps are to be 
 taken at once for its removal, which must be effected 
 with the greatest care, and with the avoidance of all 
 force. To this end the scalp is to be satm-ated with 
 sweet almond oil, which is the most elegant means; or 
 Avith ohve oil or vasehne. It is preferable to use these 
 in their natural state, but if desired, there is no objec • 
 tion to perfuming them with a few drops of the oil of 
 bergamot, T\intergTeen, or the hke. The nurse should 
 do this immediately after she has washed the child's 
 face and eyes. Then after the body has been bathed 
 and the infant dressed, she should wash the head ^ith 
 plenty of warm water and soap, such as pure castile 
 or glyceiine soap, either sohd or Hquid. Tliis should be 
 done very gently, and if the vernix caseosa is not readily 
 removed, she should re-apply the oil and wait until the 
 next day, when it will be easily washed oif . Should it 
 stiU prove obstinate, let her patiently repeat the process 
 until it comes off. In no case should the fine toothed 
 comb be used. For some weeks the infant's scalp should 
 be lightly oiled, as this ^^'iU prevent any accumulation of 
 sebaceous matter, and protect the tender skin from in- 
 jury from atmospheric causes until the hair gi'ows, 
 care being taken to wash the head daily to prevent the 
 oil from becoming rancid. Wlien the hair is gro\\Ti 
 the scalp need not be so often oiled, nor should it be 
 washed more than once or twice a week.
 
 THE HYGIENE OF THE HAIR. 53 
 
 In children and adults, the scalp should be kept clean 
 so as to avoid stopping up the hair follicles with foreign 
 matter, and to prevent any irritation of the scalp, which 
 its presence might cause. This is accomplished by the 
 systematic use of the shampoo followed by careful dry- 
 ing, and the apphcation of some oily substance to the 
 scalp. It may be given as a rule, that a shampoo every 
 second to fourth week is sufficient for the scalp of those 
 who are not exposed to more than the usual amount 
 of dust; while those who are so exposed should sham- 
 poo the head every week or two. The practice of 
 daily sousing the head with cold w^ater, as is very 
 commonly done by men, is pernicious, not because the 
 water itself is harmful, but because the scalp is not 
 properly dried afterwards; no oil is applied to take the 
 place of the oil that has been removed by the water, 
 the wet hair cannot be thoroughly brushed, and soon 
 becomes dry and brittle. Women avoid getting their 
 hair wet, and this may be one reason why they are 
 less often bald. 
 
 The proper manner of shampooing the head is as 
 follows: Choose some good soap, such as Pears' " Gly- 
 cerine Soap, " Sarg's ' ' Liquid Glycerine Soap, " pure 
 Castile soap, the tincture of green soap, or the tincture 
 of prepared olive soap, and with plenty of warm water 
 make a good lather on the head, and rub the head vig- 
 orously with the fingers, or Avith a rather stiff, long 
 bristled brush. Another excellent liquid soap is com- 
 posed of Castile soap eighty parts, bicarbonate of soda 
 twenty parts, and water one hundred parts (Pasch- 
 Kiss, 134 ap.). A very little of this makes an abun- 
 dant lather. If the scalp is very sensitive to irritants, 
 borax and water may be used instead of soap, or a 
 mixture composed of the yolks of three eggs beaten 
 up in a pint of lime water. When the head has been 
 thoroughly shampooed, wash out the lather with a
 
 54 DISEASES OF THE HAIR AND SCALP. 
 
 copious supply of warm water, or, where practicable, 
 with alternate douches of warm and cold water, and 
 then dry both scalp and hair with a good bath towel. 
 "VAHien all is dry, nib on the scalp, not on the hair, a 
 small quantity of some unctuous substance, such as 
 sweet almond oil or vaseline. Care must be used in 
 drying the hair, specially in women, who should sit 
 b.?f ore an open fire, or in the sunhght when doing it, and 
 who should not dress the liair until it is perfectly dry. 
 To oil the scalj), the hair should be parted and the oil 
 rubbed in along the part, then another paii made, and 
 the operation repeated, and so on till the whole scalp is 
 gone over. In using a fluid oil a medicine-dropper 
 will be found convenient. Should there be an excess 
 of oil upon the hair, a condition which is disagreeable 
 to many, it may be removed readily by pulling the 
 hair between the folds of a towel moistened with ether, 
 chloroform, or cologne water. 
 
 Brushes and Brushing.— Of far more importance 
 than shampooing is the use of the brush and comb, 
 and much more care should be given to the selection 
 and use of these common toilet articles than is usually 
 bestowed. Too often they are badly made, and gener- 
 ally, specially with men, they are used in a very per- 
 functory maimer. The brush which is to be used upon 
 an infant's head should have long, soft bristles, so as 
 not to scratch or irritate the tender scalp, and should 
 l)e employed simply in smoothing and polishing the 
 hair. For young children whose hair is well grown, a 
 stiffer brush is necessary, and for adults, two brushes 
 should be used, a stiff one and a soft one. A properly 
 made brush has its bristles placed in httle clumps or 
 groups in such a manner that the middle bristles of 
 each group are longer than those of the periphery. 
 The bristles are well set into the back of the brush and 
 the groups are A\ide apart. Most of the brushes met
 
 THE HYGIENE OF THE HAIR. 55 
 
 with in the shops are made with the bristles all of the 
 same length and the groups close together so as to look 
 pretty, but not to perform their proper function. The 
 stiff brush should be used systematically in the morn- 
 ing and with considerable vigor, so as to produce a feel- 
 ing of warmth in the scalp, and to brush out all pai'ti 
 cles of dandruff and foreign matter lodged in the hair. 
 Every part of the scalp should be gone over wuth the 
 stiff brush, and then it should be laid aside for the rest 
 of the day, and the soft one used to assist the comb in 
 parting the hair, and to give smoothness and gloss to 
 it. The stiffness of the brush and the vigor of its em- 
 ployment must vary with the tenderness of the scalp, 
 and in no case should be sufficient to cause a feeling of 
 soreness. Were brushing performed in the manner 
 indicated, the hair w^ould lie properly without the aid 
 of water or pomades, excepting of course in cases of 
 malposition of the hair, as in the so-called cow-lick, 
 or where the hair is unnaturally stiff. 
 
 Combs and Combing. — The comb is next in impor- 
 tance to the brush, its office being to open up the hair 
 so that the brush may reach all parts of the scalp, to 
 part the hair, and to disentangle snarls. A pioperly 
 made comb has long, thick, wide, perfectly smooth 
 teeth, with well-rounded ends, and set wide apart. In 
 choosing a comb it should be held up to the light, and 
 discarded if any roughness or irregularities are found 
 in the surfaces of its teeth, for such a comb w^ould catch 
 and tear the hair. Combs are usually made with a 
 coarse and a fine half, and there is no objection to this 
 arrangement if the fine pai-t is used only to disentangle 
 the hair. No attempt should be made to pick off crusts 
 from the scalp with the comb. It should be used only 
 as an assistant to the brush, and always with it in the 
 systematic morning brushing. No comb should touch 
 an infant's scalp, and the fine-toothed comb should be
 
 56 DISEASES OF THE HAIK AND SCALP. 
 
 rigorously excluded from the toilet case. It is a dan- 
 gerous instmment, the cause of many a case of eczema, 
 and only of use in removing the ova of lice from the 
 hair. Ahove all things, the tender scalp of the infant 
 should be spared from its damaging eifects. 
 
 Dressing of the Hair of "Womex. — Now we come 
 to a place in the discussion of the hygiene of the hair 
 in which fashion often interferes. Examination of old 
 fashion plates and portraits will show how women and 
 men have tortui-ed the hair, twisting it into all sorts of 
 shapes, and smothering it imder wigs, false hair and 
 powder. Happily, at present, the hair is worn more 
 simply, but stiU the crimping or the curhng iron is too 
 much used, and the hair is pulled and dragged upon 
 too much in adapting it to the varying demands of the 
 hair- dresser. Sooner or later nature is apt to rebel 
 against fashion, and the hair grows less luxuriantly or 
 faUs out. The simplest mode of wearing the hair is 
 the l:)est. It should be combed and brushed smootlily 
 back upon the top of the head, either parfed or not as 
 is most becoming, and gathered into a loose braid or 
 coil at the back of the head. Girls should wear a pend- 
 ant braid; and women whose hair is gTO^\'n and who 
 gather the hair into a coil, should use large hau'pins 
 in fastening it, preferably of rubber or bone, ^yiih abso- 
 lutely smooth surfaces. In doing up the hair care 
 should be taken not to drag upon it; and di-awing it 
 into unnatural ]:>ositions, such as pulhng the hair from 
 the back of the head over forwards to near the fore- 
 head, should be avoided. If a woman's hair curls 
 naturally, she should be thankful for the favor therein 
 bestowed, but should it not cuiI of itself, she should 
 not attempt to make it curl by singeing and squeezing 
 it between hot irons, scorching it over a hot pipe-stem, 
 or twisting it up tightly in carl papei'S. 
 
 Wigs, Hats, etc. — The hair requires for its growth^
 
 THE HYGIENE OF THE HAIR. 57 
 
 and for the maintenance of its health, both air and snn- 
 light, though not necessarily exposure to the direct 
 rays of the sun. It is difficult to prove that wearing 
 of the hat constantly is a cause of baldness, but there 
 are many indications that such is the case, and it is 
 well to avoid keeping the head covered with an un ven- 
 tilated hat. If the occupation compels one to be out 
 of doors most of the time, or exposed to draughts so 
 that a hat or cap must be worn, it should be well ven- 
 tilated, so that the heat from the head may not become 
 confined, and the hair more or less sweated. The sub- 
 ject of hats as a cause of baldness will be treated of 
 more fully under Chapter VI., upon Alopecia. The 
 wearing of wigs and false hair is bad for whatever hair 
 remains, and should not be practiced. The absurd 
 " water-falls " of a few years ago, and the no less ridi- 
 culous powdered wigs of old times are happily things 
 of the past, and should never be revived. If a woman's 
 hair is short and scanty, it is better for her to wear it 
 cut short, and endeavor to stimulate its growth by at- 
 tention to the scalp, than by wearing false braids to 
 assume a beauty which she has not. Wigs heat the 
 head and sweat tlie hair. False hair by its weight 
 drags upon the feeble hair it is designed to fortify. 
 
 The wearing of night-caps was once a custom, 
 founded upon the need of keeping the head warm in 
 the inadequately heated bedrooms of our ancestors. 
 With the improvement in house building and heating, 
 the custom has passed away, and should not be re- 
 vived, as it excludes the air from the hair continuously 
 for a good part of the day. Of course where there is 
 no hair, and the bald individual is sensitive to the cold, 
 there can be no objection to keeping the head covered 
 with a wig by day and a cap by night. 
 
 Hair Cutting.— All men wear the hair short, and 
 employ a barber at varying intervals according to their
 
 oS DISEASES OF THE HAIR AND SCALP. 
 
 fancy. As far as the health of the hair is concerned, 
 it is immaterial whether it is cut at longer or shorter 
 intervals, but it is essential that it should be well cut, 
 and a good barber is desirable. It should never be 
 "shingled," as the barbers term an operation which 
 consists in cutting the hair by a to-and-fro motion of 
 the shears, as this tears and roughens the hair. The 
 hair of cliildi'en, whether they be boys or girls, should 
 be kept cut shoi-t until the seventh or eighth year of 
 age, as the growing hair is a drain upon the nutrition 
 of the body, and at this time of hfe all the nutritive 
 forces should be expended in the gro^\i;li of muscle and 
 bone. The hair of a girl after she has reached her 
 eighth year should be allowed to grow, as the less the 
 hair is cut the fuier it is. But should the girl be so 
 situated that her scalp and hair can not be properly 
 cared for, then she will have a better chance for a good 
 head of hair in later life if it is cut when she is young. 
 The hair of women is seldom worn shoi-t, although of 
 late some young women have seen fit to adopt the style 
 of wearing the hair hke a man, along with his coat and 
 waist-coat. It is quite common for the long hair of 
 women to be split at the point. This should be looked 
 for, and if found, the hair should be cut above the 
 cleft. AU ragged ends should be lopped off, and all 
 weak hairs should be cut off near the head. 
 
 Shaving. — The shaving of the beard is regulated 
 largely by fasliion. Physiologically it is best not to 
 shave, for if we do, we rob ourselves of a useful protec- 
 tion to the throat and lungs. As shaving makes the 
 hair grow coarser, it is often resorted to very early by 
 the youth, for the purpose of rendering the do^^^l of 
 the lip or cheek more apparent. It would be better to 
 endui'e the downi for a time, as the growth of an ele- 
 gant soft beard would be the reward. If one must 
 shave, he should do it himself, and see that Ms razore
 
 THE HYGIENE OF THE HAIR. 59 
 
 are kept sharp. He should shave himself, so as to 
 avoid the risk of infection with ringworm of the heard. 
 If the razors are dull, they are apt to set up an inflam- 
 mation of the hair-follicles or skin. For shaving, a 
 mild soap that forms a thick lather should be used, 
 and after the operation, especially in cold or windy 
 weather, the face should be powdered with simple rice 
 flour or fine corn- starch. 
 
 Pomades. — Punch's advice to a man about to marry 
 is equally applicable to the use of pomades. It was: 
 '^ Don't." Their regular use upon the healthy scalp 
 is uncalled for. They are dirty, soon become rancid, 
 and emit a foul odor, unless this is covered by some 
 strong perfume, and they soil whatever the wearer's 
 head comes in contact with. If the rules already given 
 are followed, the hair will be smooth and have suffi- 
 cient lustre for beauty without pomades. If the scalp 
 is diseased, the proper remedies should be applied. In 
 the following pages it will be indicated when and what 
 pomades should be used. Most of the greases advertised 
 for the cure or prevention of baldness or grayness are 
 useless, and some harmful. The powers of some have 
 been vaunted upon grounds that are rather absurd, as 
 for instance bear's grease, because the bear is weU cov- 
 ered with hair. '' Bandoline " and the like sticky sub- 
 stances, as well as hair dyes, should not be used, as 
 the former is bad for the hair, and the latter are not 
 infrequently followed by loss of health from the poisons 
 they contain. 
 
 In some cases the hair becomes matted together in 
 a tangled mass, especially that of women during pro- 
 longed iUness. From whatever cause arising, care and 
 patience wiU usually enable the mass to be unravelled 
 and the hair saved. To do this it must be attacked a 
 little at a time with oil, soap and water, and the fin- 
 gers, and picked apart and combed straight. By proper
 
 60 DISEASES OF THE HAIR AND SCALP. 
 
 care the condition is avoidable in most cases. It would 
 be very exceptional when a patient could not bear the 
 combing of the hair with a coarse comb once a day, 
 follow^ed by plaiting it into one or two plaits. When 
 this is done gently and quietly it will prove refreshing, 
 and w^ill prevent any trouble with the hair during con- 
 valescence. If it camiot be done, then it is best to cut 
 off the hair to one half or one third of its length, so 
 that it will be less hable to tangle. 
 
 As the hair sympathizes with the general health of 
 the body, the latter should be maintained in good 
 condition by a wise conformity to the laws of 
 health. By the proper combination of the hygiene 
 of the body with that of the hair, it is possible 
 for even one who is predisposed to premature 
 baldness to ward off the evil day for years; and 
 one who comes of a strong-haired family should, 
 as a rule, not become bald or have any essential disease 
 of the hair. 
 
 f
 
 PAET II. 
 
 THE ESSENTIAL DISEASES OF THE HAIR. 
 
 Canities.— Discolorations. — Alopecia. — Alopecia 
 
 Areata. — Atrophia Pilorum Propria.— 
 
 Hypertrichosis. — Trichiasis. — 
 
 Sycosis. — Folliculitis 
 
 Decalvans.
 
 CHAPTEE TV. 
 
 Synonyms. — Trichonosis cana; Trichonosis discolor; 
 Poliothrix poliosis ; Trichonosis poliosis; Trichosis 
 poliosis; Spilosis poliosis; Poliotes; Whiteness of the 
 hair; Blanching of the hair; Atrophy of the hair -pig- 
 ment. 
 
 Canities may be congenital or acquired; partial or 
 complete; sudden or slow in its onset. The most com- 
 mon form is the acquired, which usually begins as a 
 graying of a few hairs, and proceeds more or less slow- 
 ly till it affects all the hair of the head and face. 
 
 Congenital Canities usually occurs in the form of 
 tufts, sometimes in round patches, the more or less 
 white hair showing conspicuously among the normally 
 colored mass. These cases are rare, but in some fami- 
 lies are hereditary, a white tuft of hair occurring in a 
 large number of their members. Among the cases of 
 this sort is that reported by Godlee (103), who, in 18S-1-, 
 met with a girl, six years of age, who had a patch of 
 white hair growing from a white patch of scalp. The 
 child's mother had a precisely similar patch, and stated 
 that it had occurred in two of her sisters, in one brother, 
 in her father and paternal grandfather. One of her sis- 
 ters had four children, all of them girls, similarly af- 
 fected. When the whiteness of the hair is general, it 
 is associated with delicate pink skin and eyes, and is 
 part of that condition known as albinism. 
 
 Acquired Canities may be premature or senile. Most 
 often grayness does not begin before the thirty-fifth or 
 fortieth year of age. If it occurs before that time, it may
 
 64 DISEASES OF THE HAIR AND SCALP. 
 
 be considered, for convenience, as prematm^e; if after 
 that time, as senile. Both forms are exceedingly com- 
 mon, many persons becoming quite gray between the 
 twentieth and twenty-fifth year, while it is exceptional 
 for any one to attain the age of fifty T\ithout more or less 
 gi'ay hair on the head. There are so many variations 
 in the manner of turning gray, that it is hard to give 
 a definite rule; but the hair of the temples usually 
 changes its color first, then, after a greater or less 
 length of time, that of the vertex and whole head. 
 Sometimes the beard is the first to whiten, but it more 
 commonly follows that of the head. The hair of the 
 pubes and the axillae is the last to turn gray, and often 
 it escapes entirely. When the process is due to some 
 passing cause it may cease upon the removal of the 
 cause, and cases of normally colored hair growing in 
 after the fall of the white hair have been noted. A 
 very rare instance of this has been reported to me by Dr. 
 J. W. Warxer of this city. The case was well kno\\Ti 
 to him, and was one of relapsing canities affecting a 
 gentleman living in Sharon, Conn. This gentleman's 
 hair and beard changed from black to white, and back 
 again three times in thirty years. The change from 
 black to white was always rapid, while that in the re- 
 verse direction was slow, taking some five years for 
 completion. Then would come a pause of some years 
 when the color was normal, and then it would become 
 white again. During all the thirty years his health 
 was good, he was able to attend to an active out-of- 
 door business, and never used any hair dye. Isdell 
 (104) has reported the case of his father, who, 
 in 1861, and when sixty- two years of age, had per- 
 fectly gi'ay hair on his head and beard, while in 1882, 
 when he died at the age of eighty-three, his hair w^as 
 of its natural dark color A\'ith the excej^tion of a few 
 gray hairs on the temples. This case is of the same
 
 CANITIES, OR GRAYNESS OF THE HAIR. 65 
 
 order as those of a new growth of teeth and hair in 
 extreme old age. While instances of white hair be- 
 coming normal in color again are rare, it is not un- 
 common for the grayness to remain partial and appar- 
 ently stationary for a number of years. Generally, 
 however, grayness is progressive and permanent, 
 whether it is premature or senile. 
 
 The hair in canities is usually unchanged except- 
 ing in color, but it may be drier, stiffer, and 
 even coarser than normal. As a rule, there is no 
 change in the color of the scalp. Where we find 
 gray tufts upon pale yellow patches of scalp, the 
 disease is rather vitiligo than canities. The change 
 in the color of the hair takes place at its root first. It 
 usually changes to gray on account of the mixture of 
 the essential color of the hair with the whiteness pro- 
 duced by absence of pigment and the presence of air. 
 Exceptionally, hairs are met with whose point and 
 root are white, and the intermediary part normal in 
 color ; or the point and root normal, and the interme- 
 diary part white ; or the distal ends are gray, and the 
 proximal ends of normal color. The last variety is most 
 often due to splitting of the end. Gradually, as the 
 pigment becomes more and more deficient, the white 
 color gains the ascendency, the whole hair is blanched, 
 and finally becomes of a yellowish or snowy white. 
 The darker the original color of the hair, the more 
 prone it is to turn gray ; brunettes are more often 
 gray than blondes, and become so earlier in life. 
 Canities may exist for years without alopecia, as there 
 is no direct connection between them. In the senile 
 form, however, alopecia is apt to come on as another 
 senile change, and Landois states that incipient bald- 
 ness usually follows senile canities in from one to five 
 years. Men are more often affected with canities than 
 are women.
 
 e^ DISEASES OF THE HAIR AND SCALP. 
 
 Sudden change of color of the liair from its normal hue 
 to perfect white, has been too well authenticated to allow 
 of a doubt as to its occmTence, though its possibihty has 
 been denied by good authorities, who have questioned 
 the correctness of the obseiTations reported. But both 
 medical and lay history record many instances of the 
 phenomenon, and several recently reported cases dem- 
 onstrate its possibihty. Thus Laxdois (108), in ISGG, 
 repoi-ted a case observed by himself, occurring in the 
 person of a man thirty -five years of age, who was ad- 
 mitted into the hospital suffering ^ith dehrium tre- 
 mens. His dehrium took the form of great terror 
 whenever any one approached him. On admission his 
 hair was of blonde hue, and remained so up to the 
 evening of the third day. On the morning of the 
 fourth day, the hair both of the beard and scalp was 
 noticed to have become gTay. Some, of the hairs were 
 white from root to point, some only at their points, 
 some only at their roots, while some were blonde and 
 white at different points. Another mteresting case of 
 this kind was reported by Raymond (110) in 1882. The 
 patient was a French woman, thirty-eight years old, 
 with black hair. She was of a nervous and impres- 
 sionable temperament. In July, 1881, she was gi'eatly 
 affected on account of parting with her son, and for 
 about six weeks she could not sleep. In Januaiy, 1882, 
 she was utterly prostrated l>y the loss of a large sum 
 of money on the Bourse, and since then had been ex- 
 ceedingly nervous, finding it impossible to remain quiet 
 in any position for any length of time. She lost her 
 appetite, could not sleep, and had pains in various 
 paiis of her body, especially in her head, shoulders and 
 tibiae. These pains were of two characters, the one 
 constant, and the other neuralgic and lancinating. On 
 the head and face there were various painful points. 
 "VMien she received the news of her loss she was men-
 
 CANITIES, OK GRAYNESS OF THE HAIR. 67 
 
 struating, and the flow was immediately suppressed. 
 On January 31st she had a terrible attack of neuralgia. 
 By two o'clock in tlxO morning of February Is^ her 
 hair was of normal color, at seven o'clock it was al- 
 most completely discolored. Upon the sides of the 
 head the color was preserved in part; upon the upper 
 portion most of the hair was fiery red. The remainder 
 of the hair had become completely white. The hair 
 on the rest of the body was unaffected. The pains 
 still continued. On the next day most of the red hair 
 had become white, and was rapidly falling. In fifteen 
 days nearly all the hair had fallen out, only a few hairs 
 remaining on the lateral and occipital regions. Up to 
 the thirtieth of March there was no return of the hair, 
 nor of the color in those remaining. 
 
 Ringed Hair. — Ringed hair is an anomalous variety 
 of blanching of the hair, in which the affected hairs 
 are marked by alternate rings, one ring having the 
 normal color, and the next one being white. This dis- 
 ease is of very rare occurrence, and but few cases have 
 been reported. Wilson (122), in 18(37, reported a case 
 of this kind, which, I believe, is the first on record. The 
 patient was a boy between seven and eight years of 
 age; the disease was fii'st noticed when he was between 
 two and three years old, and was increasing. It af- 
 fected only the head. The hair-cylinder was uniform, 
 the brown or normal segments measured ^\- of an inch 
 in length, and the white segnients were about one half 
 as long. 
 
 Under this name Lesser (110) reported another case 
 in 1885. This occurred also in a child four and a half 
 years old, otherwise healthy. It was born entirely 
 without hair, excepting its eyebrows, which were nor- 
 mal. Soon after birth the scalp presented the appear- 
 ance of goose flesh, which continued. The hair began 
 to grow by the second yc'ar. At time of presenta-
 
 68 DISEASES OF THE HAIR A^T) SCALP. 
 
 tion of the case, there was observed a lichen pilaris 
 appearance alorjg the border of the hair, on the neck 
 and temples. The hair of the whole head was extra- 
 ordinarily short, measuring even after two years 
 growtli, from 1 to 9 cm. ; it was dry and brittle and 
 inclined to tangle. The color was brown. The longer 
 hairs were normal. The short hairs were ringed in 
 gi'eat part, and microscopically showed alternate swell- 
 ings and contractions of the shaft, the former being 
 spindle-shaped and forming the hght or white ring by 
 dh'ect light. The distance between the contractions 
 averaged 0.6 cm. On a gieat number of the ringed 
 hairs there were appeai-ances characteristic of moni- 
 lethrix, to which disease this case more properly be- 
 longs. 
 
 Etiology and Pathology. — Senile canities and 
 most cases of the premature or presenile form, are due 
 to an obscure change in the nutrition of the hair-papil- 
 la, which interferes with the production of pigment. 
 Whatever the nature of the change may be, only this 
 function of the papilla seems to be interfered with, as 
 the hair-forming function is in normal activity, judging 
 from the fact that the hair in many cases is in full 
 vigor. Ehrmann (101), on the other hand, holds that 
 the pigment is formed in the papilla, but fails to reach 
 the hair on account of absence of certain cells in the 
 hair-root, Avhich he believes are the active agents in 
 transferring the pigment from the papilla to the hair. 
 His views are given more fully m the chapter on Phy- 
 siology of the Hair. According to Pixcus (113), in the 
 beginning of canities the pigment slowly leaves the 
 middle layers of the papilla and remains only in the 
 external layers. With the increase of the canities, 
 only a portion of the external layers of the papilla will 
 produce pigment, which in straight hair will ran in 
 streaks parallel to the long axis, and in curly hair will
 
 CANITIES, OR GRAYNESS OF THE HAIR. 09 
 
 n 1 11 in a spiral. The blending of the colored and un- 
 ( .lored streaks will produce the gray color, which will 
 gradually change to white as the pigment is less and 
 less produced. 
 
 Our study of the physiology of the hair, has 
 taught us that the color of the hair (see page 42) ; 
 is very much influenced by the amount of air con- / 
 tained in the cortex. In cases of sudden blanch- 
 ing of the hair, the change of color is dependent upon 
 the formation of air-bubbles between the hair-cells of 
 the cortex, its presence rendering the cortical sub- 
 stance opaque and obscuring the color of the pigment. 
 This is proven by placing one of the affected haii's in 
 liot water, ether, or turpentine, when the air-bubbles 
 iwill be driven out and the hair will resume its normal 
 color. This same infiltration of the hair with air-bub- 
 bles will be found also in cases of ordinary canities, 
 though usually merely secondary to some interference 
 with pigmentation. 
 
 TJiere are various agencies which act as predisposing 
 or exciting causes of canities. Age or senility is one 
 of the most prominent of these. Heredity exerts a 
 marked influence, most of the members of certain 
 families turning gray at an early period of hfe. That A 
 the nervous system works actively in the production 
 of grayness, is shown by the occurrence of sudden 
 l)lanching of the hair under the influence of fear or 
 gi-eat nervous shock; by the formation of symmetrical 
 'white bands or tracts of hair during acute outbreaks 
 I of insanity, which disappear during convalescence, as 
 noted by Shaw (IIT) ; and by the hair becoming white 
 in parts affected by neuralgia, as of the fifth nerve- 
 Hence canities may be regarded as a tropho-neurosis in 
 ^oiue instances. 
 
 Local diseases or injuries of the scalp, such as 
 wounds, repeated epilation, prolonged shaving, have
 
 70 DISEASES OF THE HAIR AXD SCALP. 
 
 been known to have local or general canities fol- 
 low them. The hair after alopecia areata comes in 
 white and may remain so, but usually the wliite haii-s 
 fall out to be replaced by normal colored ones. Wal- 
 jj^XBERG (119) reports a case of entu-e loss of hair after 
 scarlatina, in which the new hair came in white and 
 remained so, the skin at the same time losing its pig- 
 ment, and becoming milk white. In this case there 
 was a good deal of ah- in the cortex. The hair has 
 been known to turn gi^ay in winter, and to become 
 darker in summer. Prolonged residence with much 
 exposure, either in a cold or hot chmate, is given as a 
 cause of premature grayness. Albinoes, we know, are 
 most frequent in the negro races, which inhabit the 
 hot countries. On the other hand, Holder {124: ap.) 
 says that gray hair is very rare amongst the Ameri- 
 can Indians. Excessive mental application, or pro- 
 longed nervous strain, will sometimes induce canities, 
 which becomes permanent and progressive. In like 
 mamier dyspepsia of various forms, excesses of aU 
 kinds, chronic debihtating diseases such as syphihs, 
 malaria and phthisis, i)rofuse and frequent hemor- 
 rhages, have been given by various writers as causes of 
 canities. It has been noted that in women who early 
 cease to menstruate the hair is apt to become prema- 
 turely gray, while those who menstruate late in life 
 often retain the color of their hair. In this as in many 
 other diseases, no one cause or group of causes can be^ 
 proven to be the cause, but a study of those given w 
 siiow that they have one thing in common, that is, a 
 lowering of vitality. 
 
 The curious phenomenon of '^ ringed hair" is ascribed 
 by Wilson (122) to the development of a gaseous fluid 
 within the hair, and he thinks that either the white, 
 opaque and smaller segments were developed during 
 the night, and the larger and normal segments grew i 
 
 beJ
 
 n 
 
 during the day, or the separate segments were the pro- 
 duct of alternate days. The gas may have been gener- 
 ated at the time of the formation of the abnormal seg- 
 ment, or the cells which composed that segment may 
 have been originally filled with an aqueous fluid, which 
 evaporated quickly, and was replaced by air penetrat- 
 ing from without. Landois (109) does not agree with 
 Wilson, but believes that we must assume an inter- 
 mittent activity of the trophic or vaso-motor nerves of 
 the papillae, through whose influence a hair tissue is 
 formed, in which a periodic development of gas takes 
 place. Lesser (110), in whose case the hair-shaft was 
 affected with trichorrhexis nodosa, likewise found air- 
 bubbles in the white or swollen parts, which gained 
 entrance from without through the dry and cracked 
 cuticle of the hair. He offers no explanation for the 
 intermittency of the rings. In his case there was evi- 
 dently some error in the nutrition of the scalp. Beh- 
 REND (3) regards the disease as a stage of trichorrhexis 
 7iodosa, and says that the process affects already 
 formed hair. As yet no answer can be given to the 
 question, ^' What gives rise to ringed hair ?" 
 
 Treatment. — As a rule nothing can be done to per- 
 manently restore the color to white or gray hair. If 
 the malady is due to neuralgia, the cure of this will 
 sometimes be followed by restoration of color. The 
 administration of iron, phosphorus, and sulphur, has 
 been advised on theoretical grounds, and may be tried 
 if the canities seems to be due to physical debility; but 
 no f)romise of success should be made to the patient. 
 As cases have been reported in which the hair has 
 grown darker under the long-continued use of jabo- 
 randi by the mouth, or pilocarpine subcutaneously, 
 these drugs might be tried. Acetic acid also seems to 
 have a decided tendency to increase the pigmentation 
 of the hair, and might be tried. The rules of the
 
 72 DISEASES -OF THE HAIR AND SCALP. 
 
 hygiene of the scalp should be at the same time en- 
 forced. Plucking the white hairs is worse than use- 
 less. All that can be done for canities is to artificially 
 restore the color by means of hair dyes, and their use 
 is to be strongly advised against. Happily the custom 
 of dying the hair is falling out of fashion. 
 
 Hair Dyes. — Hebra and Kaposi (15) give directions 
 for dyeing the hair black by ''henna," which is the Per- 
 sian name for a small shrub found in the East Indies, 
 Persia, the Levant, and along the African coasts of the 
 Mediterranean, where it is frequently cultivated. The 
 botanical name is Laivsonia Alha ; in England it is 
 called Egyptian privet, and in the West Indies it is 
 known as Jamaica mignonette. In the East it is used 
 for dyeing red the nails of women, the lieards of men, 
 and the manes of horses. The preparation of hemia 
 consists in reducing the leaves and yomig twigs to a 
 fme powder, catechu or lucerne leaves in a pulverized 
 state being sometmies mixed with them. Wlien re- 
 quired for use the powder is made into a pasty mass 
 with hot water, and then spread upon the part to be 
 dyed. * In an hour the hair will be red. A paste of pow- 
 dered indigo plant is now applied, and then damp heat, 
 and in a few hours the hair will have a fuie black color, 
 provided that the process has been regulated by expe- 
 rience and good judgment. Leonard ((U) gives the 
 foUo\\ing formula? for dyeing the haii* black: 
 
 iS'o. 1 
 
 . 
 
 Bismuthi citratis . 
 Alcohohs 
 
 !j = 50 
 
 3 v = 33 
 
 AquiB rosre 
 Aqua? destillat. . 
 Ammoniae 
 
 . aa 3 ij = ad 200 
 q.s. 
 
 M. Sig. Api)ly in the : 
 
 morning 
 
 * Encyc. Brit., 9th ed., art. HeniKU
 
 , CANITIES, OR GRAYNESS OF THE HAIR. 73 
 
 No. 2. 
 
 Sodii hyposulphit. . 3 xii = 60 
 
 Aquae destillat. . . 3 iv = ad 200. 
 
 M. Sig. Apply thoroughly in the evening. 
 
 Nitrate of silver in the strength of from five to ten 
 grains to the ounce of water may be used for a black 
 dye, the hair being saturated with it and allowed to 
 dry in the sunHght. If it is desired to hasten the pro- 
 cess, the application of a solution of sulphuret of pot- 
 ash, from twenty grains to two drachms to the ounce 
 of distilled water, will set the dye instantly. McCall 
 Anderson recommends the following for a permanent 
 black dye: First, a solution of bichloride of mercury, 
 two grains to the ounce of water, followed by a solu- 
 tion of hyposulphite of soda, one drachm to the ounce 
 of water. Lead may be used in the form of the sugar 
 of lead, ten to twenty grains to the ounce of water, 
 apphed to the hair and followed, when nearly dry, by 
 a solution of the sulphide of ammonia, about one- 
 quarter the strength of the British Pharmacopoeia. 
 These dyes, by means of nitrate of silver and mer- 
 cury, are dangerous on account of the metals they con- 
 tain. 
 
 For a brown dye, Pfaff (70) recommends a pomade 
 composed as follows: 
 
 01. ovorum rec. press. 
 
 Med. OSS. bovis . . .aa 50. 
 
 Ferri lactat 2.50. 
 
 01. cassias ether. . . . 1.50. 
 M. 
 
 But the number of dyes is legion, and these must 
 suffice for examples. Before the application of any 
 dye, the hair should be thoroughly cleansed with ssoap 
 and water.
 
 CHAPTEE V. 
 
 DISCOLORATION OF THE HAIR. 
 
 Synoxyms. — Tricolorosi. Trichonosis seu Trichosis 
 decolor. 
 
 Under various conditions of health and disease, 
 the hair has been known to undergo changes in 
 color, other than that of turning gray. Some of these 
 changes depend upon causes acting from within, and 
 modifying in some way the pigment formation. Some 
 are due to external agencies, and have the nature of 
 dyes. 
 
 Just as serious ilhiess will cause the hair to fall out 
 or to turn gray, so will it induce changes in color. 
 Some instances of this have been reported. Thus 
 Rayer (31) cites two cases of Alibert's, in the first of 
 which a young woman after a long and serious illness 
 lost a fine head of blonde hair, and upon recovery had 
 the loss made good by a gro^%i:h of very black hair. In 
 the second case, a man during sickness lost his brown 
 hair, which was replaced after recovery by bright red 
 hair. He further cites a curious case in which every 
 time the patient, a young woman, was attacked with 
 f(3ver, her blonde hair became ta^\my red, to return to 
 its original hue upon recovery. Beigel (123) reports 
 a case in which, after typhus fever, the blonde hair of 
 a woman feU out, and was replaced by coal black hair. 
 Smyly (136) saw the hair of a patient suffering with 
 suppurative disease of the left temporal bone, change 
 from a mouse color to a reddish yellow. The patient 
 was an infant. The left temporal bone was the seat of 
 the suppuration, but the right side of the head was
 
 DISCOLORATION OF THE HAIR. Y5 
 
 affected with the change in color of the hair. The 
 right eyebrow was Hkewise affected. There was also a 
 profuse yellow perspiration, so that the pillow and the 
 skin of the right side were stained yellow. This case 
 was one of dyeing. C. Eeinhard (135) has reported a 
 case of periodic change in the color of the hair of an 
 idiot boy who suffered with epilepsy and paralysis of 
 the legs. He was subject to violent outbursts of tem- 
 per, during which his reddish-blonde hair would change 
 in forty-eight to sixty hours to a blonde yellow color. 
 The change of color seemed to begin at the points of 
 the hair, and affected nearly all the hair. After some 
 seven or eight days, the original color would return. 
 There was no disease of the scalp, excepting that dur- 
 ing the stage of quiet, there was a scanty secretion of 
 sebaceous matter. Microscopical examination showed 
 that the light hairs contained a good deal of air in the 
 cortex and medulla; that they were dry and inclined 
 to split at their points. Their cuticle cells were dis- 
 placed; and the medulla cells were very much shrunken. 
 This would be sufficient to explain the change of color, 
 as our study of the physiology of the hair has already 
 taught us. 
 
 That it may be possible to influence the color of the 
 hair by internal medication, is inferred from the re- 
 markable case reported by Prentiss (134). He had a 
 patient with light blonde hair who suffered f i*om i)yelo- 
 nephritis with anuria, for the relief of whicli condition 
 muriate of pilocarpine was administered hypodermi- 
 cally in doses of from 0.01 to 0.02 gi-amme. The use 
 of the drug was begun on December 10, 1880, and the 
 hair commenced to grow darker by the twelfth day. 
 On the twelfth of January, 1881, the color had become 
 chestnut brown, and by the first of May it was almost 
 pure black, although the pilocarpine was stopped on 
 the twenty-second of February. The hair became not
 
 ^6 DISEASES OF THE HAIR AND SCALP. 
 
 only darker, but coarser, and grew more vigorously; 
 and the hair of the axillas was as much changed as that 
 of the head. The hair was in every respect normal, 
 and the change in color seemed to depend upon increase 
 of pigment. With the change of color in the hair, the 
 color of the eye changed from a light to a dark blue. 
 The same author (101 ap.) has reported another case 
 in which a patient with Bright's disease took from 
 twenty to thirty drops of fluid extract of jaborandi 
 several times a day. After a year's treatment his hair 
 turned of much darker color. These cases would tend 
 to show that jaborandi increases the nutrition of the 
 hair and the activity of the pigment-forming cells. 
 It would appear that the cause of the change of color 
 was the jaborandi, because the tendency of exhaust- 
 ing diseases, such as pyelonephritis and Bright's dis- 
 ease, is rather towards loss of hair and canities. Jabo- 
 randi does increase very markedly the cutaneous 
 circulation, and to this action we must look for the 
 explanation of these cases. 
 
 We have no means of explaining with certainty 
 these changes of the hair from internal causes. Of 
 course they are due to some influence upon the pig- 
 ment-forming cells, but that does not explain the mat- 
 ter. The cases reported are few, and only in those of 
 Prentiss and Smyly does an adequate explanation sug- 
 gest itself. The other changes in color of the hair, the 
 consideration of which falls within the scope of this 
 chapter, are dependent either upon a deposition of 
 colored particles from without, or upon chemical action. 
 From these causes we have green, blue and yellow hair, 
 as well as various anomalous shades. 
 
 Green Hair. — Green hair occurs in workers in cop- 
 per. A number of cases have been reported ; the fol- 
 lowing one by Petri (132) will serve as an example. 
 An old worker in copper, seventy-eight years of age, 
 presented the curious appearance of having briUiant
 
 DISCOLORATION OF THE HAIR. 77 
 
 green hair. He was in good general health. Upon 
 his gums was a well-marked green line. Both his beard 
 and scalp hair were green. The color did not affect 
 the whole length of the hair, but was darkest and 
 most intense at the point, and for a distance of 3 cm. 
 therefrom. From that point it grew gradually less 
 pronounced, till at 10 cm. it had disappeared. Be- 
 yond this the hair was gray. The microscopical ex- 
 amination of the green hairs showed a deposit upon 
 the epidermis of the hair, of small, sometimes bluish, 
 sometimes indefinitely colored, sometimes darkly con- 
 toured or yellowish, sharply cornered, pyramid- shaped 
 masses of crystals, with transparent edges Here and 
 there little patches of dirt were found. The crystals 
 could be seen only with very strong light. By the ad- 
 dition of liquor amnion, caust., the color changed to 
 dark or blackish blue, which is the chemical reaction 
 of ammo^na with the salts of copper. The color could 
 be washed out of the hair, and was doubtless due to 
 particles of copper oxide floating in the atmosphere of 
 the work-shop, and deposited on the haii". Billi (124:) 
 reports a case of green hair occurring in a patient of 
 his, whom he was treating for trichophytosis capitis. 
 For the ringworm a wash of corrosive sul)limate was 
 ordered, and an ointment of the yellow oxide of mer- 
 cury. The next time he was seen his hair was a bril- 
 liant green, the color being disseminated over the whole 
 head, and the hair colored from bulb to tip. The mi- 
 croscope showed that all the elements of the hair were 
 colored. The patient was not a worker in copper, nor 
 had he used any other application to his scalp. Cases 
 of green hair have been reported in which no cause was 
 discoverable. Thus Orsi (131) met with a case in a 
 railroad hand, who was forty-nine years old, and whose 
 hair was gray. Suddenly his hair became green, the 
 green hairs being intermixed with the gray and white. 
 The scalp hair alone was affected. Washing with vin-
 
 78 DISEASES OF THE HAIR AXD SCALP. 
 
 egar, ether, alcohol or a dilute solution of potash, did 
 not affect the color. The microscope showed that the 
 roots of the affected hairs were thick and fihrous; the 
 coi*tex by natural light was violet, by artificial fight 
 gi^eenish in color; while the medulla was yefioTvfish. 
 When the hair was cut off, gray hair grew in. Even 
 in this case, since the hair came in of normal color, 
 there was, doubtless, some external agency at work. 
 In some cases of canities, a greenish yeUow tint wiU 
 be observed, a transition stage from the original color 
 to the gray, and tlfis also might be an explanation of 
 the foregoing case. 
 
 Blue Hair. — Blue hair is met T\ith in workers in 
 cobalt mines and in indigo works. The color is gener- 
 afiy easily removed by waslung, and under the micro- 
 scope Beigel (123) found in a case of his own, that the 
 whole hair was not uniformly colored, but that particles 
 of indigo were deposited in an UTegular manner upon 
 the cuticle of the hair. In some exceptional specimens 
 a number of hairs were embedded for some distance 
 in a mass of indigo, or stuck with neighboring hairs. 
 The edges of the epithelial scales were more pronounced 
 than in the normal condition, owing to the deposit along 
 them of a fine blue dust. The blue color did not pene- 
 trate into the substance of the hair. 
 
 Yellow, Browx, and Black Hair. — Yellow hair 
 has been observed in patients suffering from icterus ; 
 red-brown hair occurs in handlers of crude aniline ; 
 and black, or rather coal-black, hair is often seen on 
 those who work in coal. In all these cases of change 
 in color of the hair from the deposit of foreign matter, 
 the element of time was marked, and the lighter the 
 color of the hair was originally, the easier did it become 
 altered. 
 
 Change of Color after Death. — The color of the 
 hair may change after death. Thus Hauptmaxn (127) 
 reports a case in which the hair of a corpse, exhumed
 
 DISCOLORATION OF THJ: HAIR. 79 
 
 after twenty years' burial, was found to have changed 
 from a dark brown to a red color. 
 
 Color altered by Chemicals. — The action of vari- 
 ous chemical agents will change the color of the hair, 
 the change generally being transitory. This is illus- 
 trated by the action of the various dyes and bleaching 
 fluids used by the hair-dresser. Further, bicarbonate 
 of sod^, used for a long time, will change the color of 
 dark hair to a dirty red brown. Chrysarobin colors 
 the hair, as well as the skin, a mahogany red. Naph- 
 thol I have seen change white hair to a bright corn- 
 yellow color. Chlorine gas will bleach the hair. 
 Sweat acts upon the color of the hair, and we often 
 find the hair of the axillae of persons who sweat much 
 of lighter color than that of the head. Leonard (64) 
 cites a case, in which the brown head hair of a young 
 man turned to a positive red after a few years' resi- 
 dence in the hot climate of Sumatra. It is not uncom- 
 mon for the color of the hair to grow darker or lighter 
 under the influence of exposure to sunlight. 
 
 Anomalous Cases. — In some cases, according to 
 Oesterlen (130), hair will be met with which 
 is more intensely pigmented towards its root than 
 towards its point, depending upon an irregular 
 deposit of pigment, or alteration in the texture of 
 the hair. One of the most curious anomalies is re- 
 ported by Squire (137) as occurring in a young man 
 sixteen years old, the left side of whose head was pie- 
 bald like a tortoise-shell cat. The condition dated from 
 birth, and there was no assignable cause. The light- 
 colored patches were auburn, the dark patches brown, 
 and they were abruptly hmited. The opposite or right 
 side of the head was covered with dark-brown hair, of 
 the same tint as the dark patches on the left side. The 
 curious condition known as ringed hair will be found 
 described in the chapter on Canities in this work.
 
 CHAPTEE YI. 
 
 ALOPECIA. 
 
 Derivation. — The term is derived from the Greek 
 word dXGOTtrjC^ meaning a ^^fox," on account of its re- 
 semblance to the appearance presented in the "fox- 
 mange." 
 
 Synonyms. — Capillorum defluvium; Athrix depihs; 
 Phalacrotes; Depilatio; Trichosis athrix; Gangraena 
 alopecia ; Atrichia ; Defluvium, seu Lapsus seu Fluxus 
 pilorum ; Lipsotrichia; Vulpis morbus; Pelada; Oligo- 
 trichia ; Calvities ; Psilosis; Trichorrhoea ; Ophiasis ; 
 Calvitie (Fr.); Kahlheit, Fuchsraude (Ger.); Calvezza 
 (It.); Baldness (Eng.) 
 
 Definition. — An abnormal loss of hair, arising from 
 any cause, which usually affects the scalp, but may in- 
 vade any portion of the body. 
 
 Varieties. — 1. Alopecia adnata, or congenital bald- 
 ness. The form occurring in infants born either totally 
 or partially without hair. 2. Alopecia senilis. The 
 absolute or relative baldness of old age. 3. Alopecia 
 prematura, seu presenihs. Baldness occurring before 
 the time when the hair usually falls, on account of ad- 
 vancing years. It may be idiopathic or symptomatic. 
 4. Alopecia areata, in which the hair falls out in circu- 
 lar patches. 
 
 The older writers used various terms to denote 
 the different phases of baldness. These, happily, 
 have faUen into disuse. They were the following: 
 Madesis or Maderosis, used to denote a thinning of the 
 hair. Phalacrosis, to denote baldness beginning at 
 the forehead. Ophiasis, to signify baldness occurring
 
 ALOPECIA. 81 
 
 in a serpentine line, running from the occiput towards 
 the ears, and sometimes towards the forehead. Opis- 
 thophalacrosis, baldness beginning at the back of the 
 head. Hemiphalacrosis, baldness affecting one half of 
 the head. Anaphalantiasis, used to designate loss of 
 the eyebrows, and sometimes general baldness. OKgo- 
 trichia, to denote thinness of hair. According to 
 FouRNiER, alopecia should be used to denote the process 
 of hair-fall, and calvities the completed baldness. 
 
 1. Alopecia Adnata. 
 
 Symptoms. — This is the atrichia of the old waiters. 
 It is congenital baldness, as the name indicates, and is 
 either partial or complete. Most infants come into the 
 world with a good equipment of hair. In rare instances 
 the child is born partially bald, and more rarely com- 
 pletely so. Hairless races have been reported. One 
 of these is said to exist in Australia. Hill (157). 
 
 Etiology and Pathology. — The disease is due to 
 arrested development of the piliary system; and micro- 
 scopical examination of sections of the skin in inveter- 
 ate cases, shows a deficiency of hair-follicles. In a case 
 reported by Jones and Atkins (ICO), of a boy who 
 never remembered having had hair, microscopical ex- 
 amination of the scalp revealed only a few aborted 
 hair-follicles, forming shallow pits in the epidermic 
 layer with open extremities looking downwards. In two 
 cases reported by Schede (1T9) in 1S72, one of which 
 was a boy thirteen years old, and the other a girl six 
 months old, brother and sister, there was no hair what- 
 ever on the body, not even lanugo hair. Microscopical 
 examination of a section from the boy's scalp showed 
 large, well-formed sebaceous glands, opening directly 
 on the scalp. In the neighborhood of some of these 
 glands, just above their lower extremity, were found 
 a great mnnber of ''atheromas" separated from the
 
 82 DISEASES OF THE HAIR AND SCALP. 
 
 
 glands by connective tissue, and apparently developed 
 in a species of short tubes, which in structure corre- 
 sponded with that of the outer root-sheath, and were 
 no doubt the beginnings of the rudimentary hairs. 
 Luce (166), in 1879, reported a case in which the hair 
 ' did not grow until the sixth year, and in which the 
 appearances of keratosis pilaris were present. Hutch- 
 inson (158), in 1886, reported a case of congenital ab- 
 sence of hair in a boy three and a half years old, the 
 son of a woman who had been almost wholly bald from 
 alopecia areata since she was six years old. In this 
 case there was a withered condition of the whole in- 
 tegument, and an absence of nipples. A somewhat 
 similar case is reported by De Mol^nes (115 ap.). The 
 mother had had alopecia areata some years before 
 giving birth to the child whose case is reported. At 
 birth there was a scarcely perceptible down upon the 
 scalp, no eyebrows, and hardly visible eyelashes. At 
 five months the eyelashes fell out and the scalp be- 
 came white and smooth. There was no keratosis pi- 
 laris. Teeth and nails were normal. Under stimu- 
 lating treatment during three years the hair grew in, 
 excepting on a small place behind the left ear. In 
 some families there is an hereditary predisposition to 
 congenital alopecia. 
 
 Prognosis. — The prognosis is usually good. The hair 
 in most cases will grow in course of time, although it 
 may not be as abundant as it should be. According to 
 MiCHELSON (171), when congenital alopecia takes the 
 form of circumscribed patches, the prognosis is bad. 
 Delayed dentition and diseased nails will often be noted 
 in children affected with this disorder. 
 
 Treatment.— As to treatment, the disease usually 
 requires none, as it generally remedies itself. If it is 
 very disfiguring, or the parents require something to 
 be done, stimulating remedies may be used, as in alo-
 
 ALOPECIA. 83 
 
 pecia areata. If there is keratosis pilaris, the free use 
 of soap frictions every day, followed by inunctions with 
 oil, will serve to remove the epidermis which clogs up 
 the hair-foUicles, and will thus give the hemmed-in 
 hair a chance to grow. 
 
 2. Alopecia Senilis. 
 
 Symptoms.— This form of baldness is that which oc- 
 curs in old age. It is often preceded, accompanied, or 
 soon followed by other signs of advancing years, such 
 as graying of the hair, fall or decay of the teeth, and 
 diminution in keenness of the sight. The hair usually 
 first becomes gi'ay, loses its lustre and suppleness, and 
 then falls out either slowly or rapidly. At first there 
 may be only a general thinning of the part about to 
 become bald, but at last absolute baldness sets in. The 
 fall of the hair usually begins at the vertex, and it is 
 not uncommon to see this region alone affected for 
 some time, giving the appearance of the tonsure. It 
 may begin at the anterior superior part of the skull. 
 Generally the course of the disorder is from behind for- 
 wards, or from before backwards, but the whole top of 
 the head may be affected at once. In most cases the 
 lateral and posterior parts of the skuU are spared, and 
 the bald patch is bounded on either side and behind, by 
 a semi-circle of hair, running along the temples to the 
 neck. It is always symmetrical. Neumann (27) draws 
 attention to the fact that both in senile and premature 
 alopecia, the region commonly affected corresponds 
 quite nearly to that supplied by both supra-orbital 
 nerves, and in very extended cases the regions supplied 
 by the temporal and the occipitalis major and minor 
 are also included. A certain amount of seborrhoea sicca 
 is sometimes present. The scalp appears smooth, 
 stretched, shiny, sometimes oily, and thinned. 
 
 Etiology. — This form of baldness is but one expres-
 
 84 DISEASES OF THE HAIR AND SCALP. 
 
 1 
 
 sion of that general lowering of nutrition, incident to 
 advancing years. The age of forty-five is that usually 
 chosen to designate the dividing hne between man's 
 fullest development and commencing decay, and it is at 
 about this period that senile baldness begins. Women 
 are far less often bald than men. Why this is so we 
 do not certainly know. In the section on premature 
 baldness, some reasons for their exemption will be 
 given. Neither canities nor seborrhoea are causes of 
 this form of alopecia. Kaposi (19) says that atrophy 
 of the scalp tissue does not precede, but follows it after 
 a considerable lapse of time. 
 
 Pathology.— There is a lessening of the subcutane- 
 ous fat, and an atrophy of the corium, the coimective- 
 tissue fibres of which have undergone, in part, fatty, 
 and in part, colloid degeneration. The sebaceous 
 glands are in some places shrunken and in some wid- 
 ened; the hair-follicles are filled with epithelial scales, 
 the remains of the root sheath, and often contain a 
 thin hair. In many foUicles the hair papiUa has disap- 
 peared. Kaposi (19). Pixcus (71) found in senile 
 baldness that there was a rapid relative increase in the 
 shedding of the '' spitzen " hairs, (that is, those hairs 
 which have not been cut\ and a marked and increasing 
 diminution in the diameter of the long hairs; also an 
 absence of seborrhoea sicca in most cases, and a well- 
 marked atrophy of the scalp. Like in other senile 
 changes, so here the retrograde process begins in the 
 arterial supply to the scalp, and we find a fibrous endar- 
 teritis narrowing the lumen of the cutaneous arteries, 
 till finally the capillary circulation about the hair- 
 foUicles is obliterated. 
 
 Prognosis. — The loss of hair is permanent. In some 
 rare cases the hair has grown again in old age, and tliis 
 has been attended by the development of new teeth. 
 
 Treatment. — When the scalp is atrophied and bound
 
 ALOPECIA. 85 
 
 down to the skull, the hair-follicles are too far gone for 
 any stimulation to affect them, and our best endeavors 
 to restore the lost hair will be in vain. 
 
 3. Alopecia Prematura. 
 
 There are two main varieties of premature baldness; 
 Alopecia Prematura Idiopathica, and Alopecia Prema- 
 tura Symptomatica. 
 
 Alopecia Prematura Idiopathica. 
 
 Symptoms.— Alopecia prematura idiopathica is that 
 form of baldness which begins at any time before mid- 
 dle age, and arises uninfluenced by any antecedent or 
 concomitant, local or general disease. Usually the hair 
 does not begin to fall before the age of twenty-five 
 years, and it is apt to progress slowly. The hairs which 
 first fall out, are replaced by those of less vigorous 
 growth, and these in their turn are shed to make way 
 for still weaker ones, and so the process is repeated 
 until complete baldness results. In its general course 
 it is similar to the senile form. Like it, it is symmet- 
 rical, it begins most often upon the vertex, forming 
 the tonsure, it progresses slowly, has the same boun- 
 daries which it does not go beyond except in extreme 
 cases, and leaves a smooth, shiny, bound-down scalp. 
 It often begins anteriorly and recedes at the sides, giv- 
 ing that wide and high forehead thought to be indica- 
 tive of wisdom. It may leave for a long time a little 
 islet over the middle and anterior part of the skull. 
 Unlike senile baklness, it is not preceded by canities, 
 or any other senile change. In some cases the fall of 
 the hair will be rapid, then cease for a time, to begin 
 again and progress steadily. The beard in all forms of 
 baldness is affected rarely, a luxuriant beard being 
 very often associated with a more or less bald head. 
 
 Etiology. — The disease is in many cases hereditary,
 
 86 DISEASES OF THE HAIR AND SCALP. 
 
 it being not uncommon to meet ^vith families in which 
 the fathers and sons for many generations lose their 
 hair early in hfe. Pin'CUS (173) says this is due to a 
 markedly stretched condition of the aponeurosis of the 
 occipito-frontalis muscle, which becomes hereditary in 
 certain families. According to him, ^' there are but 
 two predisposing causes of alopecia prematm-a. They 
 are: 1. Inheritance. 2. A chronic eczema or impeti- 
 ginous eruption on the scalp, in the years preceding 
 puberty. The latter is the most frequent, and is often 
 connected with symptoms of relative or absolute debil- 
 ity." It is very prevalent in those leading sedentary 
 hves, especially so in brain-workers. Jamiesox (10 ap.) 
 would explain this on the theory that the nerves sup- 
 plying the scalp are in direct connection with those 
 supplying the pia mater and dura mater, and that an 
 irritable condition of the brain due to cerebral conges- 
 tion would reflexly interfere with hair-growth. The 
 continuous wearing of cajDS or of close-fitting unventi- 
 lated hats, a practice very common in this country, is 
 assigned as a cause. Some hatters claim that accord- 
 ing as the head is long or ^^dde, the baldness commences 
 on the forehead or crown. F. A. King (161) says 
 ''baldness of the vertex is due to compression, by stifit 
 hats, of the anterior temporal arteries in their course 
 over the frontal protuberances ; of the posterior tem- 
 porals at or near the parietal ridges ; and of the occi- 
 pital behind. The reason why baldness occurs in dif- 
 ferent places in different individuals is probably due 
 to differences in the shape of the head. The httle tuft 
 of hair often observed on top of the forehead, is nour- 
 ished by the two supra-orbital arteries, which escape 
 pressure, by passing over the forehead in the slight 
 concavities between the frontal eminences." The ex- 
 istence of the islet of liair in front is probably depen- 
 dent upon the fact that it lies over the f rontahs muscle, 
 
 I
 
 ALOPECIA. 87 
 
 and is not upon so tense a substratum as the other 
 liair of the vertex. Lack of care of the hair is an ac- 
 tive cause. Ellinger (150) behoves that the daily use 
 of water on the head is a frequent etiological factor, 
 and has found this the case in eighty-five per cent, of 
 his cases. He says '^ the form due to water begins at 
 the forehead, and precedes upward and to the sides ; 
 it occurs in people wlio wear the hair long, and is due 
 to the fact that the water at the point of exit of the 
 hair makes an emulsion with the sebum and the 
 scales of epidermis, which, hardening, forms a plug 
 to the hair-follicle, causes a damming up of the sel)um 
 in the follicle, and subsequent atrophy of the hair." 
 In an article upon alopecia by Pohl Pincus (17Y) it is 
 held that all forms of the disease are due either to 
 primary or secondary induration of the scalp. Some 
 causes of primary induration are said by him to be the 
 action of cold, as by an ice-bag, gleet, leucorrhoea, 
 great depression of spirits, or anxiety of mind, which 
 the subject struggles against ; while in those cases in 
 which the subject succumbs entirely to his depression, 
 these do not cause baldness. 
 
 It has been noted that eunuchs generally have hair 
 neither on the face nor pubes, if they are castrated be- 
 fore puberty ; and if castrated after puberty, they lose 
 whatever hair they had on those regions. Holder (12^ 
 ap.) says that the American Indians never grow bald. 
 They have no hair on their bodies, and but little on 
 the pubes, and on the face of the males. Women less 
 often become bald than men. The reasons given for 
 this exemption, are that they do not wear their hats^ as 
 much as men, neither are their hats so close fitting, 
 nor made of so impermeable materials as are men's 
 hats; that they give more attention to the care of their 
 hair than men do; that they carefully avoid wetting 
 their hair; that they are not so abundantly covered
 
 88 DISEASES OF THE HAIK AND SCALP. 
 
 with hail' as are men, and therefore do not suffer so 
 great a drain upon the hair-forming elements; that the 
 hair is not so often cut; and that there is a greater 
 amount of subcutaneous fat in women than in men, 
 and this is preserved longer in them. PiNCUS says 
 ''the reason why they suffer less, is due to the fact 
 that in them the spaces between the connective-tissue 
 fibres, in the deeper and middle layers of the scalp, are 
 much larger than in men, the skin of women during 
 their life preserving more of the characteristics of the 
 skin of children.-' In an analysis of one hundred 
 cases of baldness appended to this chapter, the remark- 
 able fact is brought out that there is a tendency for 
 baldness to be hereditary in the line of sex. Thus in 
 all the cases in women there was a distinct history 
 of the affection occurring on the maternal side. 
 
 That the beard is not affected is because the 
 underlying tissues are not so stretched, as is the case 
 with the part of the scalp most often affected, that 
 is, the region over the occipito-frontahs aponeurosis. 
 This reason would also hold good in regard to the 
 exemption from baldness of the other hairy regions 
 of the body, and of the parts of the scalp hair which 
 usually do not fall out. 
 
 Pathology.— From birth up to the age of twenty 
 years the scalp undergoes a continual change in struc- 
 ture, which consists in increasing thickening and ten- 
 sion of the middle layer of the connective tissue, this 
 being most marked in the regions most commonly af- 
 fected by alopecia, namely, over the aponeurosis of the 
 occipito-frontalis muscle, and least marked on the 
 temples. In both alopecia prematura simplex and alo- 
 pecia senilis the connective -tissue which binds the scalp 
 to the underlying parts, suffers stiU further changes. 
 It undergoes a narrowing of its meshes with a thick- 
 ening of its fibres, till at last in many places the meshes
 
 ALOPECIA. 89 
 
 disappear. At first the hair loses its typical length, 
 but not thickness, its lustre is somewhat diminished, 
 and both the quantity and quality of daily fall is slightly 
 increased, more short hairs being shed in propoi*tion to 
 long hairs than normally. At the same time sebor- 
 rhoea sicca generally becomes pronounced, though in 
 about ten per cent, of the cases it is wanting. The 
 thickening of the subcutaneous tissue progresses slow- 
 ly, but at last in from six months to five years, the 
 hair begins to lose in thickness, and to fall more rap- 
 idly, and baldness sets in. The diameter of the hair is 
 in direct proportion to the diameter of the papilla; and 
 as the papilla is more and more pressed upon and re- 
 duced in size by the increase of the connective- tissue, 
 the diameter of the hair is steadily lessened. At first 
 the papillae are unaltered in constituence, later they are 
 obliterated, and then no more hair can be produced, 
 and the part is bald. If the process of indui-ation 
 greatly increases, it goes beyond the aponeurosis, and 
 the whole head becomes quite bald. Pincus (173). 
 
 Prognosis. — If the disease has not progressed too 
 far, we may sometimes stay its progress. If the scalp 
 is so tightly adherent to the subcutaneous tissues that 
 it does not readily shde upon them, we can not hope 
 to better the condition. A well-marked history of 
 heredity renders the prognosis unfavorable. We can 
 best watch the progress of the case by having the pa- 
 tient save aU the hair that falls from his head for three 
 days, putting each day's faU by itself, and then count- 
 ing the pointed and cut hairs, if the case occur in a man, 
 or the hairs over and under six inches, if the case occur 
 in a woman. If the uncut hairs of a man, or the hairs 
 mider six inches of a woman, exceed one quarter of 
 the mass, the disease is progressive, and the prognosis 
 is unfavorable; if under one quarter the prognosis is 
 better.
 
 90 DISEASES OF THE HAIR AND SCALP. 
 
 Tkeatmext. — 111 pei*sons who have reason to expect 
 early hereditary baldness, prophylaxis is of the gi'eat- 
 est importance. This consists in close attention to the 
 hygiene of the scalp, and of the general health. When 
 the disease has once set in, it must be combated by 
 means of stimnlating apphcations, as in symptomatic 
 premature baldness. Shoemaker (182 and 1 S3) recom- 
 mends that to persons in apparent good health, who 
 are unconsciously losing their hair, either mercury, 
 tinctui'e of ignatia, or sulphurous acid should be ad- 
 ministered. Either the bichloride of mercury or calo- 
 mel is given by him for a short period, and then the 
 tinctm*e of ignatia in ten-di'op doses three times a day 
 ^ith a bitter tonic, and thus the treatment is varied 
 from time to time, according to the patient's condition. 
 He also advises the use of the oleate of u'on locaUy in 
 these cases. The use of jaborandi or pilocarpine would 
 seem to hold out some hope for the cui^e of this affec- 
 tion. In IS 79 two remarkable cases of hair grooving 
 on perfectly bald heads were reported by Geo. Sch^iitz 
 (ISO), after using two or three hypodermics of pilocar-^ 
 pine for some eye disease. In one case the man was 
 sixty years old aud quite bald, and yet a vigorous 
 growth of gray and black hair took place and covered 
 his scalp. In the other case the man w^as thirty-four 
 years old, vrith a small bald spot upon which the hair 
 grew so as to cover it. Cottle (52) speaks highly of 
 the i)ower of either of the following lotions to stop the 
 fall of the hair, namely: 
 
 Ac. Acetici, . 
 
 3 ss., say 6 
 
 Pulv. boracis, 
 
 . 3j., '' 1-50 
 
 Glycerine, . 
 
 . 3iij., '' 4.50 
 
 Spts. vini. 
 
 . 3SS., '' 6 
 
 Aq. rosae, 
 
 adsviij.,^' 100 
 
 M 

 
 ALOPECIA. 91 
 
 ^Or, Liq. ammon. acetat., . lij., say 25 
 ; Ammon. carbonat., . 3ss., ^' .75 
 
 Glycerine, . . . 3iij., '' 4.50 
 : Aq. sambuci, . adSviij./' 100 
 
 M 
 PiNCUS (175) advises in acute idiopathic loss of hair 
 the avoidance of all stimulation of the scalp, and tem- 
 perance in eating, drinking and mental excitement. 
 Where the fall of the hair is progressive and chronic, 
 and while it is still merely a thinning of the hair, he 
 directs the application to the scalp, for two to five 
 minutes on two or four successive days of each week, 
 of a lotion composed of: 
 
 Bicarbonate of soda . . 2 
 
 Distilled water ... 100 
 
 M 
 
 rubbing in one to two tablespoonfuls with a soft hair- 
 brush or a sponge. On the first or second day of the 
 interval between the applications, some oil is to be 
 rubbed into the scalp. This treatment is to be con- 
 tinued for a year, and then if the disease still pro- 
 gresses, more powerful remedies are to be used, such 
 as will be spoken of under the treatment of alopecia 
 furfuracea. 
 
 Mayerhausen (132 ap.) reports good results from 
 the use of static electricity. Mapother (lol ap.) be- 
 lieves that as the hair contains sulphur, silicon, iron, 
 and manganese, a dietary composed largely of oat- 
 meal and rye bread will promote its growth. 
 
 Alopecia Prematura Symptomatica. 
 
 Symptoms. — As its name indicates this form of bald- 
 ness occurs as a consequence of some other local or
 
 9^ DISEASES OF THE HAIR AND SCALP. 
 
 
 general disease. It may occur at any time before old 
 age and be either circumscribed or diffused, depending 
 upon its cause. It may be very rapid, as after fevers, 
 the hair falling out by handfuls, in which case it is 
 named ''deiluvium capillorum; *' or it may be very 
 slow, as in seborrhcea sicca, taking years to produce 
 complete baldness. Other parts of the piliary system 
 may suffer besides the scalp hair, as in trichophytosis, 
 spyhiHs, etc. In some cases aU the hair of the body 
 has fallen out at once, as after sudden nervous shock. 
 When dependent upon non- symmetrical diseases, as 
 variola, pustular diseases in general, and the parasitic 
 diseases, the baldness will be asymmetrical. 
 
 Its main varieties are : alopecia f urf uracea or alopecia 
 pityrodes; alopecia syphihtica; defluvium capillorum; 
 and a class comprising the non-symmetrical cases aris- 
 ing from local lesions, which has been named by 
 T. RoBixsoN (75) "alopecia f ollicularis. " The most 
 frequent cause of alopecia prematura symptomatica, is 
 seborrhoea sicca or pityriasis simplex, and on this ac- 
 count oar first attention must be given to 
 
 Alopecia Furfuracea.— In this there is always 
 some scaUng of the scalp, it may be in so slight a 
 degree as to constitute the commonly called "dan- 
 druff," or pityriasis simplex; or the process may be so 
 intense as to produce the thick, easily friable, grayish - 
 white, gi^easy scales of seborrhoea sicca. This 
 kind of baldness is met with in aU ages, but its most 
 serious form occurs usually between the twentieth 
 and thirtieth year of life. It has two stages. In the 
 first stage, simple seborrhoea sicca or pityriasis is pres- 
 ent, and the hair is dry and falls out slightly. The 
 subject notices that his clothing, especially about the 
 shoulders, is covered more or less tliickly with gi-ayish 
 epithehal scales mingled with sebaceous matter, and 
 that these fiU Ms binish; and that a few hairs fall out
 
 ALOPECIA. 93 
 
 of themselves or are pulled out by combing. This 
 stage lasts from two to seven years, as a rule. Now 
 the second stage begins, when to the seborrhoea is 
 added a rapid fall of the hair. The location usually 
 affected is the same as in alopecia senilis, the top of the 
 head, from vertex to forehead, and sometimes over the 
 temples, and the tuft of hair just over the forehead is 
 preserved longest. The patient does not become bald 
 at once, as there is at first only a thinning of the hair; 
 then a diminution in the length and diameter of the 
 hair; but the atrophy continues till at last only a few 
 lanugo hairs are left, which in their turn fall out and 
 complete baldness results. The bald scalp appears 
 white or of rosy hue; is often stretched over the 
 sutures, though frequently easily moved over the 
 aponeurosis of the occipito-frontalis muscle; and it 
 seems thinned. The seborrhoea keeps pace with the 
 intensity of the disease, until the hair falls out markedly, 
 when it lessens, and when baldness is fully established 
 it is no longer present. 
 
 Such is the usual course of the disease. In infants 
 seborrhoea generally gives rise to thick crusts, which, 
 being removed, bring away with them the first growth 
 of the hair. In them it does not produce permanent 
 baldness. In women the region affected is genei'ally 
 that occupied by the part. It is affirmed that they are 
 more prone to seborrhoea sicca and fall of the hair than 
 men are, but that the process in them is cnly passing, 
 and the fallen hairs are soon replaced. Seborrhoea sicca 
 will also produce a general thinning of all the hairy 
 scalp, but this is usually an acute and temporary 
 trouble. 
 
 PiNCUS (71) says: ^^ In alopecia pityrodes the definite 
 proportion between the hair growth and fall is dis- 
 turbed, the latter becoming excessive. The longer the 
 seborrhoea lasts the more the hair gi*o^\i,li will fall
 
 94 DISEASES OF THE HAIR AXD SCALP. 
 
 behind. When the proportion of short hairs to the 
 total fall is as 1:8, the average length of the hair being 
 five inches; or as 1:10, the average length of the hairs 
 being from two to three inches, the loss is abnormal." 
 If under treatment the disease is checked, and the 
 process has not lasted long enough to cause destruction 
 of the hair bulbs, imj^rovement vrWl be shown by a 
 lessening of the fall of the hair, and by and by a growth 
 of lanugo hairs and then of good strong colored hairs. 
 
 By UxxA (186) a method is proposed for proving the 
 improvement, which is as follows: The patient is di- 
 rected to gather the fallen hairs into a httle bundle 
 with the roots all looking one way, so that the condi- 
 tion and number of them can be seen at a glance. So 
 long as the fall is rapid, many hairs will be found which 
 have just passed the papilla stage, whose knob-like 
 roots are still long, and often have a drawn-out epithe - 
 lial projection. The less the fall is the less this form of 
 root wiU be found, till only the rounded full roots are 
 met with, which shows that the hairs have been a long 
 time in the ^^bed-hair" stage." 
 
 Alopecia Syphilitica next claims our attention. 
 It occurs most often early in the disease with the early 
 specific lesions, but may occur later, with the tubercu- 
 lar and gummatous lesions. Syphilitic exanthems may 
 be present on the scalp, or the alopecia may be the only 
 symptom of the disease. It has no definite time of 
 appearing, coming as early as the third month, or as 
 late as the end of the second year. When it is the result 
 of the syphilitic cachexia, seborrhoea is often present, 
 and there is a general thinning of the hair all over the 
 head, with the formation of irregular patches of bald- 
 
 *By " bed-hair '' is meant a hair which has been cast off from 
 its papilla, but not shed from the follicle. It is one of the regular 
 stages in the life of every hair, and shows that it has attained its 
 full development. 
 
 1
 
 ALOPECIA. 05 
 
 ness which do not tend to form circles. In the patches 
 we often find tufts of long hair, and the head has a 
 peculiar ragged look, as if it had been badly cut with 
 dull shears, which is quite characteristic. In some 
 cases the middle region of the scalp is alone affected. 
 When it is due to a pustular or ulcerating lesion the 
 baldness is localized at the seat of the lesion, and cica- 
 tricial tissue not infrequently takes the place of the 
 normal scalp tissue. 
 
 Other regions besides the scalp may be affected, but 
 always at the same time with the scalp. The broken 
 arch of the eyebrows is characteristic and is most often 
 seen in women. Alopecia of the eyelashes is less fre- 
 quent. The hair of the pubes is quite frequently at- 
 tacked; specially, according to Fournier (152), is this 
 the case in women. 
 
 Usually there are no subjective symptoms, and the 
 fall is more rapid than in other forms of alopecia. It 
 comes in both benign and malignant cases, more often 
 in the latter. Some authorities say that it is not so 
 common as it used to be in former times when it was 
 the custom to salivate the patients, and hence it is in- 
 ferred that it is due to the administration of mercury. 
 While we know that alopecia is one manifestation of 
 chronic mercurial poisoning, yet as alopecia occurs in 
 syphilitic cases in which no mercury has been used, we 
 can feel assured that syphilis of itself is a sufficient 
 cause of the baldness. 
 
 DEFLUvroM Capillorum is the form of baldness 
 which follows acute diseases, especially fevers, or oc- 
 curs in the course of some cachexia such as mercuri- 
 alism. Usually the hair does not fall out till after con- 
 valescence has set in, when the fall will be very rapid. 
 It is more apt to be a general thinning, attacking all 
 parts of the scalp, than a localized baldness, and in most 
 cases is associat'i^d with seborrhoea. As a rule it is
 
 96 DISEASES OF THE HAIR AND SCALP. 
 
 not very intense, and rarely produces absolute baldness. 
 At times, however, the hair of the whole body ^ill faU 
 with gi'eat rapidity so that the disease will have a 
 strong resemblance to alopecia areata mahgna. 
 
 Alopecia Follicularis. — The appearance presented 
 by this form will vary T^ith the cause. When due to 
 pustular diseases, as impetigo, the patches are not larger 
 than from the size of a dollar to that of the palm and 
 we may have cicatrices. A"\lien due to some diffuse 
 inflammatory disease, as erysipelas, the patches are 
 quite large and irregular, and the scalp is hyperaemic. 
 When due to favus or ringworm the hairs are altered : 
 in the former case they are lustreless, dry, brittle and 
 sometimes split longitudinally ; in the latter they ai> 
 pear as if gnawed off near the roots. The scalp, too, 
 is altered ; in fa^Tis in old cases it is more or less atro- 
 phied ; in ringworm it is usually covered with thick 
 scales forming a crust. 
 
 Etiology. — Alopecia prematura symptomatica has 
 many causes. We have already mentioned seborrhoea 
 sicca, syphilis, fevers, impetigo, erysipelas, variola, 
 and parasitic diseases. Besides these may be mentioned, 
 violent shocks to the nervous system and mental dis- 
 tress; parturition. lupus erythematosus, psoriasis, lichen 
 ruber, lichen scrophulosorum, lepra, and other cachex- 
 ia?. Sweating of the head will cause the hair to fall. 
 Removal to the seashore is often attended by increasec 
 fall of the hair. Scarlatina has been followed by per- 
 manent baldness. 
 
 Tlie baldness following fevers, and with syphihtic 
 and other cachexia^, is due in most cases to seborrhoea, 
 but may be purely a nutritive trouble, the bulbs being 
 badly nourished, the hair becoming loose and falling 
 out. This view is suppoiiied by the fact that the hair 
 does not fall out till some time has passed since the 
 onset of the fever, and 2:rows in again when convales-
 
 ALOPECIA. 9Y 
 
 cence is fully established. Giovannini (121 ap.) says 
 that the baldness of syphilis is due to a deep folliculitis 
 pilaris, and not to anaemia or atrophy. The baldness 
 of the pustular diseases, such as variola and the syphi- 
 lides, and of the destructive diseases, such as lupus 
 erythematosus, is due to the destruction of the hair- 
 follicles. The baldness which is found to follow the uce 
 of mercury, excess in venery and intemperance, is due 
 to their damaging effect upon the constitution of the 
 patient. Anything, in fact, which will tend to impair 
 the full vigor of a man, may secondarily contribute to 
 the production of baldness, especially if he has a pre- 
 disposition thereto. This it may do by its effect upon 
 the nutrition of the hair, or more commonly through 
 a pityriasis simplex or seborrhoea sicca. 
 
 Brocq (111 ap.) believes that many cases of so-called 
 alopecia furfuracea are really due to keratosis pilaris, 
 which is capable of destroying the hair-follicle when it 
 is attended by an inflammation. He reports the case of 
 a boy with small patches of baldness on the scalp which 
 appeared sieved and showed no sign of lanugo hairs. 
 He had keratosis pilaris both of the scalp and body. 
 
 Lassar and Bishop (163) maintain that alopecia fur- 
 furacea is contagious, and is frequently transmitted by 
 the agency of barber's brushes and combs. Hence, 
 they state, women are less often affected than men, 
 because they are not so much exposed to infection at 
 the hands of the barber. They base their opinion upon 
 the following experiments: They took a twenty-five 
 years old student, of sound health and without nervous 
 tendency, belonging to a family in which baldness was 
 uncommon. This student had been growing bald for 
 five or six years. The baldness was absolute only over 
 the forehead, but the hair was very thin from there to 
 the vertex, the sides being spared. In the thin part, the 
 hair was short and dry. The hair of the neighboring
 
 OS DISEASES OF THE HAIR AND SCALP. 
 
 parts was somewhat lustreless and brittle, coming out 
 easily on slight traction. There was only a slight, 
 dusty pityiiasis. There was a httle itching, and the 
 scalp showed some excoriated places made by the 
 patient's nails in scratching. The itching had been 
 present for some years, especially when he was work- 
 ing or reading. The hair loss had been gradual till the 
 preceding summer, when during a foot tour in hot 
 weather, it had increased more rapidly. From this 
 student's shed hair and scales, a pomade was made by 
 chox)ping them up fine and mixing them with vasehne. 
 This pomade was spread over the back of a guinea pig 
 and of a rabbit, and the animals watched while kept 
 in the best hygienic surroundings. In the course of 
 three weeks there formed upon the backs of these ani- 
 mals patches of absolute baldness as large as the palm 
 of the hand; other places showed marked thimiing of 
 the hair, wliich came out \\ith tlie sUghtest traction; 
 and there was present a mealy desquamation similar to 
 that on the student's head. To control this experiment, 
 it was repeated on another guinea pig and rabbit, and 
 upon yet a third rabbit; in these cases the hair being 
 taken from No. 1 and No. 2 respectively. The results 
 were in all cases similar, only attained more rapidly. 
 In all the cases the baldness preceded from the infected 
 into the sound parts. 
 
 It must not be thought that every case of seborrhoea 
 of the scalp will be followed by loss of hair. In those 
 who inherit naturally vigorous hair this may not oc- 
 cur. It is when there is an inherited tendency to loss 
 of hair that seborrhoea will quite surely cause alopecia. 
 
 In ISTtt, Malassez (169) and Chincholle (lJr2) de- 
 scribed a vegetable parasite as present in pityriasis sim- 
 plex, oval in shape, which disappeared ^-ith the disap- 
 pearance of the pityriasis. Malassez described it as 
 *^ constituted of spores without tubes of myceHum,
 
 ALOPECIA. 99 
 
 generally oval in shape, seldom spherical, and very 
 small. It inhabits the corneous layer of the skin, and 
 penetrates the follicles, but does not reach the orifice 
 of the sebaceous gland. It is generally very abundant, 
 and is the cause of the disease." Recent investiga- 
 tions by BizzozEKO tend to shov^ that these spores are 
 found generally upon the normal human skin (003). 
 Unna (141 ap.) has found cocci in seborrhoeal eczema 
 of the scalp from which he has made cultivations. He 
 has produced in a rabbit progressive falling of the hair 
 with pityriasis by inoculations with these cultiva- 
 tions. 
 
 Much that has been given in the etiology of idiopa- 
 thic alopecia prematura, especially in regard to the use 
 of water on the head, the wearing of hats, etc., could 
 be repeated here, since they tend to produce pityriasis 
 and in that way alopecia furfuracea. 
 
 Pathology. — As we have learned, the majority of 
 the cases of premature symptomatic baldness that are 
 not due to destructive diseases are due to seborrhoea or 
 pityriasis simplex. We will, therefore, give our atten- 
 tion first to the pathology of alopecia furfuracea seu 
 pityrodes. In seborrhoea sicca there is a too hasty cast- 
 ing off of the hning ceUs of the sebaceous glands, and 
 as these are continuous with those lining the hair- folli- 
 cle, it is probable that a like increase in the shedding of 
 the cells of the hair-foUicle takes place. This nuist be 
 followed by interference with the nutrition, and loosen- 
 ing and falling of the hair. If the process can be 
 stopped before the papiUae become atrophied the hair 
 will grow again. If the process has continued un- 
 checked for from six to ten years, the papilk^ will 
 probably be destroyed, and the baldness will be perma- 
 nent. The normal life of a hair is one year or more; it 
 may be three months or less. The shorter time the hair 
 lives, the shorter and thinner it will be. In this form
 
 100 DISEASES OF THE HAIR AND SCALP. 
 
 of alopecia, the quantitative propoi-tiou of the short 
 ("spitzen-') hairs to the total shed hail's is increased 
 markedly ^Wthout the absolute daily hair loss being 
 as markedly increased. The characteristic of the first 
 stage is that hairs suffer an increasing diminution in 
 their normal leng-th, the later gro^\i:hs often having a 
 markedly shorter length of hfe than those that have 
 gone before. The lessening of the length of growth 
 is due to a shortening of the typical life. The charac- 
 teristic of the second stage is a reduction in the diame- 
 ter of the hair. The hairs occui* in bundles of from 
 three to five together. The life, length, and diameter 
 of the bans in the same group vary considerably, and 
 they do not all die at the same time. In fever pro- 
 cesses, however, a whole group often falls at once. 
 PiNCUS, (173). 
 
 Malassez (170), a supporter of the parasitic theory of 
 alopecia pityi'odes, explains its occurrence as follows: 
 The parasite causes an irritation of the foUiculai- walls, 
 followed by their hypertrophy. This h}'pertrophy 
 closes the cavity of the follicle, causes a fibrous trans- 
 formation of the follicle, and final fall of the hair. 
 
 In defluvium capillorum, when it does not depend 
 upon a pityriasis or a seborrhoea, we may find an ex- 
 planation for the sudden faU of the hair in the ar- 
 rangement of the blood supply as suggested by Unna, 
 (82 a) and given on .page 38 of this book. 
 
 Prognosis. — This will vary with the cause. The 
 ])rognosis of alopecia furfuracea is good if proper 
 treatment is begun while tlie hair is only thinned, and 
 the scalp is not actually bald. Then we have fail* 
 ground for hope if there is no predisposition to the 
 disease and lanugo hairs are present. When the scalp 
 is atrophied and bound down to the skuU, the prospects 
 are bad. Pincus says that the nearer to pobertj the 
 disease begins, the more rayiil wiD be its com'se.
 
 ALOPECIA. 101 
 
 The prognosis of defluvium capillorum is usually 
 good. This is especially the case after fevers and par- 
 turition. It may be generally stated that the prog- 
 nosis of alopecia, due to local disease of the scalp, is the 
 more favorable the more superficial the disease is which 
 causes it; thus, it is good after eczema and erysipelas, 
 bad after lupus and the ulcerative diseases, in which 
 thei-e is destruction of tissue and production of cica- 
 trices. 
 
 Before beginning the treatment of any case we must 
 explain to the patient that rapid results cannot be 
 expected, and success wiU depend largely upon the 
 care with which he carries out directions, and upon 
 his perseverance. At least one year of treatment must 
 be stipulated for. I have found that women will give 
 much more attention to the physician's directions than 
 men, and this is probably one reason why results are 
 more satisfactory with them. 
 
 Diagnosis. — Alopecia prematura symptomatica is 
 diagnosed from the other forms of alopecia by, usually, 
 the presence of a seborrhoea or SDme local disease, by 
 its running a more irregular course, and by a less 
 marked atrophy of the scalp. From senile alopecia 
 the absence of other senile changes will distinguish it; 
 and the lack of smooth, circular, oval, or serpiginous 
 patches serves to differentiate it from alopecia areata. 
 
 Alopecia syphilitica is diagnosed by its sudden inva- 
 sion; by its non -inflammatory and non-pruritic char- 
 acter; by the ragged appearance it gives to the hair 
 with its irregular patches of baldness; sometimes by 
 the presence of syphilides on the scalp or elsewhere on 
 the body; and by the history of infection. 
 
 Treatment. — Prophylaxis. — It should be especially 
 urged upon those predisposed to baldness that, by 
 proper care of the hair and scalp, much may be done 
 to prevent the early fall of the hair. The pi-ophylactic
 
 102 DISEASES OF THE IIAIK AXJ) SCALP. 
 
 treatment consists in brushing and combing the hair, 
 washing the scalp, the avoidance of the abuse of local 
 apphcations, and the attention to certain hygienic 
 laws; matters which have already been fully consid- 
 ered in the chapter on hygiene. 
 
 Curative Treatment. — When due to seborrhoea or 
 pityriasis, the first thing to be done is to remove all 
 crusts and scales. This is accomplished by the use of 
 soap and water when there is only scahness, and for 
 our soap, the tincture of green soap, composed of equal 
 parts of sapo ^iridis and alcohol or cologne water, is 
 the best. This acts both as a cleanser and a stimulant. 
 The soap should always be washed out mth a copious 
 stream of water, using it hot and cold alternately, 
 when convenient. If there is a tendency to dryness 
 of the hair, as there generally is in these cases, after 
 diying the scalp and hair carefully, a little oil or vase- 
 line should be rubbed mto the scalp. Or instead of 
 the soap, if the scalp is very irritable, we may use a 
 shampoo of eggs — the yolks of three eggs being beaten 
 up in one pint of lime water, to which half an ounce 
 of cologne water may be added. Rub this thoroughly 
 into the head after carefully brushing it, and wash out 
 the same as after using soap. Where there are thick 
 crusts this will not suffice, and we must use oil. Let 
 the patient saturate the head with sweet almond oil, 
 put on an oiled silk cap, and keep it on aU night. The 
 next morning wash the head with borax and water. 
 This is to be repeated every night until the head is 
 clean, and afterwards an occasional wash with the 
 tincture of green soap or borax and water will suffice 
 for cleanliness. Sopping on alcohol, with or without 
 two to five per cent of tincture of benzoin, will hasten 
 the drying of the hair aft-er washing. 
 
 Cases of alopecia furfuracea as a rule need stimula- 
 tion, and to this end a multitude of hair tonics have
 
 ALOPECIA. 103 
 
 been used, such as carbolic acid; tincture of cantharides; 
 tincture of cinchona; tincture of nux vomica; tincture of 
 capsicum; ammonia; chloral; corrosive sublimate; and 
 the like. The good these substances do is by their 
 stimulating properties, and no one of them can boast of 
 any specific action. They must be made strong enough 
 to cause the scalp to glow, but not to irritate it to the 
 point of inflammation. 
 
 Carbolic acid may be used as strong as two per 
 cent, in alcohol: tincture of capsicum, and tincture of 
 cantharides of the strength of 3 j — iij (4.0 to 12.0) to 3 j 
 (30.0): chloral, up to 3 j (4.0) to 3 j (30.0); tincture of nux 
 vomica say 3j (4.0) to sj (30.0); corrosive sublimate 
 gr. i — iij to 3 j ; aq. amnion, fort, may be used in some 
 cases pure, but better diluted to the point of tolera- 
 tion. 
 
 Or ointments containing these or other substances 
 may be used. A good one is 
 
 Hydrarg. amnion., . . gr. Ix., say 9 
 Hydrarg. chlor. niitis, . gr. Ixxx., ^^ 18 
 Petrolati, . . . ad 3 j., ''100 
 
 M. 
 
 Sulphur also acts well, in the strength of 3 ss — ij, 
 to 1 j. Unna (180) recommends : 
 
 Sulph. precip., ..... 10 
 
 Adeps, 100 
 
 M. 
 rubbed in every evening, at first from before backward, 
 and then around and around. Every three or four days 
 the head is to be washed. So soon as desquamation 
 lessens, rub in every second evening, and so gradually 
 decrease. If the scalp is irritated, he substitutes uiigt. 
 zinci oxid. for the lard in the above prescription. Sul- 
 phur has proved itself of value in my hands, and it is 
 the remedy in which I have most confidence. The 
 disagreeableness of using ointments upon the scalp is
 
 104 DISEASES OF THE HAIR AND SCALP. 
 
 much lessened by using ar very little of the ointment, 
 and rubbing it, or having it rubbed, thoroughly into 
 the scalp, and not smeared on the hair. Thanks to 
 the kindness of Messrs. Daggett & Ramsdell, of this 
 city, I have been able to use for the past two years a 
 most elegant Snijyhiir Cream composed of : 
 
 5 Cerae albce, . . . . . 3vij. 
 01. petrolati, . . . . 3 v. 
 
 Aq. rosa?, ! ijss. 
 
 Sodae biborat., .... gr. 30 
 
 Sulphur, 3 vij. 
 
 This is not very greasy, and it acts efficiently. 
 
 PiNCUS (17o) ad^^ses in the first stage, when the scal- 
 ing is pronounced and the hair begins to fall, a solution 
 of bicarbonate of soda strong enough to redden the 
 patient's forehead after rubbing it a few minutes. This 
 is to be nibbed thoroughly into the scalp, a compress 
 to be applied over it, and an oil silk cap to be worn all 
 night. One objection to tliis is that it stains the hair 
 a dirty reddish brown. In the second stage, when the 
 hair fall is pronounced, 1> Tanin gr.lxxx (6.00); ungt. 
 rosae 33 (30.0) is to be rubbed in every night, and the 
 head cleansed two or three times a week. A lotion of 
 01. sabiuce gr.v—xxx(0. 30—2.0) to alcohol 3 j (30.0) M. 
 apphed every night is better, as it may be interrupted 
 for two or three weeks at a time, while the tamiin cannot 
 be stopped more than six days. A hood is to be worn 
 during the night with either of these. The ol. sabinae 
 often causes headache, nausea, vertigo, and sleepless- 
 ness, which is an objection to its use. 
 
 PoHL PiNcus (177) advises the use of a lotion compos- 
 ed as follows: 
 
 Ac. lactic, . . . . 0.5 to 1.0 
 Ac. boracic, . . . 2.0 to 5.0 
 
 Aq. destilat, . . . 220. 
 
 Spts.vini rect. . . . 30 to 40. 
 M.
 
 ALOPECIA. 105 
 
 Two to three teaspooiif uls of this are to be rubbed into 
 the head once or twice daily for three or four minutes. 
 Or an ointment may be substituted composed as fol- 
 lows: 
 
 Ac. lactic, 1 to 3 
 
 Ac. boracic, . . . . 8 ^' 12 
 
 Adeps, vel 
 
 Vaseline, 100 
 
 01. bergamii, .... q.s. 
 
 M. 
 
 Two to four pea-sized masses of this are to be rubbed 
 into the bald places once or twice daily for three min- 
 utes. After using either of these for two or three 
 weeks, he makes a pause of a few days, and then for 
 one week uses : 
 
 Sodii carbonat., . . . . 3 to 8 
 
 Adeps, vel 
 
 Petrolati, 100 
 
 01. bergamii, . . . . q.s. 
 
 M. 
 in the same manner as the previous ointment, and so 
 alternates his remedies for a year. 
 
 Lassar (163) managed the case cited under etiology 
 upon the antiparasitic plan, with the result of causing 
 a growth of strong new hair by the end of the eighth 
 week. The patient's head was daily washed with a 
 sti'ong tar soap which gave a good lather, which was 
 rubbed i]i for fifteen minutes. The soap was then 
 washed out with water, at first warm, then gradually 
 cooler, at last cold. Then a wash composed of equal 
 parts of a solution of corrosive subhmate (1. to 300.0), 
 spts. cologne and glycerine, was thoroughly applied. 
 The head was then dried and a napthol solution (nap- 
 thol. 0.5; spts. dilut. 70.0; aq. destil. 30.0) was rubbed 
 in. Finally a one and a half per cent, solution of
 
 106 DISEASES OF THE HAIR AND SCALP. 
 
 carbolized oil was slowly poured over the head. In 
 1S88 (130 ap.) he gives as a substitute for this trouble- 
 some treatment the following : 
 
 I^ Carbolic acid, 1.5 
 
 Sublimed sulphur, .... 6 
 Horse-neck fat, ... 100 
 
 M. 
 He also commends oil of turpentine with equal parts 
 of oil or alcohol. 
 
 Paschkiss (131 ap.) believes that where there is a good 
 deal of seborrhoea oily applications should be avoided^ 
 and the scalp should be washed daily with tincture 
 of green soap ; or a soap composed of castile soap 
 40 to 50 grains, potash or soda 10 grains, and water 
 half a pint. The suds should be left on from ten min- 
 utes to several hours. In women this is impracticable, 
 and we must substitute for the soap a two to five per 
 cent, solution of soda. If this fades the hair the color 
 will be restored by the use of oil. We may use benzol 
 with equal parts of alcohol. If these means do not 
 cure, resort may be had to naphthol, resorcin, or ich- 
 thyol. After the seborrhoea is somewhat lessened, we 
 should apply to the scalp every day either 
 
 1^ Quiniuce sulphat., . . . 1.50 
 Spts. vini gallici, ... 65 
 Aquae cologn., ... ad 100 
 M. or 
 
 B Tannin, . . . . . 1 to 5 
 
 Alcohol, q. s. ad solut., 
 01. amygdalae dulc, . . 40 
 
 M. 
 Shoemaker (31 ap.) recommends equal parts of oleate 
 of iron and oil of ergot or any other oil \ also sopping 
 on the tincture or fluid extract of soap bark. 
 
 Heitzmanx (156) recommends in these cases the use 
 of crude oleum i-usci in the proportion of 10 per cent.
 
 ALOPECIA. 107 
 
 to 20 per cent, in an ointment of vaseline and paraffin, 
 with enough fragrant oil to cover the smell of the tar. 
 This is to be alternated with sulphur and white pre- 
 cipitate ointments. He claims that twenty-four per 
 cent, of two hundred cases were temporarily benefited, 
 and in a small percentage the improvement was last- 
 ing. 
 
 Ihle (159) recommends the use of resorcin as follows: 
 Resorcin pur, .... 5 
 
 01. ricini, 45 
 
 Spts. vini 150 
 
 BaLs. peiiiv. . . . . 0.5 
 
 M. 
 This is to be rubbed into the scalp daily with a piece of 
 flannel. It forms an agreeable mixture with a sliglit 
 odor of alcohol. This drug, as well as tcthyol, has also 
 been highly recommended by Unna. 
 
 So much for local measures. As seborrhoea is an 
 indication of lowered vitality, the general health must 
 be cared for, and tonics given when indicated. 
 
 In syphilitic alopacia our main dependence is upon 
 the internal treatment — mercury or iodide of potassium 
 being used according to the stage of the disease. Lo- 
 cally, if any lesions are present, we may use a lotion of 
 bichloride of mercury, or an ointment of the ammoni- 
 ate of mercury. Stimulating remedies, as in alopecia 
 furfuracea, may be used with advantage. Defluvium 
 capillorum takes care of itself in most cases. Its 
 treatment, when needed, is that of alopecia furfuracea. 
 Alopecia arising from local diseases needs the treat- 
 ment applicable to the special disease present, which 
 will be given in the appropriate chapters of this work. 
 In pustular diseases affecting the scalp, if the haii's are 
 early extracted before the foUicles are destroyed, much 
 will be accomplished to prevent alopecia.
 
 108 DISEASES OF THE HAIR AND SCALP. 
 
 Loss OF Hair : A Clinical Study of its Causes, 
 Founded on One Hundred Cases. 
 
 I have chosen the term '' loss of hair," rather than 
 baldness, because in my tables I have placed a number 
 of cases in which absolute baldness was not present, 
 but a general thinning of the hair, which if not checked 
 would lead to baldness. Cases of defluvium capillorum 
 coming on after acute illnesses are also included. 
 
 Of the 100 cases, 65 occurred in men and 35 in 
 women. 
 
 Of these the nationality was : Canada, 1 ; Ireland, 1 ; 
 Germany, 3 ; United States, 95. 
 
 Condition : 
 
 Married 12 men, 16 women. 
 
 Single 45 ** 16 " 
 
 Widowed 3 '* 
 
 Not recorded 8 
 
 Occupation. Of the men : 
 
 Architect, 1 Librarian, 1 
 
 Bookbinder, 1 Lithographer, 1 
 
 Brokers, 5 Lawyers, 5 
 
 Clergymen, 2 Manufacturers, 2 
 
 Clerks, 8 Mechanics, 2 
 
 Dentist, 1 ISterchants, 2 
 
 Electrician, 1 Physicians, 15 
 
 Farmers, 2 Presser, 1 
 
 Grocer, 1 Waiter, 1 
 
 Lecturer, 1 None, 5 
 
 Of the women ; 
 
 Housewives, 16 Singer, 1 
 
 Gloves, 1 None, 16 
 
 Age at beginning : 
 
 From 10 to 20 years 7 men and 7 women 
 
 •• 20to30 " 44 " "11 " 
 
 " 30 to 40 " 12 " *• 11 *' 
 
 " 40to50 " 1 " "3 ** 
 
 Over 50 years 2 **
 
 LOSS OF HAIR. 109 
 
 The greatest number of cases began in the twenty- 
 fifth and twenty-sixth years, viz., 9 in each year. The 
 next most frequent age was twenty-two, with 8. 
 
 The baldness or loss of hair took the form of a gene- 
 ral thinning in , 6 men, 19 women. 
 
 It affected the crown and temples in 13 " 
 
 alone in 32 " 10 " 
 
 temples in . 4 " 2 ** 
 
 *' and tonsure in 5 " 
 
 tonsure in 4 * ' 2 " 
 
 occiput in 1 " 
 
 parietal region in 1 " 1 " 
 
 The following diseases were noted as complicating 
 
 the loss of hair : 
 
 Anaemia, 4 cases. Malaria, 7 cases. 
 
 Chancroid, 1 case. Measles, 1 case. 
 
 Chorea, 1 case. Menopause, 1 case. 
 
 Constipation, 1 case. Metrorrhagia, 1 case. 
 
 Dyspepsia, 11 cases. Overtrainiug, 1 case. 
 
 Dyspepsia and constipation, 5 cases. Parturition, 3 cases. 
 Endometritis chronica, 1 case. Peritonitis, 1 case. 
 
 Gonorrhoea, 1 case. Pneumonia, 2 cases. 
 
 Gout, 1 case. Spermatorrhoea, 1 case. 
 
 Headache, 4 cases. Sunstroke, 1 case. 
 
 Influenza, 1 case. Urethritis chronica, 1 case. 
 
 Uterine fibroids, 1 case. 
 
 The cases of loss of hair following influenza, measles, 
 parturition, pneumonia, peritonitis, and sunstroke 
 were what are called defluvium capillorum, and came 
 on from one to five months after convalescence. 
 
 The scalp and hair were found to be diseased in 88 
 per cent, of the cases, as follows : 
 
 Atrophied and bound down, 2 Sweating head, 5 cases. 
 
 cases. Heat of head, 4 cases. 
 
 Canities, 4 cases. Pityriasis, 1(» cases. 
 
 Eczema capitis eight years before Seborrhea oleosa, 3 cases. 
 
 hair-fall, 1 case. Seborrhoea sicca, 55 cases. 
 
 Seborrhoea congestiva, 2 cases. Fragilitas crinium, 2 cases. 
 
 In 46 per cent, of the cases there was a history of 
 baldness in the family, as follows :
 
 110 DISEASES OF THE HAIR AND SCALP. 
 
 Men. Women. 
 
 Father only 7 cases. 
 
 Father and paternal uncle 2 ** 
 
 " " " cousins 1 *' 
 
 " '* " grandfather and brothers 1 " 
 
 " " brothers 4 " 
 
 " brother, and maternal aunt 1 case. 
 
 '* and maternal uncles 1 ** 
 
 " mother, and brother ..2 " 3 '* 
 
 Paternal uncle and brothers 1 " 
 
 " *« 3 '* 
 
 " " maternal grandfather and uncles 1 " 
 
 Mother 3 " 2 *' 
 
 " and maternal grandfather 1 " 1 ** 
 
 •« " sisters 1 ** 
 
 " " brothers 1 ** 
 
 Maternal grandfather 1 " 
 
 '* uncles 1 ** 
 
 *' ♦* and brother 1 " 
 
 Brothers 2 " 
 
 In family on both sides 4 ** 1 ** 
 
 As possible contributory factors it was noted that 
 
 1 patient constantly wore a close-fitting cap. 
 
 2 patients became worse after a short residence at the seashore. 
 2 smoked to excess. 
 
 21 soused their heads daily in cold water. 
 
 What deductions can we draw from the preceding 
 figures ? 
 
 1. As to sex. We find that 65 per cent of the 
 cases occurred in men. This is in accord with the well- 
 known fact that men are more frequently bald than 
 women. Therefore mascuhnity is a predisposing cause 
 of loss of hair. 
 
 2. As to nationahty, no deduction can be drawn, as 
 a preponderance of Americans was to be expected. 
 
 3. As to condition. Although we find 61 per cent, 
 of the patients were unmarried and but 28 per cent, 
 were married, this does not allow us to draw any infer- 
 ence, because experience teaches that most men do not 
 mind becoming bald half as much after they are mar-
 
 LOSS OF HAIR. Ill 
 
 ried as before they many. Men tell me again and 
 again that they would not mind growing bald if they 
 were married. It is a common experience that men 
 are not so particular about their personal appearance 
 after marriage as before, as they have other and more 
 important things to think of. It is also to be observed 
 that our tables show that the number of married and 
 unmarried women is the same. With women the case 
 is different from what it is in men, as the condition of 
 the hair is for women a most important consideration 
 from the standpoint of j^ersonal appearance, a fine 
 head of hair being to them a matter of pride. 
 
 4. As to occupation. Here, too, I should hesitate to 
 draw an inference. If we took the figures alone we 
 would be compelled to think that doctors were espe- 
 cially liable to become bald. It is certainly suggestive 
 that 26 per cent, of the cases occurred in professional 
 men — that is, in architects, clergymen, dentists, lec- 
 turers, librarians, lawyers, and physicians. If we add 
 to these the five brokers, who certainly live under a 
 constant nervous strain, we have 31 per cent, of the 
 cases occurring in brain workers. This is not in- 
 tended to throw any slur upon the rest of the occupa- 
 tions mentioned in the tables. It, however, tends to 
 suggest that active brain work does predispose to loss 
 of hair. 
 
 5. As to age. It is evident from my tables that the 
 majority of the cases of loss of hair begin before the 
 thirtieth year of life — namely, GO per cent. We also 
 see that in 07 per cent, of the men and 31 per cent, of 
 the women loss of hair began between the twentieth 
 and thirtieth years. There is also a very marked dif- 
 ference between the sexes in the next decade — ISf per 
 cent, in men and 31 per cent, in women. We also learn 
 that the most critical years are from the twenty- sec- 
 ond to the twenty- sixth. Though the present paper
 
 112 DISEASES OF THE HAIR AND SCALP. 
 
 is not intended to touch upon treatment, I would say 
 that it is between the ages of twenty and thirty-five 
 that we are most justified in expecting good results 
 from it. 
 
 6. As to the location of the loss of hair. We find 
 that 4:2 per cent, of the cases affected the crown alone, 
 and 13 per cent, affected both the crown and temples. 
 In 25 per cent, of the cases there was a general thinning 
 of the hair, and this was three times more frequent in 
 women than in men. The tonsure alone was seen 
 only six times, but it occurred with the receding tem- 
 ple eleven times. These figui'es bear out the well-ob- 
 served fact that the top of the head is the location of 
 baldness. 
 
 7. As to comphcating diseases. In only 52 per cent, 
 of the cases did this factor enter into the field of our 
 study. Of these, anemia, or diseases inducing anae- 
 mia, constituted nearly 79 percent. — namely, anaemia, 
 chorea, constipation, dyspepsia, endometritis, gout, 
 headaches, malaria, metrorrhagia, overtraining, sper- 
 matorrhoea, menopause, chronic urethritis, and uterine 
 fibroids. Acute and general constitutional diseases 
 were met with in but 9 per cent, of all the cases. Sex- 
 ual disorders were met with only four times. A fair 
 deduction from these figures is that aucemia is a cause, 
 or at least a predisposer, to loss of hair, and that the 
 popular idea that loss of hair is due to sexual excesses 
 is wrong. 
 
 S. As to diseases of the scalp and hair, other than its 
 faU. The scalp was diseased in 82 per cent, of the 
 cases. Seborrhoea or pityriasis was present in 70 per 
 cent, of the cases, and sweating or heat of the head 
 was seen in 9 per cent. A history of an antecedent 
 disease of the scalp was seen in but one case. From 
 this the deductions are that seborrhoea is a most active 
 cause of loss of hair ; that sweating or heat of head is
 
 LOSS OF HAIR. 113 
 
 a far more important symptom of danger to the hair 
 than writers on baldness have commented on ; and 
 that an antecedent disease of the scalp, other than 
 seborrhoea, is by no means so common as Pincus would 
 have us believe. 
 
 9. As to heredity. In 4G per cent, of the cases there 
 was a history of baldness in the family. It is certainly 
 a most surprising fact, brought out by my tables, that 
 in all the cases of loss of hair in women there is a dis- 
 tinct history of the affection occurring on the maternal 
 side ; while in the thirty-five cases in which there is 
 no history of maternal heredity the men only are af- 
 fected. It will be interesting to note if further statis- 
 tical studies show the same results. From the tables 
 now presented it is fair to deduce that loss of hair is 
 markedly hereditary, and that it tends to descend in 
 the same sex. 
 
 10. As to contributing factors. In 21 per cent, of 
 the cases we find a history of daily sousing the head. 
 This is by no means as great a percentage as is given 
 by some other observers, but still great enough to sug- 
 gest that the habit is detrimental to the hair. The 
 other factors noted are so few as to be useless for de- 
 ductions. They would tend to show, however, that 
 the popular idea that wearing close-fitting head gear 
 is a frequent cause of loss of hair is not true. 
 
 Summary. — From the foregoing study of loss of 
 hair we can summarize as follows : 
 
 1. Men are far more prone to baldness than are 
 women, the proportion being as G5 to 35. 
 
 2. Neither the married nor the unmarried state exer- 
 cises any influence in the production of baldness. 
 
 3. It is probable that active brain work and nervous 
 mental strain predispose to baldness. 
 
 4. The majority of the cases of baldness occurring 
 before middle life do so between the twentieth and
 
 114 DISEASES OF THE HAIR AXD SCALP. 
 
 thirtieth years ; and this is more marked in men than 
 in women. 
 
 5. Anaemia, or diseases that predispose thereto, are 
 active causes of baldness. 
 
 6. Seborrhoea in all its forms is an active cause of 
 baldness. 
 
 7. Sweating and heat of head may be regarded as 
 danger signals, foreshadowing loss of hair. 
 
 8. Heredity is a pronounced predisposing factor of 
 baldness, and it shows a tendency to descend in the 
 same sex. 
 
 9. The daily sousing of the head is pernicious to the 
 preservation of the hair. 
 
 The study of etiology is helpful chiefly as it teaches 
 us how better to treat diseases. From the analysis of 
 the causes of loss of hair, as here given, we may, I 
 think, learn that it is essential for us to put our pa- 
 tients who are losing their hair in the best possible 
 physical condition ; to cure, or at least alleviate, any 
 disease of the scalp that may be present ; and to forbid 
 their sousing the head in water.
 
 CHAPTER YII. 
 
 ALOPECIA AREATA. 
 
 Synonyms:— Area Celsi, (v. Barensprimg) ; Area oc- 
 cidentalis diffluens, serpens, seu tyria; Alopecia cir- 
 cumscripta, (Fuchs); Alopecia occidentalis, (Wilson); 
 Porrigo seu tinea decalvans, (Bateman) ; Vitiligo capitis, 
 (Cazenave); Ophiasis; Phytoalopecia, (Gruby); Teigne 
 
 Alopecia Areata. 
 
 pelade, (Bazin); Pelade acromatosa; Pelade decalvante, 
 or, ofiasica; Pelade (Fr.); Die kreisfleckige Kahlheit, 
 (Ger.); Circumscribed baldness, (Eng.). 
 
 Definition. — A disease of the hair characterized by 
 its sudden fall and the production of perfectly bald, 
 smooth, usually circumscribed and circular patches ; 
 which generally affects the scalp, but may invade 
 other hairy parts; runs a chronic course without con-
 
 116 DISEASES OF THE HAIR AND SCALP. 
 
 coniitant symptoms, and tends towards spontaneous 
 recovery. 
 
 Symptoms. — The disease usually begins suddenly, 
 the patient finding to his surprise a bald circular spot 
 upon the head without knowing when it formed. In 
 a number of cases there wiU be a history of severe, 
 often periodic, and localized headache preceding the 
 hair-faU for weeks or months. In other cases some 
 shght prmitus, burning, or pain may ante-date the 
 alopecia. In any event the patch forms suddenly, the 
 hair falling out at once. The size of the patch varies; 
 it may be very smaU, even pea-sized, or it may be as 
 large as the palm of the hand. When it exceeds the 
 latter size, it is usually formed by the coalescence of 
 smaller patches. It tends to gain its fuU size at once 
 and to remain circumscribed, but in some cases it 
 pushes out into the surrounding parts, either preserv- 
 ing its circular shape, or becoming irregular or serpi- 
 ginous. There may be only one patch, but more com- 
 monly there are two or three patches, which appear 
 simultaneously or successively. The shape of the patch, 
 while usually oval or round, may be in stripes or bands. 
 This is seen most often after injuries to the scalp, as in 
 ScHUTz's case (210 ap.) resulting from injury to the scalp 
 by barbers' shears. This irregular form of the patches 
 is sometimes called alopecia neurotica by those who 
 believe that the usual form of the disease is parasitic. 
 The disease most frequently affects the scalp and may 
 be symmetrical. Its next most common seat is the 
 beard. It may, however, affect all the hairy parts of 
 the body, and in some cases cause universal baldness. 
 
 The appearance of the disease is striking, and not 
 readily forgotten when once seen. The bare rounded 
 spot stands out conspicuously from amongst the sur- 
 rounding hair. It is perfectly bald and smooth, with- 
 out any scaliness. In some cases there are a few
 
 ALOPECIA AREATA. 117 
 
 black points in the patch, which have been taken for 
 broken-off hairs, but are really the remains of hair- 
 roots which have not fallen out. In some cases there 
 will be a few straggling hairs remaining. It seems 
 as if the patch was depressed and atrophied, but this 
 appearance is probably due to the fact that the hair 
 and roots have fallen out of the part. In color, the 
 affected area in its earlier stages may be slightly red- 
 dened from hyperaemia, but in most of the cases that 
 we meet with, it is white and polished. To the touch 
 the skin seems soft and pliable. Sensation may be 
 normal in the patch, but often somewhat blunted, as 
 shown by the amount of stimulation the diseased 
 surface will tolerate. 
 
 The hairs at the margin of the patch at first, and if 
 the disease is spreading, will be loose, dry, brittle, 
 atrophied at the root and come out readily on slight 
 traction. Later, and when the patch has attained its 
 fuU development, they wiU be firmly seated in their 
 foUicles, and normal in appearance. 
 
 Recovery will be indicated by the appearance of fine 
 lanugo hairs in the patch. These may fall out again 
 to be followed by a new crop of white hair, which will 
 remain and, growing stronger, develop into strong 
 colored hairs. Kaposi says that, if the disease has 
 been severe and general, restitution of the hair will 
 not take place; and that even in milder cases it may 
 go no further than the production of lanugo hairs. 
 The disease is comparatively rare. Neumann describes 
 a form of this disease in which there is marked anaes- 
 thesia of the scalp. 
 
 Some of the French authors, judging from their de- 
 scriptions, would seem to have an entirely different 
 idea of alopecia areata than we have, and to have con 
 founded it with other diseases. Thus, Cazenave (48) 
 describes cases in which a change in the color of the
 
 118 DISEASES OF THE HAIR AXD SCALP. 
 
 hair took i^lace, and designates the disease vitihgo 
 capitis. This is probably the pseudo-pelade of some 
 French authors. Gruby (211) says that the patches 
 are covered with a whitish dust formed entirely of 
 cryptogamia. Hardy considers the disease as having 
 two stages : First, an early parasitic contagious stage ; 
 and second, a neuropathic stage in which the parasite 
 has disappeared. Courreges (53) regards the disease 
 as having three stages : First, one in which there is 
 discoloration of the skin and fall of the hair, itch- 
 ing of the scalp and pityriasis. This stage is short. 
 Second, the appearance on the bald spots of delicate 
 downy hairs. This period may last for years. Third, 
 the period of recovery and growth of strong hair. 
 Further, he makes two varieties of alopecia areata, 
 namely : la pelade achromateuse, and la pelade decal- 
 vante. The first is the porrigo decalvans of Bateman, 
 and the vitiligo de cuir chevelu of Cazexave. It cor- 
 responds to our usual and typical form of alopecia 
 areata. The second form is one in which a rapid fall 
 of the hair of the whole head or body takes place, and 
 corresponds to what we should regard as an unusually 
 marked form of the disease. Courreges' views as to 
 these divisions are not peculiar to himself, but are 
 quite commonly held by French authors. Bazin (190) 
 affirms that true pelade (alopecia areata) is very rare, 
 but that there is a false form which is often the con- 
 sequence of tinea tonsurans badly treated or left to 
 itself. 
 
 The disease has a tendency to recur, and sometimes 
 is hereditary. Tmx (257) reports a case in which a 
 father and three of his children had the disease ; and 
 Hard A WAY (216) has met T\ith two cases in which 
 relapses took place in the Spring of successive years 
 and attacked new areas each time. 
 
 Etiology.— The etiology of this disease has been a
 
 ALOPECIA AREATA. 119 
 
 field of battle for many years, and dermatologists are 
 divided into two great camps in regard to the question 
 of its being parasitic or non-parasitic. The large ma- 
 jority of the older authorities are against the parasitic 
 theory ; thus of forty-two authors consulted as to this 
 point, and they were taken without selection, fifteen 
 were for the parasitic theory, and twenty-seven against 
 it. In the first group were such men as Anderson, T. 
 Fox, Thin, Gruby, Bazin, Hardy, and Eichhorst ; in 
 the second group, Duhring, Kaposi, Neumann, Schwim- 
 mer, Michelson, Veiel, Yidal, Horand, Duckworth, Pye- 
 Smith, Liveing and Wilson were found. Gruby (211:) 
 was the first to allege a parasitic origin for the disease, 
 and in 1843 described the parasite, which he named 
 '' Microsporon Audouini.''^ Bazin, in 1862, brought 
 forward the claim of '' Microsporon Decalvans^^ to the 
 honor of being the cause of the disease. Thin (529), in 
 1881, described yet another fungus in this disease which 
 he called '' Bacterium Decalvans.''^ Von Sehlen (2G7) 
 in 1885 entered the field as the discoverer of the para- 
 site in alopecia areata. Robinson (215 ap.) in 1887 also 
 described a coccus as the cause of the disease. 
 
 It is true that a single positive result from the study 
 of a disease is of vastly more value than many nega- 
 tive ones, and we should have the etiology of alopecia 
 areata settled upon a firm foundation if the positive 
 results of those who believe that they have found a 
 parasite were in accord. But they are not, as will 
 be seen further on when discussing the pathology of 
 the disease. Such disparity in the findings of the in- 
 vestigators of this disease, and the fact that many 
 other well-trained and expert workers in pathological 
 histology have sought for the parasite and have not 
 found it, are in striking contrast to what obtains in 
 the other parasitic diseases of the skin. At present we 
 are forced to acknowledge that there is not sufficient
 
 120 DISEASES OF THE HAIR AND SCALP. 
 
 evidence offered to warrant us in regarding this dis- 
 ease as a dermato-mycosis. Besides the absence of 
 proof of the presence of a parasite, the suddenness of 
 onset of the disease, its occasioDal general appearance, 
 and the want of any trace of fungous growth or debris 
 upon the affected areas, are all against the parasitic 
 theory. Dermato-mycoses are slow in development, 
 usually appear primarily in a number of small foci, 
 and do not involve the whole surface at once, and 
 generally scales or crusts are present upon the diseased 
 areas. 
 
 The most probable cause of the disease is a tropho- 
 neurosis. It is true that no nerve lesion has yet been 
 demonstrated in connection with the disease. But the 
 sudden onset of the malady, all the hairs in a given area 
 being at one and the same time loosened, seems to 
 indicate that some profound disturbance in tlie nutri- 
 tion of the affected part has taken place, probably 
 dependent upon some trophic nerve disturbance. The 
 neurotic theory of the disease finds further support in 
 the occurrence of periodic headachea and disturbances 
 of sensation before the outbreak ; in the presence of 
 anaesthesia in the patches to a greater or less degree ; 
 in its frequent occurrence in children who have unstable 
 nervous systems ; in its following upon severe nervous 
 shock and injuries to the scalp. Uchermaxn (263) has 
 reported a case of alopecia areata in a boy which fol- 
 lowed a blow on the head with a stone, and involved 
 the w^hole head. Michelsox (231) has met with a case 
 following a fall. Tyson (202) has recently reported 
 three cases of complete faU of the hair following 
 rapidly upon nervous shock. Michelson (231) also 
 suggests that the disease may be due to a closure of 
 the cutaneous vessels of the affected area, and conse- 
 quent interference with nutrition, the closure being 
 due to a connective-tissue increase of the intima.
 
 ALOPECIA AREATA. 121 
 
 It is possible that the neurosis may express itself in a 
 constricting action upon the blood-vessels, either those 
 going to the middle follicle region or to the papilla, 
 and a consequent preponderance in the productivity of 
 one or the other region, and a fall of the hair. Joseph 
 (223) has recently produced in cats lesions exactly re- 
 sembling alopecia areata in man, by cutting out the 
 second cervical ganglia. His experiments have been 
 repeated by others with similar results. Mibelli (198 
 ap.) found that cutting the second cervical nerve with- 
 out extirpating the ganglion was sufficient, and that 
 the fall of hair was not confined to the district sup- 
 plied by the nerve, but was seen in regions supplied 
 by other nerves. Poxtoppidan (200 ap.) saw typical 
 patches of alopecia areata follow the operation for re- 
 moval of an enlarged cervical gland in the left carotid 
 region. In further support of the neurotic theory 
 AsKANAZY (llT ap.) cites a case following removal of a 
 tumor from the right submaxillary region and attended 
 by facial paralysis ; and another of a hyp(3chondriac 
 who suffered from severe headache and burning of the 
 top of the head. 
 
 The disease is comparatively rare. Bulkley met 
 with it one hundred and nineteen times in twelve 
 thousand cases occurring in New York city. It would 
 seem to be rathea^more common in Glasgow, Anderson 
 having had one hundred and fifty-three cases in ten 
 thousand. In London Radcliffe-Crocker met with 
 it two hundred and fifty -three times in ten thousand 
 public cases, and eighty-two times in two thousand 
 private cases. His youngest patient was three years 
 old. It befalls both sexes, though it is more common 
 in males. Children are often affected with the disease. 
 They formed about one-sixth of Bulkley's patients. 
 According to his tables, the disease in the upper classes 
 is most frequent between the ages of twenty and forty, 
 no fewer than twenty-five out of thirty-five cases oc-
 
 122 DISEASES OF THE HAIR AND SCALP. 
 
 curring between those ages. He met with it much less 
 frequently in public than in private practice. I have 
 met ^vith the disease twenty-nine times in four thou- 
 sand consecutive cases in dispensary practice up to 1887. 
 Of the patients, seventeen were males and twelve fe- 
 males. The majority of the cases occurred between 
 the twentieth and fortieth year of age, namely, eight- 
 een. There were ten patients under twenty years of 
 age, and but one was over forty. The youngest was 
 a girl of five years, and the oldest a man of forty-four 
 years. 
 
 Up to comparatively recent times the disease was not 
 considered contagious. The most earnest advocates 
 of the contagiousness of the disease are the French. 
 BucHiN (1:6 ap.) cites a number of cases of contagion. 
 Vaillard and Vixcext (225 ap.) report an outbreak 
 of the disease in which forty-four soldiers w^ere at- 
 tacked. Clemexceau de la Loquerie (53 ap.) gives 
 many like instances, as in a school in Amiens in which 
 fifty out of four hundred children had the disease, 
 and an epidemic of eighty cases in^ a regiment at 
 Montpellier. He regards the modes of conveyance to 
 be by the barbers' shears, wearing of infected caps, 
 cushions of public conveyances, and the like. Feulard 
 (170 ap.) reports the occurrence of forty -four cases in 
 one company of a regiment stationed in Paris, and 
 states that in 18!U and 1802 it occurred in the propor- 
 tion of about 3.30 per 1,000 of the army. He thinks 
 that the liair clipper is responsible for its prevalence. 
 It is most frequent in the cities. In Germany Eichhoff 
 (168 ap.) reports several instances of apparent con- 
 tagion. Crocker and HtllierIu England also report 
 cases of contagion. In this country the only epidemic 
 of a disease simulating, if not identical with, alopecia 
 areata is reported by Putxam (210 ap.) as occurring in 
 an asylum for girls near Boston. The cases were ex- 
 amined by Drs. White and Bowen of Boston. In this
 
 ALOPECIA AREATA. * 123 
 
 epidemic sixty out of sixty-five girls were attacked by 
 the disease. Morrow has also met with cases appa- 
 rently contagious. In the light of these observations, 
 it seems impossible to deny that the disease is conta- 
 gious at times. It is equally impossible to assume that 
 errors in observation have been made in all these cases. 
 
 Contagiousness of the disease is, however, contrary 
 to the experience of most observers, and at best is a 
 rare exception. The disease has been seen in the same 
 patient coincidently with ringworm of the head, and 
 probably such occurrences have led to mistakes in 
 diagnosis. The ^Hinea decalvans" of Tilbury Fox, 
 in which perfectly bald circumscribed spots occur with 
 parasites in the neighboring hairs, may have been of 
 this kind. Liveing (220) thinks that it is just possible 
 that trichophytosis may in some cases so interfere 
 with the nutrition of the hair as to favor the subse- 
 quent development of alopecia areata. Alder Smith 
 (79) draws attention to the fact that a patch of tricho- 
 phytosis capitis may be changed into a perfectly bald, 
 smooth place by tlie apphcation of an ethereal solu- 
 tion of boracic acid. There seems to be some relation 
 between alopecia areata and ringworm, as in a country 
 where one is common the other abounds. Until fur- 
 ther light is thrown on the subject, it is probably best 
 to hold that there are some cases that are contagious 
 and may be parasitic, and some that are non-conta- 
 gious and neurotic. 
 
 The following are considered to be predisposing 
 causes, viz. : The nervous diathesis ; disturbances of 
 the general nutrition of the body, as from recent con- 
 stitutional syphilis (Squire, 34 a); menstrual disorders 
 (Nayler, 52); arsenic (Wyss, 272); parturition and 
 pregnancy (Graham, 213). De Tullio (1G7 ap. ) reports 
 a case of progressive spread of the disease in a sus- 
 pected case of syphilis in which the iodide of mercury 
 had been administered during three years.
 
 1^4 DISEASES OF THE HAIR AND SCALP. 
 
 Pathology. — Hairs extracted from the margin of 
 an advancing patch of alopecia areata show marked 
 atrophic change, and are seen to terminate abiniptly 
 in a pear or chib-shaped extremity. Sometimes a por- 
 tion of the root sheath is attached to the phicked 
 hair, sometimes not. As we approach the free end of 
 the hair an oval swelling will someti7nes be fonnd ta- 
 pering again towards the extremity of the hair, which 
 is often spht. Duhrixg (202) draws attention to the fact 
 that these changes differ from those found in senile 
 alopecia only in the suddenness of their occurrence. 
 Sometimes ampullary sweUings are found near the root, 
 composed of a concentration of granular pigment 
 matter; and sometimes there are adherent folhcular 
 and sebaceous matters round the shaft. Below the 
 swelling a stricture is apparent, which again passes 
 into the deeper bulb elements above the papilla and 
 at the base of the sac. Sometimes bright refracting 
 granules are seen investing the hairs, which are not 
 easily removable by ether, and no doubt suggested the 
 fungus theory, but are in reality fatty particles. The 
 swelhng of the cuticular scales of the hair simulates 
 a fung-us. DuHRiXG (2< )2) says that what is described 
 as the microsporon Audouini is an accumulation of 
 an appreciable amount of sebaceous matter, broken up 
 epidermic scales, and debris about the roots of the 
 han; further, that sebum when subjected to a reagent 
 has a tendency to split and break up into fine particles, 
 which adhere so closely and with such tenacity to the 
 hair as to accurately resemble spores. 
 
 According to Giovaxxixi (175 ap.)the disease begins 
 by a perivascular infiltration by leucocytes, especially 
 about the lower part of the hair-follicle, where they 
 invade the circular connective-tissue layer. From 
 there they often enter between the cells of the matrix,
 
 ALOPECIA AREATA. 125 
 
 internal root-sheath, lower part of the neck of the 
 hair, or both root-sheaths. Either in the matrix or 
 internal root-sheath of the infiltrated hairs the cells 
 undergo karyokinesis, diminishing in number until 
 they disappear completely. At the same time the 
 cells of the matrix, neck of the hair, and internal root- 
 sheath degenerate. Degeneration is accompanied by 
 disappearance of pigment. Destruction of the hair-bulb 
 follows, and then that of the neck of the follicle and 
 the internal root-sheath. The follicle itself atrophies, 
 but usually not to the degree of destruction. A new 
 hair generally forms in the follicle, unless infiltration 
 continues, in Avhich case it will fall. If the process 
 becomes chronic the follicle and the sebaceous glands 
 will eventually be destroyed. 
 
 All those who describe the parasite in this disease give 
 explicit directions as to the preparation of the hair for 
 examination, and lay great stress upon the difficulty 
 of finding the fungus. Gruby (214) described the 
 parasite as follows: The cryptogam ia are arranged 
 so as to form a tube or vegetable sheath about the hair. 
 They consist of trunk, branches, and sporules. The 
 trunks have an undulated form following the direction 
 of the hair fibres, are transparent, and have a diameter 
 of .002 to .003 mm. They bifurcate at times, giving 
 off branches at an angle of thirty to fifty degrees. The 
 branches are distinguished from the trunk by the 
 sporules which accompany and cover them. The 
 sporules are oval or round, the diameter of the former 
 being 0.002 to 0.008 mm., and of the latter 0.001 to 
 0.005 mm. They are transparent, and do not contain 
 molecules in their interior, and swell in water. These 
 are the microsporon Amlouini. They commence to 
 develop at the surface of the hair, 1 to 2 mm. from 
 the epidermis. They are first seen parallel to the axis
 
 126 DISEASES OF THE HAIR AND SCALP. 
 
 of the hail', and spread by immediate contact from 
 hair to hair. Bazix (190) gives a similar description. 
 T. Fox (210) says the fmigus occm-s in the form of 
 very dehcate waxy mycehal threads. Thin (259) fomid, 
 after careful preparation, minute round or elongated 
 rounded bodies in the hairs which resembled in shape 
 and refractive power his ^ ' bacterium foetidum. ' ' These 
 he believes are tlie cause of the disease, and names 
 ^^ bacterium decalvans.^^ They were in position and 
 arranged so as to show that they were distinct from 
 the rows and aggregations of minute granules which 
 are found in healthy hairs. They were found fre- 
 quently in pairs, the long axis of each member of a 
 pair forming a continuous line. Sometimes tlij-ee 
 were found end to end, with the appearance of one 
 continuous sheath for the three. Malassez (22S) de- 
 scribes the spores as occm-ring in the epidermic scales, 
 in the superficial layers of the epidermis, and occa- 
 sionally upon the hair. According to him they are 
 spherical or ovoid highly refractive bodies, not larger 
 than 4 to 5 mm. They are double contoured and 
 many small buds project from their circumference. 
 Some smaller spores (2 mm.) were without the double 
 contour, and some still smaller were simply spherical. 
 They were found singly or in groups or chaplets. 
 Von Sehlen's (267) micrococci were found in the root- 
 sheaths of the hair, but his description of the cases 
 from which the hairs examined were obtained is so 
 strikingly hke that of trichophytosis capitis that we are 
 led to think that he made an error in diagnosis; and 
 BoRDONi Uffreduzzi (193) has found micrococci iden- 
 tical with these upon the roots of the hair of the nor- 
 mal skin. 
 
 The findings of the different obseiwers vaiy amongst 
 themselves so much that it is best to await further 
 developments before deciding that the disease is para-
 
 ALOPECIA AREATA. 127 
 
 sitic. It is noticeable that the different parasites de- 
 scribed are all superficial to the skin and in or upon 
 the hair. This is not the way in which perfectly 
 smooth bald patches could be produced; for that it is 
 necessary that the hair papillae should be affected. In 
 this connection it is interesting to note that Nystrom 
 (237) found spores identical with those described by 
 Malassez upon a napkin hung in a moist corner of a 
 room, and therefore regards them as derived from the 
 atmosphere. Michelson (231) has found on normal 
 hairs by cultures the same cocci as described by Von 
 Sehlen. He also found them on hairs taken from 
 the edge of alopecia areata patches. Thus far his at- 
 tempts at inoculation of these have been failures, and 
 he regards them as being a normal condition. 
 
 Robinson, in 1887 (215 ap.), is the first to describe 
 cocci deep down in the follicle as the cause of the 
 disease. Like Giovannini, he found perivascular infil- 
 tration of the upper part of the corium by small cells, 
 affecting the papillary portion. With this there was 
 proliferation of connective-tissue coi'puscles, fall of the 
 hair, and finally coagulation in some of the blood- and 
 lymph-vessels. The hair-roots showed atrophic altera- 
 tions. Lanugo hairs were apparently formed, in the 
 upper part of the follicle. In chronic cases the follicles 
 were sometimes hairless, and the sebaceous glands 
 were either normal, degenerated, or destroyed. The 
 areas of baldness corresponded in size to the areas 
 supplied by the plugged-up blood-vessels. In the 
 lymphatic vessels and in the walls of a few blood-ves- 
 sels he found small, round, dark bodies of equal size 
 and grouped in zoogloea masses. These were not acted 
 on by acids or alkalies. They are cocci, 8 /< in diame- 
 ter, and in size similar to staphylococcus pyogenes 
 aureus. There were also some diplococci. These were 
 less numerous in chronic cases.
 
 128 DISEASES OF THE HAIR AND SCALP. 
 
 Dyce Duckworth (201) had the opportunity of 
 examining a case of alopecia areata occurring in 
 the person of a boy aged thirteen years who was 
 drowned. The disease first came on when he was 
 four years of age, and had gone and come several times 
 since. After death portions of the scalp were carefully 
 examined, and the results reported, as follows: There 
 was found to be: 1. A distinct atrophy of the hair- 
 f oUicles and the sebaceous glands in connection with 
 them. 2. Infiltration of the hair-follicles, specially 
 their outer root-sheath, with a new round cell gi'owth. 
 This growiih appeared to be perivascular, and tracts of 
 it were found in the middle layer of the corium lead- 
 ing up to the papillary layer. 3. The hair follicles in 
 the affected part were mostly quite atrophied, their 
 nourishment having been cut off by the new growth. 
 In some instances remains of the papilla3 were seen, 
 but the capillary loops were infiltrated with the cell 
 growth. In other instances the follicles appeared to 
 be making efforts at repair by throwing out numerous 
 digitations. 4. The vitreous membrane of the follicles 
 was in some cases hypertrophied. 5. The sweat glands 
 were practically unaffected, though parts of their ducts 
 were imphcated in the new growth. 6. No parasitic 
 elements were found. 
 
 Wagner and Schultze (21S) have examined pieces 
 cut from the hving scalp with negative result. 
 
 Diagnosis. — The diagnosis is easy, as a rule, the dis- 
 ease presenting so striking an appearance as hardly to 
 be mistaken for anything else. As in psoriasis, the 
 symptoms are so well pronounced that students, once 
 having seen a case, do not easily forget it. Some- 
 times, however, it may be difficult to distinguish it 
 from ringworm of the head, and it must also be 
 diagnosticated from favus, from other forms of 
 alopecia, and possibly from vitiHgo.
 
 ALOl^KCIA AREATA. 
 
 12D 
 
 Differential Diagnosis from Trichophytosis Capitis. 
 
 Alopecia Areata. 
 
 1. Occurs suddenly without 
 antecedent lesion, and the patch- 
 es often attain their full size at 
 once. 
 
 2. Patch usually perfectly cir- 
 cular and does not contain 
 "gna wed-off " hairs, scales, or 
 crusts, but is perfectly smooth 
 and shiny. 
 
 3. Hairs about patch unalter- 
 ed, though at times they may be 
 easily extracted. 
 
 4. Occurs only on hairy parts 
 of the body. 
 
 5. No parasite found, or at 
 least none readily detected. 
 
 Trichophytosis Capitis. 
 
 1. Begins usually at one point 
 by a small erythematous papule 
 or patch, and spreads from it 
 more or less slowly. 
 
 2. Patch more or less circular, 
 with broken and gnawed-off 
 hairs in it, and floor covered 
 with thick, grayish crusts or 
 abundant scales. 
 
 3. Hairs in and about patch 
 ai'e brittle, break easily when 
 pulled on, and bend at an angle. 
 
 4. Occurs both on hairy and 
 non-hair^'^ parts of the body; and 
 patch will sometimes spread 
 from non-liairy to hairy parts, 
 or vice versa. 
 
 5. Fungus found abundantly 
 in har and scales. 
 
 The two conditions are less easily distinguished 
 when ringworm of the head has lasted some time, 
 involves a large portion of tlie scalp, and is in an in- 
 active condition. But even here there will be more or 
 less scaling, and an occasional broken-off stub of hair; 
 and careful search will discover the fungus in the hair 
 or scales. 
 
 Favus lacks the circular development of aloi)ecia 
 areata, is more disseminated, has the sulphur- yelloAv 
 cup -like crusts characteristic of it, or else the scalp is 
 covered with powdery scales. It developes slowly, is 
 inflammatory in character, and leaves cicatricial 
 patches where it has run its course. The microscope 
 shows the fungus abundantly in scales, c-i^usts, and hair. 
 
 Alopecia Senilis and Praematura develop slowly, 
 beginning either at the vertex and spreading forward, 
 or at the forehead and spreading backward , involve only 
 the upper middle region of the head, and take months 
 or years to produce complete baldness. There is often 
 a history of preceding disease of the scalp, su(*h as 
 seborrhoea. In alopecia areata the baldness occurs
 
 180 DISEASES OF THE HAIR AND SCALP. 
 
 suddenly, occupies the lateral parts of the head quite 
 as often as other regions, and generally there is no 
 antecedent disease of the scalp. If it involves the 
 greater part of the head, there will yet be the history 
 of distinct patches at the begining. 
 
 Sometimes syphilitic alopecia will present appear- 
 ances very much like alopecia areata. In syphilis we 
 meet with two forms of baldness, one occurring as the 
 result of the cachexia of the disease, and the other from 
 the absorption or breaking down and ulceration of a 
 syphilide. The first form sometimes resembles a severe 
 case of alopecia areata, affecting more or less generally 
 the whole head, and causing great loss of hair. It 
 differs from it in giving a characteristically ragged 
 look to the head, and in showing no tendency to the 
 formation of circles. The history of the case will aid 
 in making the diagnosis. Should there be any cuta- 
 neous manifestations of syphilis present, the decision 
 will be easily reached. The second form of alopecia 
 syphihtica resulting from ulcerating lesions is differ- 
 entiated from alopecia areata by its history and by the 
 cicatricial tissue present. 
 
 Bald spots arising from liurns and other injuries to 
 the scalp should offer no difficulty in diagnosis; their 
 history and cicatricial appearance show their origin. 
 
 Vitiligo should not be confounded with alopecia 
 areata. It is a disease affecting only the color of the 
 hair. 
 
 Prognosis.— The disease tends to recover spontane- 
 ously, especially in yomig people. In older people 
 the prognosis is not so good. Neumann (27) says the 
 outlook in the anaesthetic form is bad; and the serpi- 
 ginous form is considered by Squire (34a) to be of less 
 favorable prognosis than the circular form. Cases of 
 general alopecia, especially those coming on suddenly, 
 are more grave than the circumscribed cases. The
 
 ALOPECIA AREATA. 131 
 
 duration of the disease is variable. Eecoveiy has 
 taken place in six weeks, but this is exceptional. 
 From six months to two years may be given as a rea- 
 sonable time in which to look for recovery. The pa- 
 tient should be apprised of the tendency the disease 
 has to relapse. Cases of universal alopecia are of bad 
 prognosis and often never recover. 
 
 Treatment. — Many of thesuiferers from this malady 
 show some indication for the exhibition of tonics. 
 When occurring in children they will often be found to 
 be anaemic. They should be taken out of school and 
 allowed plenty of air and exercise until they attain to 
 a better degree of health. Cod-liver oil, iron, phos- 
 phorous, arsenic, and quinia are the drugs most indi- 
 cated as tonics. The use of phosphate -bearing food 
 is advised by some, as oatmeal, cracked wheat and 
 the like. We should endeavor to place our patients 
 under the best possible conditions, to relieve them as 
 far as may be from all sources of anxiety, and to, 
 alter anything that may be wrong on the side of the 
 general economy. 
 
 The local treatment consists in stimulation of the 
 scalp. In the beginning of treatment it is well to re- 
 move by epilation all the loose hairs about the margins 
 of the patches. The best method of effecting this is 
 by pulling the hair between the thumb and an ordi- 
 nary spatula or stout card held in the hand. This pro- 
 cedure sometimes seems to check the further growth 
 of the patch. 
 
 For stimulants, carbolic acid ; tincture of cantharides; 
 cantharidal collodion ; tincture of nux vomica, vera- 
 trine, capsicum, phosphorus, or aconite ; suli)hate of 
 quinine; strychnine; liquor ammonise fortior; sulphur; 
 bichloride ; yellow sulphate, and oleate of mercury ; 
 croton-oil and castor-oil, each and all have their advo-
 
 132 DISEASES OF THE HAIR AXD SCALP. 
 
 cates, and are used either separately or two or more 
 of them combined. As the diseased scalp will bear, 
 as a inile, a good deal more stimulation than the healthy 
 scalj), we must regulate the strength of our chosen 
 stimulant solely by the amount of reaction it causes. 
 Thus, liquor ammonice fortior, in full strength, may 
 be freely aj^plied to the scalp, and its use persisted 
 in for weeks without apparent OTer-irritation of the 
 scalp. As our object is simply stimulation, I can see 
 no reason for combining any of the above-mentioned 
 stimulants, excepting that the castor- oil may be used 
 as an eligible excipient for some other remedy. We 
 may choose as a vehicle for the stimulant either an 
 oil, an ointment, lard, vasehne, or water. It is well 
 to change oui- stimulant from time to time. 
 
 Good results have been reported from the use of 
 electricity, the galvanic current being used with one 
 pole at the nape of the neck, and the other brushed 
 over the affected parts; and G. H. Fox has reported 
 improvement in some cases treated with static elec- 
 tricity. H}iDodermic injections of i to yV grain of 
 the muriate of pilocarpin every few days are well 
 spoken of by some observers. 
 
 Sulphur ointment is advocated by Thin {^Ih'S), and 
 he has published a series of excellent results from this 
 treatment, maintaining that these results are due to 
 the action of the ointment as a parasiticide. 
 
 The treatment by blistering has in some cases pro- 
 duced rapid results. For this purpose either croton- 
 oil or cantharides may be used. Thus, Horand (21 S) 
 advises painting the bald spots with croton-oil, cov- 
 ering with cotton, and wearing a hood over all. If 
 ulceration is caused, the part is to be dressed with 
 oHve-oil. When healed, the application of the croton- 
 oil is to be repeated. This method of ti'eatment is to 
 be continued till the hair grows. Vidal (2G6) recom-
 
 ALOPECIA AREATA. 133 
 
 mends the following: If the subject is a child, the 
 whole head is to be shaved. If the patient is older, 
 the scalp is to be shaved for half an inch around the 
 bald spot. Now apply a bhster, which should never 
 be larger than a twenty-five cent piece, to each bald 
 area, putting it on in the morning and taking it off 
 when the epidermis begins to rise. If a large bleb 
 forms, it should be opened. Powder the blisters with 
 starch and cover with linen. If there are numerous 
 bald spots, apply the blisters to them successively. 
 If the hair does not grow after thorough bhstering, 
 repeat the operation as soon as the effects of the first 
 application have disappeared. If blisters are not well 
 borne, use sinapisms. When the hair begins to gi'ow, 
 shave, and rub in, every morning and evening, a lo- 
 tion of 
 
 Liq. ammon. . . . . 
 
 3 
 
 Alcohol, 
 
 . 12, 
 
 Decoct, foliae juglandis, . 
 
 . LOO, 
 
 M. 
 
 
 For alopecia areata of the face he uses bhsters in some 
 cases. Generally he has the part shaved every day 
 and uses frictions of tincture of cantharides, either 
 pure or with one-fifth to one-sixth of the tincture of 
 rosemary. 
 
 CouRREGES (53), a believer in the parasitic origin of 
 this disease, directs that the head be washed twice a 
 day with a lotion of 
 
 Chloride of ammonia 
 
 Bichloride of mercury, . . aa 1. 
 
 Water, 500. 
 
 M. 
 or that the following ointment be applied twice a day; 
 
 Yellow sulphate of mercury, . 1. 
 
 Lard, 30. 
 
 M.
 
 1C.4 DISEASES OF THE HAIR AND SCALP. 
 
 This lie does to destroy the parasite. To stimulate the 
 gi*o^^i:h of the hair he advises shaving once or twice 
 a week. If there is only one patch or but two or 
 tln*ee, these and their inunediate neighborhood are to 
 be shaved. Should there be many patches, the whole 
 scalp is to be gone over with the razor. 
 
 Cottle (52) du*ects that the affected area be painted 
 with acetic acid until the scalp whitens, and then 
 sponged off with cold water. This is to be repeated 
 every three or foiu' days; and in the inteiwals an oint- 
 ment composed of three drachms of balsam of Peru in 
 one ounce of benzoated lard is to be apphed. 
 
 GuiBOUT (14) recommends shading, fiictions T\'ith 
 camphorated alcohol, and bathing very often during 
 the day with equal parts of camphor and sulphm-ous 
 ether. 
 
 A.E. EoBixsox (33) speaks favorably of inunctions 
 with a five to ten per-centum ointment of clirysarohin 
 preceded by vigorous friction with soap and water 
 and a rough towel. He later, 1SS7, recommends equal 
 parts of croton oil and any other oil, reducing the 
 strength if too much reaction. 
 
 Lassar reports satisfactory effects in two cases from 
 the use of corrosive sublimate lotions, followed by dis- 
 infectant oils such as salicylated or carbolised oil. In 
 some cases of alopecia areata I have used a solution 
 of corrosive sublimate, not on account of its parasiti- 
 cide qualities, but solely for its stimulating effect. 
 The strength of the solution used was three parts of 
 the bichloride of mercury in one thousand parts of 
 water, or say one grain and a half to the ounce. This 
 was apphed once or twice a day, and has given satis- 
 factory results. One patient, a man aged thirty years, 
 had upon his head a number of perfectly bald patches 
 of alopecia areata, some of which had lasted for more 
 than a year. He was given the bichloride lotion just 
 indicated. In fourteen days lanugo hairs had begun
 
 ALOPECIA AREATA. 135 
 
 to grow in all the patches, and in three months they 
 were completely covered with vigorous though white 
 hairs. He had used the lotion alone and shaved the 
 patches once in two weeks after the hair had begun 
 to grow. Unfortunately, this is the only case in 
 which I have been able to watch the effect of this 
 
 treatment. 
 
 In a few cases I think that I have produced benefit 
 by using a pomade of jaborandi, made by boiling down 
 the fluid extract to one half its volume and adding 
 this to lard in the proportion of one of the jaborandi 
 to four of the lard. This is to be thoroughly rubbed 
 in twice a day. In the first case, of the recurrent type, 
 the hair in two relapses returned under this treatment 
 in the course of ten weeks. But it had no effect in 
 preventing the formation of new patches. In the 
 second case, occurring in a child with chorea, after the 
 use of various other remedies for three months, the 
 spots continually growing larger, the jaborandi was 
 used, and in ten weeks the disease had ceased spread- 
 ing, and the hair was growing on every patch. In a 
 third case, affecting the mustache of a medical student, 
 its use was followed in seven weeks by the appearance 
 of new hairs in the patch, shaving being practiced at 
 the same time. In these three cases, the return of 
 the hair took place some six or seven months after 
 the beginning of the disease. Pilocarpine may be 
 substituted for the jaborandi in the strength of two 
 or three grains to the ounce. Lanolin is a good ex- 
 cipient for it, as it penetrates the skin more readily 
 than lard. It should be diluted with one or two 
 drachms of castor-oil to the ounce to make it more 
 fluid, and the whole may be jjerfumed with one or 
 two drops of oil of roses. 
 
 MiCHELSON (40), in Ziemssen's Handhuch (vol. II. pg. 
 \?>\)), speaks highly of the use of warm salt-water baths
 
 136 DISEASES OF THE HAIR AND SCALP. 
 
 five per cent, salt) three times a week and of twenty- 
 five minutes duration. In conjunction with this, twice 
 a week the faradic current is to be apphed to the scalp 
 with a brush electrode for ten minutes. Upon the 
 days when the baths are not used, the scalp is to be 
 rubbed with a stronger aqueous solution of salt. 
 
 Chatelaix (102 ap.) advises painting the patches, as 
 well as for a short distance beyond their borders, with 
 iodine one part, collodion thirty parts. This is to be 
 renewed when it falls off. After a few applications 
 the pellicle is to be pulled off, and with it the fine new 
 hairs. If it causes a good deal of dermatitis, it may 
 have to be stopped for a while. The rest of the hair is 
 to be treated with an antiseptic solution. 
 
 MoTY (201 ap.) expects rapid results from injecting 
 five or six drops of a solution composed of 
 
 Ijt Hydrarg. bichlor., . ... 4 
 Cocain. hydrochlor., .... 2 
 Aquae destillat., 100 
 
 M. 
 
 In a small patch only one injection is made; in 
 larger patches four or five injections are made about 
 the periphery. Intervals of four or five days should 
 1)6 made between the injections. He finds that the 
 hair will begin to grow in about three weeks. 
 
 QuiNQUAUD (212 ap.) recommends washing the 
 patches in the morning ^vith soap and water, and ap- 
 plying 
 
 5 Hydrarg. biniod., 20 
 
 '' bichlorid., . . . .1. 
 
 Alcohol, 40. 
 
 Aqua3, ..••... 250. 
 M.
 
 ALOPECIA AREATA. 137 
 
 At night the parts are to be washed again, and then a 
 solution of six per cent, of Hq. ammon. in equal parts 
 of balsam of Fioraventi and spirits of camphor. Af- 
 ter eight days substitute tincture of pyrethrum for 
 the ammonia, and so alternate every eight days. 
 Every sixth day the following ointment is to be used : 
 
 5 Chrysarobin, 
 
 Ac. salicyl., 
 " boric, . • . . aa 2 
 
 Vasehni, 100 
 
 M. 
 
 KA.YMOND (213 ap.) saw recovery take place in four 
 months by Moty's treatment, the hair coming in of 
 normal color, and recovery beginning often at the pe- 
 riphery. Sometimes the method is very painful, but 
 tolerance seems to be established after a time. He 
 has seen one case recover after seven injections of 
 pure water. He thinks the application of Bidet's 
 vesicating liquid gives as good results as Moty's 
 method. He has seen recovery take place in thirty to 
 forty days after using Quinquaud's method. He him- 
 self recommends shaving the periphery of the patch 
 and washing its surface with carbolic soap twice a 
 week. Every morning the following wash : 
 
 IJ Hydrarg. bichlor., 
 
 . 
 
 .50 
 
 Tinct. cantharidis, 
 
 . 
 
 . 25. 
 
 Balsam of Fioraventi, 
 
 , 
 
 . 50. 
 
 Aq. Cologniensis, 
 
 . 
 
 . 150. 
 
 M. 
 
 
 
 is to be applied to the whole head and rubbed into the 
 patches with a paint brush for one or two minutes. 
 In the evening the spots are to be rubbed with a mix- 
 ture composed of
 
 138 DISEASES OF THE HAIR AND SCALP. 
 
 5 Ac. salicyl., 2 
 
 ^ uaphthol, 10 
 
 Ac. acetic, crystal , .... 15 
 
 01. riciui, 100 
 
 M. 
 
 This treatment should cause only redness and should 
 cure in fifty days, the hair often coming in normal. 
 
 BusQUET (^161 ap.) speaks enthusiastically of the 
 treatment by 33^ per cent, of essence of cinnamon or 
 spikenard in ether. Others have tried it with no 
 benefit. 
 
 Morel-Lavellee (193 ap.) recommends superficial 
 scarifications of the patches before the application of 
 an antiseptic ointment, and expects return of the hair 
 after the third scarification. 
 
 Morrow (200 ap.) advises appl3dng to recent patches 
 either chrysarobin eight to ten per cent., or salicylic 
 acid two to five per cent., every three or four days. 
 In more severe cases equal parts of acetic acid and 
 chloroform are to be used two or three times a week at 
 first, and later at longer intervals. Between the ap- 
 phcations of any of the foregoing this mixture ; 
 
 ^ 01. eucalypti, 
 
 01. terebinthinae, . aa 3ss., say 15 
 
 01. petrolei crud., 
 
 Alcohol, . . . . aa3 j., say 35 
 M. 
 
 is to be used d?*V with massage for about five min- 
 utes. 
 
 BuLKLEY (160 ap.) advises the application of pure 
 carboUc acid to small portions of large patches at a 
 sitting. Cutler (166 ap.) recommends equal parts of 
 carbohc acid, chloral, and iodine painted on the parts 
 every few dc'^s. This has given good results in my 
 hands.
 
 ALOPECIA AREATA. 139 
 
 As alopecia areata has a tendency to get well of it- 
 self, n,' It'^ own good time, it is hard to determine how 
 far our remedies are active in hastening a cure. So 
 good an authority as Kaposi (19) has said that reme- 
 dies have httle if any effect on the disease. 
 
 Even after the damage to the hair has apparently 
 been made good, it is advisable to counsel our patients 
 to use some mildly stimulating lotion to the scalp, and 
 to pay particular attention to the hygiene of the hair 
 for some months.
 
 CHAPTER YIII. 
 
 ATROPHIA PILORUM PROPRIA. 
 
 Atrophy of the hair exists under three forms, 
 namely: FragiUtas crinium, Trichorrhexis nodosa, and 
 Aplasia pilorum propria. In all the hair-shaft is easily- 
 friable and splits, or breaks off of itself or upon the 
 sUghtest traction. The three forms differ, in that in 
 the first there is only a simple or compound cleavage 
 of the hair; in the second, there is also the formation 
 of nodular swellings along the hair-shaft, and a brush 
 like breaking up of the elements of the hair; while in 
 the third, the fracture occurs through the internodu- 
 lar portion. 
 
 Fragilitas CRmiUM. 
 
 Synonyms : — Scissura pilorum. — Trichoptilosis. — Tri- 
 choxerosis. 
 
 Definition. — That condition of the hair in which it 
 is more or less dry, and its shaft is split either at its 
 end or in its continuity. It may be symptomatic or 
 idiopathic. 
 
 1. Symptomatic Fragilitas Crinium^— This form is 
 by far the most common variety of the disease, and 
 needs little comment here. In the parasitic diseases of 
 the hair — trichophytosis capitis et barbse, and favus — 
 the hair becomes dry, brittle, and broken off. This con- 
 dition of the hair is always met with in these diseases 
 and is a diagnostic symptom. In any disease of the 
 scalp if of long continuance we meet with dryness and 
 brittleness of the hair, and this is notably the case in 
 seborrhoea sicca and eczema. In any general consti- 
 tutional disease, as in fevers, phthisis, scrofula, and 
 the various cachexiae, in which there is a lowering of
 
 ATROPHIA PILORUM PROPRIA. 141 
 
 the nutrition of the body, the hair sympathizes, loses 
 its lustre and suppleness, and takes on the condition 
 of fragilitas crinium. 
 
 Etiology. — The causes of this condition are easily 
 discoverable. In the parasitic diseases, the fungus 
 grows in and about the hair and its root, and by its 
 presence causes a degeneration of the hair. In favus, 
 a complete destruction of the hair-follicle and papilla 
 takes place. In seborrhoea and eczema the hair be- 
 comes dry, because it is deprived of its proper lubricant, 
 on account of alterations in the sebaceous matter, and 
 because its nutrition is interfered with. In the gen- 
 eral constitutional diseases, mal-nutrition is the cause 
 of the fragility of the hair. 
 
 Treatment. — This will depend upon the disease 
 which the condition accompanies, and will be given 
 in the proper chapters. 
 
 2. Idiopathic Fragilitas Crinium. — In this form, 
 without any apparent disease of the scalp or underly- 
 ing skin, and often without any general constitutional 
 disease, the hair becomes dry, brittle and split. The 
 cleft in the hair may be either at its free end, in the 
 continuity of the shaft, or even within the bulb. When 
 beginning at the free extremity, it may run for some 
 distance up the shaft. When it begins at the exit 
 fi'om the follicle, the cleft extends for a variable dis- 
 tance, it may be for the whole length of the shaft. In 
 this case and in the case in which the cleft occurs in 
 the middle of the shaft, the filaments will either sepa- 
 rate widely or hold together. When the split occurs 
 at the end, the filaments will either separate from 
 each other more or less, or will curl up upon them- 
 selves. The disease occurs most often upon tiie 
 scalp, the beard being the part next most frequently 
 affected. It is by far most commonly met with in 
 the long hair of women. The affected hairs are
 
 U2 
 
 DISEASES OF THE HAIR AND SCALP. 
 
 scattered here 
 
 y 
 
 ■.'\ 
 
 5p 
 
 Pi 
 
 ?ftr if 
 
 Splitting: of the end 
 of a hair. T.n, Trichor- 
 rhexis nodosa. S.p, 
 Scissu ra piloruni. 
 (Michelson.) 
 
 and there throughout the general 
 mass of hair, wliich may appear nor- 
 mal or be somewhat drier than it 
 should be. In some cases all the hair 
 of a certain portion of the scalp is 
 found broken up into filaments. Be- 
 sides the splitting, the affected hairs 
 may show no other abnormality, al- 
 though they are often irregular and 
 uneven in their contour. 
 
 In a case reported by Duhring (280), 
 which is unique, the beard was the 
 region affected. In it the hak began 
 to split within the bulb, and the pro- 
 cess was attended by so great an irrita- 
 tion of the f oUicles as to cause follicular 
 papules and pustules. '^The hairs," 
 he says, "were very bristly; sometimes 
 they were of good length, sometimes 
 short, sometimes thicker than normal, 
 sometimes abnormally slender, some- 
 times straight, sometimes crooked. 
 Sometimes they came out easily when 
 pulled upon, or fell out of themselves, 
 and sometimes they were quite fast in 
 the follicle and broke off, leaving the 
 root behind, when epilation was at- 
 tempted.'' 
 
 Pathology. — In most cases the 
 microscopical examination shows noth- 
 ing of importance, ai)art from a lit- 
 tle irregularity in the contour of 
 the shaft, and the split at the end 
 with its diverging filaments. The 
 bulb of the hair may be normal or 
 atrophied. In Duhring's (280) case,
 
 ATROPHIA PILORUM PROPRIA. 143 
 
 there were marked atrophy of the hair-bulbs and 
 fissure of the hair-shaft beginning within the bulb, 
 separation of the segments taking place at the 
 bulb or at varying distances beyond it. The corti- 
 cal substance presented a dry and brittle look in the 
 narrowed portions, and a spongy luxuriant appearance 
 in the thickened parts of the hair. The medulla was no- 
 where normal, but was present here and there in 
 broken tracts. 
 
 Etiology. — The cause of this disease is yet undeter- 
 mined. Kaposi (19) would explain the splitting of the 
 long hair of women upon the theory that it is due to 
 the distance of the distal extremity of the hair from its 
 source of nourishment — the hair-root or papilla. Tliis 
 is not an altogether satisfactory explanation, as it is by 
 no means always the longest hairs which present the 
 cleft end. Nor would this theory account for the 
 disease as met with in the short hairs of the beard. 
 Gamberini (59) would find its cause in want of due care 
 of the hair and in allowing it to grow to excess. But 
 as in the symptomatic form, there is some evident dis- 
 ease affecting the nutrition of the hair, and as in some 
 of the idiopathic cases, there is an atrophy of the bulb; 
 we can feel sure that the idiopathic form also is depend- 
 ent upon some interference with the nutrition of the 
 hair. 
 
 Treatment. — In all cases the scalp or underlying 
 skin should be kept in good condition, as is directed 
 in Chapter III. When the disease occurs in tlie 
 long hair of women, besides attention to the scalp 
 and the brushing and combing of the hair, the cleft 
 ends should be carefully cut off just above the 
 split. If the disease occur in the beard it should 
 likewise be regularly clipped, and all rough rubbing 
 and handling of it should be avoided. In shaving, we 
 have a last resort by which the deformity may be
 
 144 DISEASES OF THE HAIR AND SCALP. 
 
 removed, and possibly after a time the hair may grow 
 normally: but this should be ordei^ed only in very 
 aggravated cases in women, as it is an heroic plan of 
 treatment for them, and milder measures will gener- 
 ally be sufficient. In all cases we should strive to cor- 
 rect any thing that we find wrong in the health and 
 well-being of the patient. 
 
 Trichorrhexis Nodosa. 
 
 Synonyms: — Trichoclasia ; Trichoptylose ; Clasto- 
 thrix; Trichosyphilis; Nodositas crinium. 
 
 Definition. — Trichorrhexis nodosa is that condition 
 of the hair in which nodular swellings occur along its 
 shaft and the hair breaks easily, usually through one 
 of the nodes, and exhibits a peculiar brush-like spread- 
 ing out of the fibres of the broken-off hair, while the 
 underlying tissues are normal. 
 
 This disease was first described by Beigel (276) in 
 1855, under the title ^' Auftreibung und Bersten der 
 Haare." Wilks (309) recognized the disease in 1852, 
 but did not publish an account of it until 1857. Wil- 
 son (311) asserts that he described it in 1849 in his 
 book, ^^ Healthy Skin," under the title of ''fragilitas 
 crinium," and proposed the name of ' ' clastothrix " for 
 it. In 1867 he exhibited to the Eoyal Medical and 
 Chirurgical Society of London, specimens of what he 
 called trichosyphilis of the beard and whiskers, which 
 he considered as a disease distinct from fragilitas 
 crinium. This was probably a case of trichorrhexis 
 nodosa. Eichhorst (281) reported a case in 1858; since 
 then various authorities have met with the disease 
 and published cases of it. Kaposi was the first to 
 propose for it the name of '' trichorexis nodosa," which 
 has been accepted by the profession as the proper 
 name for the disease. The spelling, however, has been 
 slightly changed, and it is now spelt either as '^tricho-
 
 ATROPHIA PILORUM PROPRIA. 145 
 
 rhexis" or "trichorrhexis." Wo have adopted the 
 latter style, as it is the one used by the best wi-iters of 
 the German school. The disease is rare. Bulkley 
 met with it but four times in eight thousand cases. 
 
 Symptoms. — The disease comes on without any ante- 
 cedent symptoms, the patient first noticing upon 
 handling his beard that the hairs when pulled through 
 his fingers, feel irregular and knotty, or else that the 
 hair breaks easily and the beard looks ragged. If we 
 examine the beard we find, along the hair-shaft, one or 
 more whitish or grayish, shiny, transparent, nodular 
 swelhngs, looking not unlike the nits of pediculi, but 
 more oval^and evenly involving the whole circumfer- 
 ence of the hair. Should the hair be red, the color of 
 the nodes may be black. The number of nodes upon 
 a single hair varies from one to five, and their diameter 
 varies with that of the hair, being greater in the coarser 
 than the finer hair. The nodes occur nearer the distal 
 than the proximal end of the hair, and usually in the 
 upper third of its length. The hair is exceedingly 
 brittle and fractures upon shght traction, as on comb- 
 ing, or spontaneously, the fracture taking place almost 
 invariably through a node, and the hair fibres of the 
 broken ends separating like the hairs of a paint bmsh. 
 Very rarely the fracture is internodular and the ends 
 pointed. Sometimes the hair does not entirely break 
 off, but the fibres splinter about the node, and the 
 appearance presented is like that seen when two small 
 paint brushes are pushed together, end to end. The 
 fracture is usually transverse through the node, but 
 sometimes, if there is an excessive amount of medulla 
 present, it is longitudinal. 
 
 Sometimes the hair -has an irregular contour and is 
 frayed along its entire length. When many hairs are 
 affected, there will always l)e many frayed-out ends, 
 and the beard will look as if it had been singed. The
 
 146 DISEASES OF THE HAIR AXD SCALP. 
 
 liairs are usually firmly fixed in the follicles, and the 
 disease exists for many years with no tendency to the 
 production of alopecia. 
 
 The disease, in nearly all the reported cases, affected 
 the beard, and therefore occurred in men; but it does 
 occur at times in the scalp-hair and also in women. 
 Tlius W. G. Smith (303) reported a case which occurred 
 in the scalp- hair and was pecuHar in that the fracture 
 took place in the internodular portions, and the ends 
 of the broken hairs were not frayed out. There was 
 also one nodose hair found amongst the pubic hair. 
 MiCHELSOX (40) beheves that the condition is far more 
 frequent in the scalp -hair than is supposed, and that 
 the reason it is most frequently observed in the beard 
 is because the hairs of that paii are of larger diameter, 
 and allow the condition to be more readily seen. On 
 thin hairs the little nodes can be more easily felt than 
 seen, indeed they can be hardly distinguished by the 
 naked eye. He has met with the disease many times 
 in cases of various forms of alopecia. Detergie (279) 
 has also reported a case that occurred in the scalp-hair 
 of a woman. Abramow^tsch (230 ap.) reports a case 
 affecting the scalp-hair of a man. I have met with 
 two cases in w^omen, both of whom came to me on 
 account of their hair being short. They were both 
 debilitated. The disease has been seen on the axillary 
 hairs and those of the eyebrow^s. 
 
 Etiology. — The cause of the disease is obscure. 
 Beigel (270) believed that it was due to an accumula- 
 tion of gas within the substance of the hair, which, 
 exercising pressure from within, first gave rise to the 
 bulbous-formed swelling, and ultimately burst the 
 hair. Wilks (310) and Wilson (211) look to nutritive 
 debility for an explanation of the malady. Eich- 
 horst's (281)* theory is, that the swellings are caused 
 by fatty infiltration of the medulla, taking place at 
 certain points, and that the splitting is purely acciden-
 
 ATROPHIA PILORUM PROPRIA. 147 
 
 tal, the result of pulling, in brushing and combing the 
 hair. He thinks it probable that a swelhng of the 
 medulla first ojccurs that causes a bulging outwards of 
 the cortical substance till it finally bursts and breaks 
 asunder. 
 
 So much for the earlier theories. Of more recent 
 date are those of Schwinimer, Startin, Pye-Smith, 
 Kohn, Pincus, Wolfberg and Michelson. Schwimmer 
 (301) says that the disease is a nutritive disturbance, 
 probably a tropho-neurosis. Startin (305) holds that 
 it is due to a degeneration of the medulla, a consequent 
 rapid accumulation of ceUs at one point, and eventually 
 a bursting open of the hair. 
 
 Pye-Smith (289) regards a gradual drying of the cor- 
 tical substance, and a consequent loss of coherence of 
 its constituent fibre cells, as the cause; this being fol- 
 lowed or attended by the breaking up into a granular 
 material and sweUing of the ceUs of the nieduUa, and 
 finally a rupture of the cortex, there being nothing 
 left to hold it together. S. Kohn (2SG) beheves that 
 the process is analogous to the splitting of the long 
 hair in women, and is to be considered as an atrophy 
 of the medulla taking place at different points, or as 
 a partial disappearance of the same. Pincus (2D6) 
 regards the disease as in part due to an interference 
 with the nutrition of the hair and in part to a deficient 
 action of the sebaceous glands. Wolfberg (312) puts 
 forth the view that repeated mishandling of the thick 
 medullated hairs of the beard, as in violent lubbing 
 in drying after washing, is sufiicient to cause the dis- 
 ease in many people, and in this way he has designedly 
 produced appearances microscopically identical with 
 those of trichorrhexis nodosa. He believes this to be 
 the only cause of the disease, and gives the following 
 four reasons: 1. The anatomical appearances. The 
 hair outside of the nodes is perfectly normal. The 
 same appearances can be produced mechanically, and
 
 us DISEASES OF THE HAIU AND SCALP. 
 
 tlie disease occui*s often in diseases of the beard which 
 are itchy and hence cause it to be much rubbed. 
 
 2. Location. It occurs most always in the strong 
 medullated hair of the beard, the node formation being 
 favored by the central canal. These appearances are 
 difficult of production in fine non-medullated hairs. 
 
 3. Because the explanations heretofore offered are 
 not sufficient, -i. The obstinacy of the disease to 
 treatment. This is easily explained, because it has 
 consisted in rubbing the beard with irritating sub- 
 stances. Sherwell (302), in his case, suspected a some- 
 what similar cause on accoiuit of his patient's habit of 
 rubbing cologne water into his beard; but subsequently 
 he abandoned the theory. Michelsox (40) looks upon 
 abnormal dryness of the hair-shaft as the cause. 
 
 AVe have thus ten different views expressed in re- 
 gard to the cause of tliis singular affection. To choose 
 any one as the true cause, would be un\\'ise at present. 
 The disease is not parasitic. Tliis I beheve is the unan- 
 imous testimony. Cheadle and Morris (278) have, 
 it is true, reported a case to which they gave the name, 
 amongst others, of trichorrhexis nodosa, but it was so 
 different in its appearances from the disease in ques- 
 tion, that we should rather call it " tinea nodosa.'' It 
 does not seem to depend upon any diathesis, nervous 
 or otherwise. Axdersox (274) has reported one case 
 or other^\ise. Newtox (211 ap.), who studied the dis- 
 ease in two cases, is convinced that it is a pure neu- 
 rosis. Anderson (274) has reported one case which 
 shows an hereditary inffiience. The disease in his case 
 was congenital, or d early so, and could be traced back 
 as far as the great-grandmother. Those members of 
 the family who had what they called ^'weak hair," 
 were almost invariably of dark complexion. He gives 
 the following "family tree,'' those marked with an 
 asterisk ("••) having ^'weak hair.'' (By this term is 
 apparently meant hair that sphts easily.)
 
 lTrophia pilorum propria. 140 
 
 Mr. L. Mrs. L.* 
 
 Mrs. B.* 
 
 Robert, James, John,* David, William, Thomas,* Samuel. 
 
 Marion, James,* Jane,* John, John, William, James,* Thomas, 
 
 Mary,* Margaret,* Thomas.* | William.* 
 
 Thomas, James,* Walter, Margaret.* Mabel,* Maud. 
 
 I have met with but two cases of the disease. Both 
 occurred in men and in the beard; and both patients 
 were in the habit of handUng the beard. As far as 
 these cases are concerned I would be incUned to 
 adopt Wolfberg's theory. The fracture of the hair is 
 probably always due to mechanical causes. 
 
 Pathology.— Beigel (276), who first described the 
 disease, found minute globular bodies in the shaft of the 
 hair which he took to be air-globules. Wilson (311), 
 in his case of syphilitic degeneration of the hair, which 
 was probably a case of the disease we are now discuss- 
 ing, observed "the diseased portions of the hair look- 
 ing as if composed of a dark cylinder enclosed in a 
 transparent envelope. Closer examination showed 
 that the fibrous structure of the hair was lost, and 
 its place occupied by a dark gummous-looking sub- 
 stance. The essential peculiarity of structure of the 
 diseased hair was arrest of development of the fibrous 
 portion at its cellular stage, the dark cylinder which 
 formed the bulk of the diseased part being compose( . 
 of large and small nucleated cells commingled with 
 pigment matter, irregularly formed air-cells and frag- 
 ments of crystaline substance." Eichhorst (281) saw 
 "in hairs which were examined dry or in glycerine, 
 that the individual fibres of the cleft hair were in 
 places covered with fine ghstening kernels. As these 
 were not seen in preparations in Canada balsam and 
 in turpentine, and as they were colored very black by
 
 150 DISEASES OF THE HAIR AND SCALP. 
 
 hyi^er-osmic acid, they were doubtless fat drops. The 
 further the sweUing had proceeded, the less were they 
 seeu. The nodes were exclusively on the medulla, the 
 cells of which could be traced into the spindle-formed 
 broken-up nodes, and appeared unaltered. But when 
 hquor potassae and hyper- osmic acid were used, the 
 medulla cells were seen to be overladened with drops and 
 masses of fat. ' ' Wilks found, interspersed in the broken 
 fibres, a few dark granules. Such were the findings of 
 the earher investigators. Now let us turn to the more 
 recent investigations and see what they teach us. 
 Pye-Smith (29S), in 1879, reported upon certain speci- 
 mens of the disease as follows: ''Fust stage; hair 
 swollen in fusiform nodules at inteiwals of a few lines. 
 Later, the cortical layer has begun to spht up and to 
 separate transversely. In the more advanced cases a 
 fine, granular material oozes out from the medullary 
 portion. Lastly the hair breaks across leaving the 
 brush-like broken end formed by the frayed-out cor- 
 tical fibres. Under a high power the exuded material 
 appears as a uniform, finely granular substance. This 
 has some resemblance to fish roe and might be mis- 
 taken for sporules. There is no vegetable substance 
 present. It is not probable that a development of gas 
 causes the hair to spht. Apparently the cortex be- 
 comes more and more dry, its constituent fibre-ceUs 
 become less coherent, tlie medulla cells l)reak up into 
 this gi-anular material and swell, till the rupture of 
 the cortex is complete, and nothing remains to hold 
 the hair together. There is no fatty degeneration 
 present." 
 
 S. KoHN (286), in 1881, writes: ''The httle clear 
 bodies on the outer filaments of the split nodes, which 
 are not altered by different methods of handling, shut 
 out the parasitic nature of the disease, because they 
 are only occasionally met with, never in the nodes nor 
 
 f
 
 ATROnilA PILOKU:SI PROPRIA. 151 
 
 other parts of the hair, and because they are out of 
 aU proportion to the disease. They are merely deposits 
 from the outer air. The theory of atropliy has sup- 
 port in the following microscopic appearances: In 
 treating the hair- shaft with concentrated caustic potash 
 or acetic acid, a swelling of the medulla is caused. This 
 swelling we have never found in a node, but only in 
 the beginiiing stage of the disease when no node could 
 be seen. In those places where there are nodes, there 
 is no medulla. The nodes under the microscope ap- 
 pear as brush-hke masses of split-up fibres. The fibres 
 are partly directed outwards, and in part, the opposite 
 fibres are shoved into each other. If the hair is broken 
 off, we will find the remaining portion looking like a 
 brush with its fibres spreading outwards. Between 
 the stage of swelling of the medulla and the stage in 
 which the broken node is met with, there is a stage in 
 which holes are formed in the cortex. One sees plainly 
 that the single cells of the cortex are loosened and be- 
 ginning to fall apart. Transverse sections of the nodes 
 show a jmrt of the medulla replaced by air. '' Michel- 
 son (40) says, in Ziemssen's Handbuch, Vol. XIV., 
 *' In some places on the hair there is the appearance 
 as if two brushes were pushed end to end; at a little 
 distance from them the shaft is split into several 
 fascicuH, whose ends are frayed and present a broom- 
 like appearance. As a rule, the partial longitudinal 
 splits are very nearly in the middle of the shaft, and 
 if any medulla is present, it will be destroyed. Some- 
 times, however, the hair splits into a larger fasciculus 
 embracing the medulla, and into one or more smaller 
 fascicuU. The affected part of the hair, akeady de- 
 prived of its cuticle, bursts, and perhaps, with its 
 fibres spread out in aU directions, forms an admirable 
 net to catch atmospheric dust. All sorts of particles 
 are deposited, and sometimes caught so fast that
 
 152 DISEASES OF THE HAIR AND SCALP. 
 
 they can not be dislodged by any mode of handling. 
 Specially striking are the dark, sharp-cornered coal- 
 particles, and the blue ultramarine gi-ains. A good 
 deal of air finds lodgment also in the sphts and holes. 
 In the microscopical examination, this air a\411 be more 
 or less rapidly expelled from the hair by the fluid me- 
 dium, and the appearance thus caused was the founda- 
 tion for Beigel's theory of the development of gas 
 within the hair, as the cause of the disease. We have 
 ne^'er found any parasite present. Many hairs in the 
 neighborhood of the affected hairs present an atropine 
 appearance." Hans Hebra (16) describes the hair 
 roots as "presenting a shrunken appearance, and ap- 
 proximating to the size of the shaft." Giovannini 
 (237 ap.) says that the hairs have a triangular contour. 
 
 From consideration of these various microscopical 
 appearances, we learn that there is first a swelling of 
 the shaft, forming the node; then a transverse fracture, 
 taking place through the node, combined with a spHt- 
 ting up of the hair-fibres; and lastly a lesion of con- 
 tuiuity occurs, and a brush -like end is presented by 
 the broken hair. P'urther, in the node there is no 
 medulla present. Michelson, Pye-Smith, and Wilson 
 seem to find the beginning of the disease in the cortical 
 portion of the hair; while Kohn, and Eichhorst, regard 
 degeneration of the medulla as the first step in the 
 process. The hair-roots are either unchanged or else 
 slightly atrophied. 
 
 Lesser (2SS) has repoi-ted a case of "ringed hair" 
 which presented the appearance of trichorrhexis no- 1 
 dosa, excepting that, in his case, the fracture always 1 
 took place through the constricted portion, which he i 
 believes to be the diseased part. The beguming of the 
 fracture in Ms case was marked by a transverse break- 
 ing of the cuticle, which often ran in a circular manner 
 quite around the hair, and the raised epidermis formed
 
 ATROPHIA PILORUM PROPRIA. 153 
 
 a sort of collar. In a case of W. G. Smith (303), the 
 fracture likewise occurred in the internodular por- 
 tions. These last two cases were doubtless instances 
 of aplasia pilorum propria. In parasitic diseases of the 
 scalp, the appearances of trichorrhexis nodosa are not 
 infrequently observed. 
 
 Treatment. — Thus far all modes of treatment have 
 proved very unsatisfactory. All sorts of applications 
 have been made to the affected parts, generally of a 
 stimulating character, and particularly the various 
 forms of mercurials, but without curative effect. Gam- 
 BERixi (59) recommends either bathing the part with 
 a lotion, composed of 15 grammes of subcarbonate of 
 potassium to 150 grammes of dilute alcohol (say 3 
 drachms to 4 ounces); or using inunctions of tannic 
 acid or oil of cade. Schwimmer (301) advises that 
 an ointment composed of a half gramme (gr. vii) of 
 oxide of zinc, 1 gramme (gr. xv) of washed sulphur, 
 and 10 grammes ( 3 ijss) of simple ointment, be rubbed 
 in morning and evening. 
 
 But the chief reliance is placed upon shaving, with 
 the hope that it will stimulate the nutrition of the hair, 
 and that after a time the hair will grow in a proper 
 manner. Wolfberg (312) founds his treatment upon 
 his theory, and advises that the hair be left entirely 
 alone. As other treatments have failed of doing any 
 good, it would seem worth while trying this expectant 
 plan in cases in which handling the beard is a possible 
 etiological factor. 
 
 Aplasia Pilorum Propria. 
 
 Synonyms: — Aplasia pilorum intermittens; Monile- 
 thrix; Moniliform hairs; Cheveux moniliformes. 
 
 This is the third variety of atrophy of the hair, that 
 has often been mistaken for trichorrhexis nodosa, as 
 it too presents nodes along the hair-shaft. It differs, 
 however, from that condition principally in two par-
 
 154: DISEASES OF THE HAIR AND SCALP. 
 
 ticulars, viz. : the nodes are here the normal parts of 
 the hair, while the internodular portions are the abnor- 
 mal parts; and the fracture takes place through the 
 internodular parts. 
 
 Symptoms. — The disease is congenital in nearly all 
 cases, and appears in infancy. A few cases have 
 come on later in life. Usually the child is born with 
 apparently normal hair, but in the course of a few 
 weeks the hair breaks off either over the whole head 
 or in patches, and the scalp assumes the appearances 
 of keratosis pilaris or of trichophytosis capitis, being 
 covered by small, scaly, elevated cones, and it is some- 
 what reddened. Pustules may form on it. Sometimes 
 complete baldness results, and many cases of congeni- 
 tal alopecia are doubtless due to this disease, the scalp 
 having been destroyed, as evidenced by the presence 
 of many small cicatricial points scattered over it. 
 From the little scaly hair-cones the short, stubby hairs 
 protrude. They look as if scorched, and some are 
 bent. They are very brittle, and easily break on slight 
 traction. They are seldom longer than a quarter of 
 an inch; they may present simply as black points. 
 If examined with care many of the hairs will show 
 fusiform swellings with contractures between, through 
 which fracture has taken place. After a time partial 
 recovery may take place, but it is never complete. 
 All the hairy regions of the body may be affected, and 
 there may be a general keratosis pilaris. 
 
 Apart from the loss of hair, the subjects of the dis- 
 ease may be in good health; sometimes they may be 
 in poor physical condition. 
 
 Etiology. — In many cases the disease is inherited, 
 and seems to be a deformity of the skin rather than a 
 disease, just as is icthyosis. It is also prone to descend ' 
 in the same sex, and to affect more than one member 
 of a family, a pecuharity shared by several other der- J
 
 ATROPHIA PILORUM PR0PRL4. 155 
 
 matoses. Thus Sabouraud (2tL3 ap.) traced the disease 
 back to a great-grandfather and found evidence of 
 seventeen cases in the family. Lesser (241 ap.) re- 
 ports a case of a man and two sons, and a history of 
 eight cases in the same family in two generations, the 
 descent being direct and through the males. Hudelo 
 (239 ap.) reports the case of a girl whose mother had 
 the disease, that was hereditary on the mother's side 
 back to her great-grandfather. A sister of the patient 
 had weak hair. Tennesox (251 ap.) met with three 
 cases, all girls, in a family of five, the father of whom 
 had the disease, as w^ell as his brother and sister; and 
 Payne (216 ap.) reports two brothers with the dis- 
 ease. Isolated cases do arise, as well as those in which 
 there is no history of inheritance. We do not know 
 the cause of the disease. 
 
 Pathology. — Under the microscope the nodes on 
 the hair show better than when viewed by the naked 
 eye. Indeed, in some fine hairs the nodes are only 
 seen by the microscope. The hairs will be found to 
 have on them at regular intervals alternate strictures, 
 or narrow places, and swellings. The latter are about 
 1 mm. long, fusiform in shape, of darker color than 
 the narrow portions, and about three times longer and 
 three times wider than they are. The difference 
 in color is due to the fact that the constricted parts 
 contain neither medulla nor pigment, and may consist 
 of the cuticle layer of the hair alone. The hair-bulbs 
 are atrophied. It has been noted by Beatty and 
 Scott (231: ap.) and by Sabouraud (219 ap.) that the 
 hair examined in sections of the skin shows a deformity 
 of the Huxley's layer of the root- sheath at the part 
 corresponding to a node. The nodes are all along the 
 hair from root to point. Fracture takes place through 
 the internodes, and frayed-out or brush-like ends may 
 or may not be found. Sabouraud found that the
 
 156 DISEASES OF THE HAIR AND SCALP. 
 
 constrictions formed at two days' intervals^ and Ja- 
 mieson's (240 ap.) experiments led to the same result. 
 
 Treatment thus far has been of none effect. Stim- 
 ulation might be tried, but the prognosis is bad. 
 
 Under the name of end atrophy Crocker describes 
 a case, reported by McMurray (242 ap.), in which the 
 distal ends of the hairs were bulbous and of lighter 
 shade than the rest of the hair. 
 
 Besides the foregoing atrophic conditions, there are 
 certain other somewhat allied deformities that are 
 here noted. 
 
 There is also a condition of the hair called ^'P7mg- 
 mesis,^^ in which feathers adorn the body instead of 
 hair. T. Robinson (299) cites a case of this natm^e, 
 which occurred in a boy who was exhibited in Bremen, 
 and was reported upon in Bauerle^s Magazine for 
 1831. The boy's head is said to have been covered 
 with feathers in place of hair. 
 
 Ferber (282) reports two pecuHar cases of change in 
 the texture of the hair. Both patients were nervous 
 individuals, and their hair in a few hours would change 
 from being soft and curly, to become straight and 
 bristly. The change followed, m one case, nightly pol- 
 lutions, and in the other any special deterioration of 
 the always feeble health. After a time the hair would 
 return to its usual condition. 
 
 NoDULi Laqueati is that condition of the hair 
 in which it seems to tie itself into knots. The hair 
 is usually dry and curly. According to Michelson 
 (40), the condition is common in trichorrhexis nodosa. 
 The loop of the knot forms an excellent net to 
 catch dust and fl}ing particles, and hence under 
 the microscope, all sorts of dust elements are found 
 with the hair. A case of this sort is repoii^ed by 
 L. D. Bulkley (277), which oiJcmTcd in the pubic
 
 ATROPHIA P:L0RUM PROPRIA. 157 
 
 liair of a man who was troubled with itching and 
 sweating of the genitals. The hair looked as if in- 
 vested with the nits of pediculi, but the microscope 
 showed that the appearance was due to the presence 
 of a double knot on each hair, composed of several 
 turns. 
 
 I have recently met with a case of undoubted in- 
 chorrhexis nodosa of the beard, in which this knotting 
 of the hair occurred. The patient was of unsound 
 mind, and kept constantly pulhng at his beard, and to 
 this habit was ascribed the knotting. Michelson as- 
 cribes the disease to improper combing, and pulling of 
 the beard through the fingers.
 
 CHAPTEE IX. 
 
 HYPERTROPHIA PILORUM. 
 
 Synonyms:— Hypertrichosis; Hirsuties; Trichauxis; 
 Pohi;richia; Dasyma; Dasytes; Trichosis hirsuties; 
 Foils accidentels (Fr.); Superfluous hair; Hairiness. 
 (Eng). 
 
 Defixitiox: — A growth of hair which is either ab- 
 normal in amount or occurs in places where, normally, 
 only lanugo hairs are present. While it is normal for 
 a man to have a beard from four to six inches in length, 
 it would be abnormal for him to have one reaching to 
 his feet. Again, while normally the hair grows thick 
 and strong upon the cheeks, chin, and upper Hp of a 
 man after puberty, should such a growth occur upon 
 the face of a woman it would be abnormal. 
 
 Symptoms. — Hypertrichosis may be general or par- 
 tial, congenital or acquired. Of these the general form, 
 liyperfricliosis nniversah's, is very rare, w^hile the ac- 
 quired form, or hypertrichosis partialis, is the most 
 frequent, and is f amihar to every one in the cases of the 
 unfortmiate bearded women. 
 
 Hypertrichosis universalis is generally congenital, 
 and, in spite of its name, does not affect the 
 whole body. Hair never develops, even in tins dis- 
 ease, in places in which normally no hair is found. It 
 is not met with, therefore, upon the palms of the 
 hands, the soles of the feet, the backs of the last pha- 
 langes of the fingers and toes, the inside of the labia 
 majora, the prepuce, ot on the glans penis. Subjects 
 of this malady are usually born covered more or less
 
 HYPERTROPHIA PILORUM. 150 
 
 thickly with hair, which may be Hght or dark in color. 
 This continues growing longer, coarser, and darker till 
 it reaches its full development. As a rule the long 
 hair covering the body is fine, resembhng more the 
 hair of the head than of the beard, as is also the case 
 with the hair on the face of these persons. It follows 
 a definite direction in growing, and this is away from 
 certain well-defined centres. Thus on the back it 
 grows on each side downward and outward from the 
 spinal column; on the forehead away from the middle 
 line, following the lines of the eyebrows; on the face, 
 also, from a line running down the middle. With this 
 excessive growth of hair there is usually combined a 
 deficiency of teeth, specially marked in the upper jaw. 
 MiCHELSON (353) has seen a family which was very 
 hairy, in many members of which there was a defect 
 of all five back teeth, the alveolar processes for the 
 same being wanting. 
 
 These homines pilosi are met with in all pai^s of the 
 world. Thus we have records of the Kostroma family 
 from Eussia, a father and son. They first attracted 
 notice some twelve years ago, and were described in a 
 number of European medical journals. The father 
 died about four years ago in Paris. The son was on 
 exhibition in this country in 1886. Nothing is known 
 of the parentage of the father, nor have I found any 
 record of the boy's mother. An excellent likeness and 
 description of the father is given in the last volume of 
 Ziemssen's Hanclhuch der speciellen Fathologie unci 
 TJierapie. The son was in 188G sixteen years of age, 
 and looked like a well-developed boy, though some- 
 what under the average height. He appeared to be 
 muscular, and was active and energetic in his actions. 
 He seemed intelligent, and certainly showed acuteness 
 in the rapidity and correctness with which he gave me 
 change for a dollar bill when I bought his photograph.
 
 160 
 
 DISEASES OF THE HAIR AXD SCALP. 
 
 He spoke his native language with great rapidity, and 
 has picked up some German and Enghsh words. His 
 agent said that he was docile, and his health was good. 
 His head was covered with a luxuriant growth of fine, 
 glossy hair of blonde color, some six inches long. This 
 extended further down on the neck than is usual. The 
 scalp was normal, white and soft. Coming forward, 
 
 The Dog-faced Boy. 
 
 the hair grew well down on the forehead, and then 
 continued over the whole face, though on the face it 
 was finer and lighter in color than on the head. The 
 facial hair did not resemble in texture the usual hair 
 of the beard, even where it grew in the places ordina- 
 rily occupied by that growth in men, but was much 
 softer. Upon the upper lip there was a space, occupy-
 
 HYPERTROPHIA PILORUM. 161 
 
 ing about the middle third, where the growth was very 
 scanty. Under the eyes the hair also was absent for a 
 space of about half an inch. Otherwise the whole face 
 was covered with long hair, growing from the inside 
 and outside of the nose, and continuing all down the 
 neck. There was also a luxuriant growth of hair from 
 the inside and outside of the ears. Under each eye 
 there was a group of three or four black hairs. The 
 hair of the face was some four inches long. Upon the 
 body the most remarkable growth was down the spinal 
 column, where the hair stood out not unlike a horse's 
 mane. The rest of the trunk and the extremities 
 were completely covered with hair, but not veiy much 
 more so than in not a few other hairy people. The 
 backs of the hands presented nothing remarkable. On 
 the body the hair was exceedingly fine and delicate, 
 and more fluffy than that on the head and face. 
 There was a cast in his left eye, and he was near- 
 sighted. He had only five teeth, two uiiper canine, 
 and two lateral, and one middle lower incisor. The 
 alveolar ridges show no sign of there ever having 
 been any more teeth. The teeth he has are badly 
 shaped and discolored. His father is said to have had 
 no teeth till he w^as seventeen years old, and then only 
 four in the lower and one in the upper jaw. The Lon- 
 don Lancet in IS 73, reported the boy as having fom- 
 incisor teeth in the lower jaw, so he must have lost 
 one. 
 
 Other instances of universal hypertrichosis have 
 been reported. Thus the case of Barbara Ursler is 
 cited by Stricker (370) as occurring in the seventeenth 
 century. This woman's whole body was covered with 
 blonde, soft, curly hair, and she had a thick beard reach- 
 ing to her girdle. In a book pubhshed in 1642 and en- 
 titled Aldrovandi Monstrornm Historia there is an 
 account of a hairy family consisting of the father aged
 
 162 DISEASES OF THE HAIR AND SCALP. 
 
 forty, a son aged twenty, and two daughters aged 
 eight and twelve. They came from the Canary 
 Islands, and were covered with hair, excepting that 
 the daughter's lips, nose, neck, breast, and hands were 
 smooth. In 1851, Chowne (32 S) reported a case of 
 iniiversal hirsuties occurring in a Swiss woman twenty 
 years of age. Her body was covered with hair except- 
 ing on the breasts and chest, which were free of the 
 growth. In Beigel's (41:) book on The Human Hair, 
 accounts of several cases of this deformity are given, 
 viz.: that of Julia Pastrana, a Spanish dancer; and of 
 Shewe Maon and his daughter Maphoon, in India. 
 The latter 's second child was hairy hke its mother. In 
 the father and daughter there was an absence of the 
 canine and molar teeth. But it is useless to multiply 
 examples, as the foregoing cases are sufficient. 
 
 Oi partial congenital hypertrichosis we have an im- 
 mense number of examples. This condition is apt to 
 be of the nature of na?vus. It must be held in 
 mind that the distinction between a locahzed hy- 
 pertrichosis and a naevus is made mostly upon the 
 color of the underlying skin. In the former case 
 the skin is perfectly normal, while in the latter it 
 is pigmented and may be otherwise altered. Thus 
 we have, in the Lancet of 1869, an account of a 
 Mexican woman who had a nsevus pilosus extending, 
 like a pair of bathing trowsers, from the umbihcus an- 
 teriorly and the sixth dorsal vertebra posteriorly, to 
 about half-way down the thighs, covering the but- 
 tocks. Cummin (329) mentions the case of a lady who 
 was noted for the beauty of her face, whose body from 
 breast to knee was covered with a profusion of black, 
 thick, bristly hair. Waldeyer (83) reports the case of a 
 girl nine years of age, who had a lock of hair running 
 from the first to the fourth lumbar vertebra, and a 
 emaUer one from the third to the fourth cervical verte-
 
 HYPERTUOPHIA PILORUM. 163 
 
 bra. These localized and partial cases of hypertri- 
 chosis are most frequently met with in the sacral or 
 lumbar region, and not infrequently are associated 
 with spina bifida. Ornsteix (2S1 and 282 ap.) says 
 that sacral hypertrichosis is common in Greeks, and 
 reports two cases of tails in Greek soldiers, one a 
 quarter of an inch long and cone shaped, the other not 
 quite so long and stumpy. 
 
 Partial acquired hypertrichosis is more common 
 than the congenital variety, and takes the form either 
 of an excessive growth of hair in regions wliere it is 
 usually found, or of the development of hair in regions 
 usually hairless or only provided with downy or lanugo 
 hairs. 
 
 The following cases are instances of excessive growth 
 and precocious development. Chow^ne (3JS) speaks of 
 a boy, eight years of age, who had the whiskers of a 
 man. Beigel (321) has seen a six-year-old girl with 
 pudenda hke a twenty-year-old woman, both in shape 
 and hair. This form is called '^ Hetero -chronic of 
 Hair" by Bartels (318). As cases of excessive 
 growth may be cited the following: Leonard (04) 
 mentions the case of a man in his neighborhood whose 
 beard measured seven feet six and a half inches in 
 length. Other instances of excessive length of beard 
 are met with in medical literature, such as that of the 
 carpenter at Eidam, whose beard was nine feet long, 
 and who was accustomed to carry it in a pocket de- 
 voted to the purpose; and that of the Biirgermeister 
 of Braunau whose beard reached to the ground. Wil- 
 son (378) met with a lady who was five feet five in- 
 ches in height, whose hair, when she walked, trailed 
 three or four inches on the floor. Many men have an 
 excess of hair upon the chest and shoulders. Hair is 
 generally more developed upon the forearm than upon 
 the upper arm, and upon the leg than upon the thigh.
 
 164 DISEASES OF THE HAIR AND SCALP. 
 
 As men grow old they are apt to have long hair grow 
 from the nostrils and the ears. These are instances of 
 the growth of strong hair where normahy lanngo hairs 
 alone are present. But these cases are interesting only 
 as curiosities and as subjects of study. 
 
 Bearded Women. — The growth of the beard in 
 women is the form of hypertrichosis which concerns 
 
 Bearded Woman. 
 
 US most, as it is the deformity which w^e will be called 
 upon to cure. It has been called heterogenic. As women 
 grow old, especially after they have passed through the 
 climacteric period of middle life, a slight mustaclie or 
 a few straggling dark hairs on other parts of the face 
 often appear. These will seldom annoy them much, 
 as they are accepted as evidences of advancing years. 
 The case is very different when a young woman is 
 
 I
 
 HYPERTKOPHIA PILORUM. 165 
 
 afflicted with a beard, and many of the patients who 
 apply for relief froni their facial hair are between 
 twenty and thirty-live years old. The hair generally 
 begins to grow so as to be noticeable at about the 
 eighteenth year of age. To get rid of the trouble the 
 tweezers are first resorted to, and this only makes 
 matters worse. Then depilatories are tried whicli 
 have but a passing effect, and some of them leave bad 
 scars. Sometimes burning is attempted, and as a final 
 refuge the razor is used. All the time the hair grows 
 coarser and more abundant. Were this all, though it 
 would be bad enough, these cases would not so greatly 
 need our aid. The deformity is only the beginning of 
 evils. These women shun company, keep themselves 
 shut up all day, their health deteriorates, and, con- 
 stantly brooding over their misfortune, they are prone 
 to become hypochondriacal and melancholic. Anyone 
 devoted to dermatological practice must have seen 
 these nervous, sensitive women, whose health is 
 broken and spirits depressed on account of, it may be, 
 no very formidable facial hirsuties. The amount of 
 hair presented by these cases varies. Perhaps the 
 commonest growth is a mustache alone. In most of 
 my cases the hair has grown thickest and coarsest 
 under the chin and upon the front of the throat. 
 It is rare, even in the best developed cases, to have 
 much hair under the lower lip. Sometimes the growth 
 is as complete, as heavy, and as coarse as is met with 
 in men. An excellent account of such a case is de- 
 scribed by DuHRiNG (330). The skin of many of my 
 cases has been coarse, muddy, greasy, and studded 
 with acne. 
 
 From time to time cases of transitoru hj/jiertrichosis 
 have been reported. This has been noticed during the 
 treatment of a fractured limb, the hair being much 
 more prominent upon the part that has been kept quiet
 
 166 DISEASES OF THE HAIR AND SCALP. 
 
 and warm. In some of these cases the increase is pro- 
 bably more apparent than real, the hair not having 
 been rubbed off by friction. Likewise, after injury 
 to nerves the hair sometimes becomes hypertrophied, 
 only to fall off after recovery. Continued irritation 
 of a part, as by blisters, may stinmlate hair-growth 
 which may or may not be transitory. The most in- 
 teresting of this group of cases are those instances 
 of hirsuties occurring during pregnancy or amenor- 
 rhoea, and disappearing again some months after par- 
 turition. Wilson reported a case of delayed appear- 
 ance of menstruation in which hair grew upon the 
 face. After the menstrual function was established, 
 the hair ceased to grow and gradually fell off. Thin 
 (291 ap.) and Gottheil (263 ap.) have reported cases 
 of hirsuties that disappeared after conception. 
 
 Etiology. ^ — The cause of hypertrichosis is very ob- 
 scure in some of its forms, while in other varieties 
 we can more readil}" discover it. In universal hirsuties 
 heredity plays an important part. Such instances as 
 those of tlie Kostroma father and son ; of Shewe 
 Maon, and his daughter and grandchild, and others 
 like them, attest this fact. But hereditary tendencies 
 will not explain the first appearance of these congenital 
 cases. YiRCHOw (375) endeavored to account for them 
 upon the theory of nervous influence, founded upon 
 the fact that in the Kostroma people the lack of devel- 
 opment of the teeth and jaws was in the same zone 
 of nervous influence as was the over-development of 
 the hair on the forehead, nose, cheeks, and ears; these 
 regions all being supplied by branches of the trigem- 
 inus or fifth cranial nerve. Parreydt, quoted by 
 Geyl (5C) ap.), thought that those who had large teeth 
 were apt to have a profuse growth. This theory is 
 not borne out by facts. Atavism is another theory
 
 HYPERTROPHIA PILORUM. 1G7 
 
 to account for these cases. When we remember that 
 the foetus is completely covered with hair of some 
 length and coarseness, though not coarse, there is good 
 ground for believing that Unxa's* theory of congenital 
 hypertrichosis is right, namely : '^That it is due to a 
 persistence of the foetal or primitive hair ; the change 
 of type between the primitive and permanent hair not 
 taking place." While normally tlie change in type 
 does take place and the primitive hair of most of the 
 body is replaced with lanugo hair, in some individuals 
 for some unknown cause the primitive hair remains, 
 grows stronger, and we have the homines pilosi. 
 
 At the present time it is hardly necessary for us too 
 gravely to discuss the theories of maternal impressions, 
 fecundation of the human female by a hairy animal, 
 and the like. 
 
 The cause of acquired hirsuties is, in some cases, not 
 far to seek. Heat and moisture will apparently in- 
 crease the growth of hair, just as they favor the 
 growth of vegetable life. Thus the hair has grown 
 luxuriantly under the stimulation of poultices, and on 
 the limbs when confined in a fracture box. To these 
 factors must be added an increase of the flow of blood 
 to the part, which will stimulate hair-growth indepen- 
 dently of heat and moisture. At least Prentiss' (134) 
 case of hair growing more luxuriantly and coarser under 
 the use of pilocarpin, which causes hyperaemia of the 
 skin, would seem to indicate this. Hypertrichosis fol- 
 lowing injury to nerves is probably dependent upon 
 vaso-motor disturbances. The growth of hair upon 
 exposed parts, as upon the arms and chests of laboring 
 men, sailors, and the hke, is due to the local irritation 
 of the sun and wind. 
 
 Now we come to the more obscure cause of facial 
 
 * Ziemssen's Handbiich, Vol. XIV., p 50.
 
 lOS DISEASES OF THE HAIR AND SCALP. 
 
 hirsuties in women. In the majority of cases it will 
 be found that the deformity is hereditary on the fe- 
 male side, the mother, maternal aunt, or maternal 
 grandmother having hirsuties. To account for this, 
 numerous hypotheses have been formed. Probably 
 the one most generally accepted is that it is in some 
 way connected with derangement of the uterus and 
 appendages. Because in some bearded women there 
 has been some evident derangement of the sexual or- 
 gans, it has been affirmed that some similar derange- 
 ment is present in all, just as many of the laity believe 
 that the too free use of alcohol is the cause of rosacea. 
 In the cases I have met with, the majority were as free 
 from uterine trouble as the rest of their sex. While 
 it is true that some of these women are of masculine 
 build, and have a mascuhne voice, most of them do 
 not exliibit these characteristics. The heaviest bearded 
 of ni}' female patients was the mother of three children, 
 and this experience is not unique. In some cases, how- 
 ever, there does seem to be some relation between the re- 
 productive organs and the growth of the beard. Seve- 
 ral instances illustrative of this have been given above. 
 Eecently, I have met T\4th a case of a woman with a 
 dark but not very heavy beard, which began to grow 
 about one month before the birth of her fourth child. 
 The appearance of hair on the face of women who 
 have ceased to menstruate would suggest such re- 
 lationship. It is a common idea with women who 
 have a good deal of hair on the face, that they have 
 brought it on themselves by their endeavors at remov- i 
 ing a very sHght, hardly perceptible growth. This is ' 
 an error. Though undoubtedly sha\ing or cutting the 
 beard may somewhat increase its coarseness, and to a j 
 certain extent stimulate its growth, still it camiot make^ 
 new hairs grow. It is exceedingly hkely that even if 
 these women left the hair entirely alone it would in
 
 HYPERTROPHIA PILORUM. 160 
 
 time become of itself coarse and dark, though it would 
 be more silky. 
 
 The question of the inheritance by the daughter of 
 the physical character of the father or male ancestors 
 is worth investigating. By this I mean, whether she 
 resembles the father in her general build more than 
 the mother. 
 
 We may sum up the evidence on the etiology of fa- 
 cial hirsuties in this way : While at times there ap- 
 pears to be a relation between the uterine, or, more 
 properly, the menstrual function, and the growth of 
 hair on the face, shown by a decrease or deficiency of 
 the first, and an increase of the second, still in the ma- 
 jority of cases no such relation is discoverable, and it 
 must be viewed as a defoi-mity or freak of nature. 
 
 An interesting study of the relation between hirsuties 
 in women and insanity was made by Hamilton (339). 
 He regards hair growth on the face in women as the 
 inevitable result of the overactive and continuous ex- 
 ercise of the uterine and ovarian functions. He l)e- 
 lieves it to be of neuropathic origin, connected with 
 disorders of the fifth cranial nerve; and when it occurs 
 upon the face of an insane person it is indicative of an 
 unfavorable form of insanity, especially if the subject 
 has not reached middle life. Shaw (364) speaks of the 
 hair of chronic lunatics changing from fine to coarse 
 and increasing in quantity, specially during or after vio- 
 lent outbreaks of insanity, and ascribes it to the effect 
 of long-continued increase of temperature of the scalp, 
 leading to a greater activity of the hair-bulbs. 
 
 Treatment. — The treatment of hypertrichosis is sim- 
 ple and efficacious, though laborious and tedious. For 
 general hypertrichosis we can practically do nothing. 
 This, not because we cannot destroy the hair so that it 
 will not grow again, but because of the great amount 
 of time it would take to destroy it. Happily, a super-
 
 170 DISEASES OF THE HAIR AND SCALP. 
 
 fiuity of hair on the body does not incommode the 
 bearer of it, nor, in most cases, do him any damage. 
 One case, however, is upon record where the conse- 
 quences of too much hair resulted in serious damage. 
 It is that of a woman in old times whose face was very 
 beautiful, and who made an advantageous marriage. 
 But the husband was disgusted to find her body cov- 
 ered from breast to tliighs T\ith a profuse gi'owth of 
 stiff coarse hair, and upon the strength of tliis he was 
 divorced from her on the next day. 
 
 The only form of hirsuties which urgently calls for 
 rehef is that occurring upon the face of women. Until 
 recently there was no cure for this, but in IS 75 Michel 
 (3S0), of St. Louis, devised a method for removing the 
 hairs in tricliiasis by means of electrolysis, which was 
 taken up by Hard a way (34:1), of the same city, for 
 the removal of superfluous hair. Piffard (29) in IS 76 
 spoke of the removal of superfluous hair from hairy 
 naevi by this method ; and Leon Le Fort, in his edi- 
 tion of Malgaigne's ^^ Manuel de Medecine operatoire " 
 in 1877, pubhshed his method of destroying hair by 
 electrolysis, which he had used since IS 75. As Mi- 
 chel published his method in IS 75, to him belongs 
 the priority. The question is often asked: *^ Is the 
 removal, by this method, permanent ? " This question 
 may be answered, ^'It is, without a shadow of a 
 doubt." The object being to destroy the papiUa, and 
 that being very small and often placed at an unex- 
 pected angle to the surface of the skin, it is not possi- 
 ble always to accomplish this at the first attempt. The 
 amount of success on going over the face the first time 
 will vary with the operator, and, according to his skill, 
 there will be a return of from twenty to fifty per cent, 
 of the hairs removed. It wiU be necessary, therefore, 
 to go over the face a second or a third time, but then 
 there will be no return. At times, after the dark
 
 HYPERTROPHIA PILOKUM. 171 
 
 coarse hairs have been removed there will be found a 
 number of finer and Hghter hairs. This appearance 
 is due partly to the uncovering of these hairs, and, 
 partly it may be, to lanugo hairs becoming stronger 
 under the stimulation of the operation. Cases occur- 
 ring in young women are much more tedious in their 
 treatment than those in women past the climacte- 
 ric, because while in the latter the growth is limited in 
 amount, in the former new hairs form from new fol- 
 licles, just as in a young man's beard, and it is impos- 
 sible to tell when the process will stop. It is well 
 always to tell these patients that they must be pre- 
 pared for a long course of treatment, as only the hairs 
 that have appeared can be destroyed, and we have no 
 means of preventing the formation of new hairs ; 
 that these new hairs do not form in the old follicles, 
 but are simjDly developed in time from those already 
 in the skin. They will have to be treated from time 
 to time during a number of years until all the hair 
 papillae have produced their hairs and these have been 
 destroyed. In most cases, with proper care and the 
 use of a fine needle, the amount of scarring will be 
 very slight, amounting to nothing more than fine 
 punctate cicatricial spots. In some peculiarly irritable 
 skins it is very difficult to prevent the formation of 
 plainly visible scars. If the proper conditions are not 
 observed, the operator must expect to produce a good 
 deal of disfigurement. 
 
 The amount of pain experienced by the patient will 
 vary greatly. Some women will complain bitterly of 
 a current of half the strength that other women will 
 bear with ease. Certain parts of the face are far more 
 sensitive than others. The most sensitive points, ac- 
 cording to my experience, are over the ridge of the 
 lower jaw on each side of the chin, and upon the 
 upper lip. On the whole, the pain does not amount to
 
 172 
 
 DISEASES OF THE HAIR AND SCALP. 
 
 much. After a time the skin seems to become tolerant 
 of the action of the current and the patient no longer 
 
 complains. 
 
 Twenty Cell Galvanic Battery. 
 
 Hyperpigmentation may be produced by 
 the operation. This is 
 a very rare complica- 
 tion, and is only men- 
 tioned by way of warn- 
 ing. I have seen it in 
 two cases. Instead of 
 the redness which is 
 always produced about 
 the point of puncture 
 fading away in a few 
 days, it gives place to a 
 dark-1 )rown stain which 
 may remain for a num- 
 ber of months. 
 
 The instruments nec- 
 essary for the operation 
 are a good twenty cell zinc-carbon (galvanic) batteiy, a
 
 HYPERTROPHIA PILORUM. 
 
 173 
 
 sponge electrode, a proper needle-holder, a fine needle, 
 a pair of epilating forceps, and, if the operator's eyes 
 
 
 Leviseur's Sponge Electrode. 
 
 are not good, a lens of low power. A galvanometer is 
 not essential, but is an aid to exactness in working. 
 
 WAITE & BARTLETT MF'G. CD. NEW YORK, 
 
 Needle-Holder. 
 
 Any sponge electrode will answer. There are various 
 patterns of needle-holders, any one of which may be 
 
 £. EISNER. MX 
 Leviseur's Needle-Holder. 
 
 used. I prefer one which is not longer than three or 
 three and a fourth inches, with a diameter of about
 
 174: DISEASES OF THE HAIR AND SCALP. 
 
 three-sixteenths of an inch. It should be long enough 
 to be held with ease, and not too long to be readily 
 manipulated. If the woman has a large bust, a high 
 chest, and a short neck, a short holder will be found a 
 great convenience when working under the chin. 
 Tliere is a form of needle-holder in the market fur- 
 nished with an attachment for cutting off the current 
 and letting it flow again after the needle is in place in 
 the follicle. This I cannot recommend, as it causes a 
 very uncomfortable shock to the patient, much more 
 than that experienced in using the method detailed 
 below. Another needle-holder, invented by Leviseur 
 (272 ap.), is ingeniously arranged so that the needle may 
 be placed at varying angles. The most essential in- 
 strument is the needle, and for the best success this 
 must be carefully chosen. At first the finest cambric 
 needle was used, and it did fairly well. Hardaway 
 (342) recommends a needle made of iridium and plati- 
 mum, claiming that it will follow the direction of the 
 hair-follicle and hit the papilla more surely than the 
 steel nee.dle will. I have used these needles, but have 
 not found them so satisfactory as the steel ^^ broaches," 
 which are fine-pointed steel needles used by jeweller's 
 and obtained at any jeweller's supply store. They 
 come in many grades of fineness. It is advisable to 
 have two grades, No. 5 for the coarser hair. No. 7 for 
 the finer, and for the lip. Care should be exercised in 
 selecting them, as they are so fine that their points are 
 sometimes broken while in the packages. A lens is gen - 
 erally not needed. Piffard (359) has inven ted a needle- 
 holder with a lens attachment, which he has found use- 
 ful. Good eyesight and a steady hand are the essentials 
 to be supplied by tlie operator. If he has not these, he 
 had best not attempt the operation. A good fight is ne- 
 cessary for the operation, that is, one that is steady and 
 not glaring. A cloudy day with changing light is try-
 
 HYPERTROPHIA PILORUM. 175 
 
 'ing to the eyes. I have been able to work with much 
 comfort on dull days, even mider the chin, by spread- 
 ing a white napkin over the patient's throat and upper 
 chest. An operating or reclining chair is a comfoi-t, 
 and the patient should be so placed that the part to be 
 operated on is on a level with the operator's eye. 
 
 The operation is done in the following manner: The 
 patient, being in position, is to be given the sponge elec- 
 trode attached to the positive pole of the battery, and 
 told to hold it in one hand. The hair to be extract- 
 ed is to be seized with the forceps, and put slightly on 
 the stretch in the direction in which it naturally grows. 
 The needle-holder is attached to the negative pole, and 
 held like a pen -holder. The needle is then inserted paral- 
 lel with the hair and into the follicle. One soon learns to 
 know whether the follicle is entered or not by the sense 
 of touch. When the follicle is entered the needle glides 
 along smoothly; when it is not entered a sense of re- 
 sistance is communicated to the fingers as the skin is 
 punctured. The depth to which the needle is to be 
 thrust will vary with the case. Roughly speaking, it 
 is from one-sixteenth to three-sixteenths of an inch. 
 The needle being inserted, the patient is told to place 
 the palm of the disengaged hand over the sponge elec- 
 trode. Watching the effect on the skin, a slight hy- 
 peraemia will be noticed about the point of insertion of 
 tlie needle, which almost instantly gives place to a 
 blanching of the tissues. In a few seconds there will 
 be frothing about the needle, and in from half a min- 
 ute to a minute, the hair will come away upon the 
 very slightest traction. 
 
 Such is the operation. Care must be taken to use 
 the negative pole, for otherwise, instead of an electro- 
 lytic action, a charring of the tissues will result, and per- 
 manent blackish spots will be left in the skin. The 
 hair must not be pulled on with any force, for the ease
 
 1?G DISEASES OF THE HAIR AND SCALP. 
 
 with which it leaves the follicle is a guarantee of the 
 completeness of the operation. The hairs must not he 
 extracted in close proximity, because the inflammatory 
 action thus set up will lead to more or less ulceration 
 and subsequent prominent scars. At first, at least 
 some three -sixteenths of an inch should be left be- 
 tween the hairs: later, when the susceptibility of the 
 skin is known, they may be taken out nearer to each 
 other. It is best only to extract the coarser hau' and 
 to leave the lanugo hairs alone. The strength of the 
 current to be used will depend upon the qualit}^ of the 
 patient's skin and the recentness of the filling of the 
 battery. Eight cells are the fewest I have used, and 
 fifteen the greatest number: that is, a current of froii] 
 one half to one and a half milliamperes. 
 
 The immediate effect of the operation is the produc- 
 tion of a number of wheals which are evanescent. On 
 the next day only red points are seen, and in a few 
 days no traces of the operation are visible, or else min- 
 ute cicatricial points, when the skin is examined with 
 the greatest care. In some skins, however, the re- 
 action is much greater. The finer the needle is, the 
 less the reaction wiU be. The patient should be di- 
 rected to bathe the face in Ji of water after the opera- 
 tion, and to anoint it with cold cream. If these direc- 
 tions are carefuUy carried out, and the requisite 
 skill in the introduction of the needle is acquired 
 by practice, an absolute cure will be the result. 
 
 While the just detailed operation is the only one 
 which is at all certain of success, various other means 
 have been tried to destroy superfluous hair, and, for 
 completeness, must be given in this place. Depilatories 
 are of very ancient date, and there are many vaunted 
 ones now in the market. Many of my patients have 
 used many kinds. That they have come to be operated 
 on by electrolysis tells the tale of the failure of depila-
 
 HYPERTROPHIA PILORUM. l77 
 
 tories. Still, they are useful in some conditions. When 
 the patient's hair-growth is very fine they may he ad- 
 vised, as fine hair is not so favorable for operation as 
 is coarse hair. When the hair-growth is partly fine 
 and partly coarse it is a good plan to remove the whole 
 by a depilatory, and thus lighten our work, as the 
 coarse hairs will naturally appear first in growing, and 
 then can be removed before the fine hair obscures them. 
 Depilatories act only on the hair above the surface 
 and not on the roots. Anderson recommends one 
 composed as follows: 
 
 Sulphuret of barium, 
 
 . 
 
 3iss=G, 
 
 Oxide of zinc. 
 
 , 
 
 3vj=24 
 
 Carmine, 
 
 • 
 
 gr.j=00. 
 
 Some of this powder is to be mixed with enough 
 water to make a paste, applied to the part and washed 
 off in three minutes. Duhring (10) gives the following 
 formula: 
 
 ^ Sodii sulphid, . . . . 3ij=:8. 
 Cretae preparat, . . . . 3vj = 2-I:. 
 M. 
 
 This is to be made into a paste with water and ap- 
 plied as a thin coating, and left on for ten or fifteen 
 minutes. As soon as it causes heat of the skin, it is to 
 be washed off, and the part is to be anointed with a 
 bland ointment. 
 
 Leonard (64) tells us that in Eastern harems, where 
 it is the fashion to destroy the axillary and jnibic hair, 
 they use a composition called ' ' rusma ' ' made of 
 
 Arsenici tersulphuret, . . 3 ss=2. 
 
 Calcis, §ss=lG. 
 
 Farinae tritici, . . . . 3ij=2.5. 
 Aqua3 ferv. qs. ut. ft. pasta. 
 M.
 
 178 DISEASES OF THE HAIR AND SCALP. 
 
 This is applied with a wooden spatula, to the thick- 
 ness of a knife blade, and left on for from five to ten 
 minutes, or until it begins to sting, when it is scraped 
 off with a blunt-edged knife, and the skin w^ashed with 
 warm water and dusted with rice or starch powder. 
 '. Xeumaxx (27) gives an extended list of depilatories in 
 his work on the skin. All of them require careful 
 watching, as it is possible that their action may go too 
 far. 
 
 Nothing need be said about cutting the hair, shav- 
 ing it, and pulling it out bv tweezers. The most 
 ancient method of getting rid of hair is by fire — burn- 
 ing it off. 
 
 C. Heitzman (3.14), in ISSl, reported the results of a 
 number of experiments with hyj^odermic injections, the 
 hair being extracted and then tlie needle introduced 
 and the injection made. He first tried the tincture of 
 iodine, one part in ten, and extracted fifty hairs. 
 More than one half returned in three months. He 
 then used equal paiis of carbonate of potash and water. 
 Nearly all returned. Then caustic potash, one to six 
 or four, was injected. Twenty-four hairs were ex- 
 tracted from his own arm and in six months only six 
 retm-ned. He thinks that in the strengih of one to 
 four with a fresh solution it is capable of destroying- 
 hair under symptoms of suppuration. The needle 
 should be run obliquely under the skin and given a 
 rotatory motion. Many other attempts to destroy hair 
 by means of introducing needles dipped in various sub- 
 stances into the folhcle have been made with indiffer- 
 ent success. It would seem that the medicament 
 would be rubbed off against the walls of tlie upper part 
 of the f oUicle before it could reach the papilla, and that 
 any good effected would be due to exciting a suppura- 
 tive action at or near the surface of the skin. 
 
 BuLKLEY (32-1:), in 1S7S, reported several successful 
 
 J
 
 HYPERTROPHIA PILORUM. • 179 
 
 cases treated by means of a three-cornered surgical or 
 glover's needle, which was passed into the follicle and 
 rotated while in the region of the papilla so as to break 
 up its substance. The hair is to be seized with the 
 epilating forceps, put slightly on the stretch, and the 
 point of the needle placed at the niouth of the follicle. 
 The needle is to be slowly pressed in and the hair pulled 
 out when the needle will pass into the follicle. Gener 
 ally no bleeding occurs, and the operation is not very 
 painful and no scarring results. This is a good method 
 of treatment where there are only a few hairs to be re- 
 moved and a galvanic battery is not at hand.
 
 CHAPTEE X. 
 
 TRICHIASIS AND DISTICHIASIS. 
 
 These diseases belong to the domain of the opthalmic 
 surgeon, rather than to that of the dermatologist, but 
 they are usually included in systematic treatises upon 
 the skin, imder the section upon Hypei-trichosis. They 
 occur not infrequently: the last report, (1SS6,) of the 
 Manhattan Eye and Ear Hospital showing 20 cases in 
 tl5S cases of diseases of the eyehds. 
 
 Trichiasis is a congenital or acquired misplace- 
 ment of the ciha, so that they are directed backward 
 toward, and scratch upon, the globe of the eye; com- 
 bined with a growth of lanugo hairs with the same in- 
 clination backwards. This condition is usually ac- 
 quired, though there may be some original irregularity 
 of the ciha. These are not only misplaced so as to 
 point backward, but are often twisted or distorted. 
 As a rule both the upper and lower lid are affected; and 
 l)oth eyes may be involved in the disease. The lanugo 
 hairs that are met with develop after tlie distortion of 
 the ti-ue ciha has existed for a gi'eater or less length of 
 time. They gTow from every portion of the tarsal 
 margin, and even from the mucous membrane of the 
 hds. 
 
 This disease is dependent upon some long-continued 
 inflammatory disease of the eyehds, which causes a dis- 
 tortion of the lid and interference ^^^th the direction 
 and nutrition of the hair-folhcles. It therefore very 
 conmionly foUows upon granular and puiTdent opthal- 
 mia.
 
 TRICHIASIS AND DISTICHIASIS. 181 
 
 Distichiasis is a congenital or acquired condition in 
 which the ciUa grow in two distinct rows, the inner 
 row being directed inwards so as to impinge upon the 
 cornea. It differs from trichiasis in an entire absence 
 of lanugo hairs, the supernumerary hairs being nor- 
 mal ciHa. Sometimes the inner row cannot be seen 
 until the lid is everted. The condition may be pai-tial 
 or complete, usually the former. According to Michel 
 (380) generally the outer third of the upper lid is affect- 
 ed alone, the deformity is symmetrical and bilateral, and 
 of embryonic origin. The second row of cilia springs 
 from the flattened tarsal margin near its posterior 
 edge. Where this arrangement of the cilia is not con- 
 genital, it is dependent upon the same causes as trich- 
 iasis. Both diseases cause irritation of the cornea, 
 opacity of the same, panus, and ulceration, matters 
 which do not concern us here. 
 
 The treatment is palliative, as by epilation; or rad- 
 ical, by operation. Until recent times the opthalmic 
 surgeon has made a radical cure by cutting out either 
 a piece of the lid so as to shorten it and somewhat 
 evert it, or by excising a part of the tarsal cartilage 
 with the offending hairs. For these matters, books on 
 the diseases of the eye are to be consulted. To Michel 
 (380), of St. Louis, is due the credit of first destroying 
 the supernumerary and distorted hairs by means of 
 electrolysis. The operation is the same as is given in 
 the preceding chapter. Michel states his preference 
 for a No. 8 cambric needle, because its action is not so 
 limited as is that of a finer one.
 
 CHAPTER XI. 
 
 SYCOSIS. 
 
 Derivation. — Gr. ovnooai^, a Fig. 
 
 Synonyms. — Sycosis non parasitica; Sycosis menti; 
 Sycosis barbce (Celsus) ; Mentagra (Plenck) ; Acne 
 mentagra; Folliculitis barbce (Kobner); Folliculitis pi- 
 loruni; Herpes pustulosus mentagra (Alibert); Lichen 
 menti ; Acne sycosis (Morris) ; Coccogenous sycosis 
 (Unna); Fr. ; Sycosis non parasitaire; Dartre pustu- 
 leuse mentagra; Adenotrichie (Hardy); Ger. : Bart- 
 finne, Bartflechte, Fikosis; Eng: Barber's itch. 
 
 Definition. — A chronic follicular and peri- follicular 
 inflanmiation of the long, hau's, chiefly affecting the 
 bearded portions of the face; characterized by an 
 eiTiption of papules, pustules, and nodules perforated 
 by hairs; by the formation of infiltrated patches; and 
 by a gTeater or less amount of crusting. 
 
 Symptoms. — It is only of comparatively recent years 
 that tliis disease has been recognized as a separate en- 
 tity, and it is stiU regarded by some authorities as merely 
 a form of eczema. But the expei'ience of the major- 
 ity of dermatologists has taught them, that the disease 
 is quite independent of either eczema or trichophytosis 
 barbae. The disease begins by the formation of a num- 
 ber of red inflammatory papules and nodules, which 
 are more or less conical, usually raised above the sur- 
 face of the skin and always perforated by hairs. Their 
 appearance is preceded and accompanied by disagi'ee- 
 able local sensations, such as pricking, burning, and 
 smarting, and at times by a feeling of tension in the 
 part, on account of sweUing of the skin. In acute
 
 SYCOSIS. 
 
 183 
 
 cases there is considerable redness of the skin between 
 the papules, and the inflammation may be so intense 
 as to give rise to enlargement of the neighboring lym- 
 phatic glands. The papules and nodules vary in size, 
 from that of a millet seed to that of a pea, and are iso- 
 lated or grouped, not every hair-follicle in a diseased 
 part being affected by the peri-foUicular inflammation. 
 
 Sycosis. 
 
 Only in very severe outbreaks or in acute exacerba- 
 tions do the papules and tubercles tend to run together 
 and form infiltrated patches. 
 
 The papules and nodules soon change into pustules, 
 which preserve the same characteristics of grouping 
 and are likewise always pierced by hairs. These pus- 
 tules, conical in shape and perforated by hairs", are 
 pathognomonic of the disease. In old cases they are 
 met with in the infiltrated patches, arising apparen^^ly
 
 184 DISEASES OF THE HAIR AND SCALP. 
 
 without the preceding appearance of papules and 
 nodules. The pustules show no tendency to rupture, 
 but the pus accumulates below, wells up alongside of 
 the hair, appears upon the surface of the skin and 
 dries into thin crusts. The amount of crusting is never 
 very great, far less than in eczema of the beard, and 
 is appreciable mainly when the beard is growing. If 
 the crusts are removed from a well-developed patch, 
 the skin looks as if pitted, with the hairs standing in 
 the pits. If the inflammation is very intense, we may 
 meet with small cutaneous abscesses here and there, 
 instead of pustules. According to A. R. Eobinson (33) 
 the amount of pus j^roduction varies with the indi- 
 vidual attacked, being more rapid and abundant in 
 the robust than in the scrofulous; in acute than in 
 chronic cases. 
 
 The hair, if of any length, is early affected in appear- 
 ance, becoming lustreless. It is at first firmly seated 
 in its follicles, and when puUed upon gives rise to pain, 
 and if extracted its root-sheath will appear as a clear 
 glassy cylinder. Later, as pus forms more abundantly 
 in the peri- follicular tissues, and the follicles themselves 
 are involved in the process, the hair becomes loosened 
 and easily extracted, when its root -sheath wiU be found 
 swollen with pus. If the pus j^roduction is excessive, 
 the hairs will fall of themselves or upon the slightest 
 traction. When this occurs the hair papilla may be so 
 damaged that no new hairs will form. In chronic 
 cases the beard is markedly thinned, though perma- 
 nent loss of hair is the exception. 
 
 The disease may attack any part of the bearded face, 
 and may be met with in other hairy regions, as the 
 neck, the eyebrows, scalji, axilla, and pubes. But 
 the beard is by far most often the site of the disease, 
 the other situations being affected in the order in 
 Vvdiich they are named. Occurring in the beard, it may
 
 SYCOSIS. 185 
 
 be limited to a single region and show no tendency to 
 spread. Thus, it is met with very frequently upon the 
 upper lip alone, or at times only upon the chin. It 
 may attack the whole bearded face in an acute out- 
 break, or it may involve it by extension from a limited 
 area during a number of successive outbreaks. In 
 chronic cases it is usually symmetrical. The course of 
 the disease is chronic and made up of a number of 
 acute exacerbations. If left to itself it may produce 
 a good deal of deformity, the tubercles and pustules 
 breaking down, ulcerating, and leaving cicatrical tis- 
 sue and more or less baldness. 
 
 A typical case of sycosis presents the following ap- 
 pearances. Upon a single region, two or more regions, 
 or upon the whole bearded portion of the face, there 
 will appear a number of isolated or grouped papules, 
 nodules or pustules pierced by hairs. The skin about 
 the lesions is reddened and swollen, it may be indu- 
 rated, and there is a slight amount of crusting. There 
 is no tendency for the disease to spread to non-hairy 
 parts, but very commonly the eyebrows will be simi- 
 larly affected, and a blepharitis will be present. In 
 some chronic cases there will be much loss of hair 
 and some scarring, and perhaps few pustules, but a 
 red, thickened, slightly scaly skin. 
 
 When the case is watched for a time, marked ex- 
 acerbations will arise, often without apparent cause, 
 last for a few days, and then the disease will sink into 
 a subacute condition. 
 
 When the disease affects the vibrissae of the nose, by 
 extension from the upper lip, the Schneiderian mem- 
 brane becomes swollen and exquisitely sensitive. 
 
 Etiology. — The etiology of the disease is not settled. 
 Statistical tables show that it occurs about six times 
 in every thousand cases of skin diseases. It probably 
 occurs more often than this, as some cases recovf^r
 
 ISO DISEASES OF THE HAIR AND SCALP. 
 
 rapidly under domestic treatment or even when left 
 alone. It is non-contagious. Unxa (312 ap.) and 
 some others believe that the disease is due to the 
 entrance of pus cocci into the hair-follicles. It is seen 
 in men almost exclusively, as we might expect, and 
 attacks them most frequently between the ages of 
 twenty -five and fifty. Both the well nourished and 
 the poorly nourished, the rich and the poor, suffer 
 from it. I have seen it very frequently in tailors, and 
 in them it has proved very obstinate. Eczema is often 
 a forerunner of sycosis, the one process passing over 
 into the other. A nasal catarrh is the cause of the 
 majority of cases occurring on the upper lip. Shaving 
 with a dull razor against a stiff beard is sometimes an 
 exciting cause, though those who do not shave are by 
 no means exempt from the disease. An irritant ap- 
 plied to the skin may excite it, such as exposure to 
 hitense heat, the dust of a workshop, cosmetics and the 
 like. Exposure to inclement weather is regarded by 
 AViLSON (38) as the principal cause. One of the worst 
 cases I have ever met with was directly traceable to a 
 poultice applied to the face for the relief of a neuralgia. 
 
 Given a hypersemic or irritable condition of the skin 
 of the face arising from any internal or external cause, 
 the hairs, especiaUy if they are coarse, may excite the 
 disease, acting as irritants when touched or moved. 
 Hebka ( 3i>4) thinks that some cases may be due to an ab- 
 normality in the growth of new hairs. Wertheim as- 
 cribed the inflammation to irritation of the hair-foUi- 
 cles by hairs whose diameter was relatively too large 
 for their follicles. 
 
 Pathology. — A. E. Eobinsox (400) w^ho has made ai 
 exhaustive study of the pathological anatomy of thi 
 disease, teaches us that it is " primarily a peri-foUiculi 
 inflammation of the skin. The first changes whicl 
 take place occur around the follicle in the x^eri-foUici
 
 SYCOSIS. IST 
 
 lar region, and are those which are usually observed in 
 vascular connective-tissue inflammations. The trans- 
 uded serum penetrates the hair-follicle, and as the in- 
 flammation proceeds and the pus and serum increase 
 in quantity, the follicle becomes more and more affected. 
 Its sheaths become softened and more or less destroyed, 
 and a portion of the pus may enter tlie follicle through 
 the ruptured sheaths. The cells of the external root- 
 sheath become swollen and soon begin to break down; 
 similar changes occur in the cells of the hair-root: they 
 swell, the protoplasm becomes more granular in ap- 
 pearance, and there is evidence of commencing destruc- 
 tion. After the rupture of the follicle-sheaths, or even 
 before, the cells of the hair-root and of the root-sheaths 
 rapidly become broken np and changed by the trans- 
 uded serum entering the follicle. If pus corpuscles 
 have also entered the follicle, the hair- root is infiltrated 
 with a sero-purulent matter; it does not in every case 
 enter it in large amount. In the i)ustular stage the 
 principal changes take place within the follicle; the 
 hair-root and its sheaths are broken down and separated 
 from the follicle sheaths, so that the hair lies loosely 
 within the follicle. 
 
 ' ' As the inflammation progresses, the connective- 
 tissue around the follicle becomes crowded with pus 
 ceUs, as far as the surface of the skin. If the hair is 
 allowed to remain within the follicle until expelled by 
 the accumulating pus, the root-sheaths and soft parts 
 of the hair are destroyed, and only the hard part re- 
 mains. The folhcle-sheath, and the peri-follicular tis- 
 sue are more or less destroyed, and the Malpighian layer 
 becomes ruptured at the neck of the follicle. The pus 
 reaches the surface by breaking through the epidermis 
 near the hair; some passes to the surface between the 
 hair-shaft and the follicle -sheath. The cells from 
 which the hair grows seem to resist the inflammatory^
 
 18$ DISEASES OF THE HAIR AND SCALP. 
 
 process more than the other cells of the bulb. When 
 permanent alopecia results both the follicle-sheaths and 
 the base of the follicle are completely destroyed. If 
 eczema is present the root-sheaths and follicle-sheaths 
 are acted upon in their entire length at the same time. 
 
 ' ' The sebaceous glands may also become affected, 
 though not at so early a stage of the disease as the fun- 
 dus of the hair, and the whole gland may be destroyed 
 by a process of molecular retrograde degeneration. 
 The sweat glands generally escape, but the epithelial 
 cells may become detached or the glands destroyed. " 
 
 GiovANNiNi (86 ap.) has found the affected hairs 
 thicker than normal, with more or less notched con- 
 tour, so that the hair presents from two to six irregu- 
 lar projections. In the middle of the hairs he has 
 found broad and irregular cavities filled with pigment, 
 fat, and detritus. Unna (312 ap.) teaches that sycosis 
 may be caused by the common pus cocci gaining access 
 to the hair follicles by traumatism or mechanical fric- 
 tion. The hair remains unaltered for some time after 
 the invasion of the follicle. Any pustular inflamma- 
 tion may start this form of sycosis. Tommasoli (311 
 ap.) describes a bacillary f orm due to short, rod-shaped, 
 somewhat tliick, and elliptical bacilli with rounded 
 ends, the bacillus sycosiferus foetidus. This he be- 
 lieves to be of tubercular nature. 
 
 Diagnosis. — The distinguishing characteristic of sy- 
 cosis is the presence of pustules pierced by hairs. It 
 must be diagnosed from trichophytosis barbae, eczema 
 barbae, the small pustular syphiloderm, acne, and lupus. 
 
 Differential diagnosis from trichophytosis barbae :
 
 SYCOSIS. 
 
 189 
 
 Trichophytosis harhm, 
 Begins as a small scalj'^ spot, 
 a superficial ring-worin, and 
 gradually involves the deeper 
 parts of the hair. 
 
 Has its favorite seat upon the 
 chin and the sub-maxillary re- 
 gion ; rarely attacks the upper 
 lip. Often asymmetrical. 
 
 The eruption consists of tuber- 
 cles and nodules which tend to 
 group and are studded with a 
 number of hairs. The inter- 
 nodular portions of the skin of- 
 ten remain unaffected. 
 
 Is a deep inflammatory pro- 
 cess as soon as the hairs become 
 affected. 
 
 Hair is diseased primarilj'-, and 
 is twisted, split and broken. 
 
 May readily be removed by 
 slight traction and without pain. 
 Its root is often dry. 
 
 Subjective symptoms slight, 
 may be only slight pruritus. 
 
 Patches of ringworm often 
 present on other parts of the 
 body, and sometimes the dis- 
 ease extends upon the neck or 
 face. 
 
 Hairs and scales loaded with 
 the tricophyton fungus. 
 
 Is a progressive disease, and 
 when cured not liable to relapse. 
 
 Sycosis. 
 
 Begins siiddenl}'- with an out- 
 break of papules which soon be- 
 come pustules, each of which at 
 the start involves a hair. 
 
 Its favorite seat is the upper 
 lip, and sometimes it alone is in- 
 volved. Involves the hairy por- 
 tions of the face more generally 
 and often symmetrically'. 
 
 The eruption consists of pa- 
 pules and pustules, each of 
 which is pierced by a single 
 hair, and they show no disposi- 
 tion to group. The intervening- 
 skin is generally reddened, and 
 maj' be diffusely infiltrated ; and 
 abcesses may form. 
 
 Is a more superficial inflam- 
 mation. 
 
 Hair diseased secondarih' and 
 comes away at first with difli- 
 culty, causing much pain. Later 
 is easily removed and its root is 
 swollen with pus. 
 
 Subjective symptoms of prick- 
 ing, burning, and tension of the 
 part. These are often intense 
 and attended with swelling of 
 the face. 
 
 Limited in most cases to hairy 
 parts of the face. No tendency 
 to extend on non-hairy parts of 
 face or neck. 
 
 No fungus present. 
 
 The course of the disease made 
 up of a number of acute out- 
 breaks. Liable to relapse. 
 
 The differential diagnosis from eczema of the beard 
 cannot be made with so much certitude, and often we 
 must remain for a while in doubt as to the true nature 
 of the case. At times the sycosis is a legacy left by a 
 preceding eczema, and we may meet with a case in 
 the transition stage when a sure diagnosis would, 
 manifestly, be impossible. A typical case of pustular 
 eczema is attended by a far greater amount of crust- 
 hig than is sycosis, and the crust is of a more greenish 
 or blackish color. Ui^on removing the crust in eczema
 
 190 DISEASES OF THE HAIR AND SCALP. 
 
 a moist and oozing surface will be exposed, while in 
 sycosis we will do no more than remove the tops from 
 a number of pustules. In eczema the pustules break 
 down more readily than in sycosis, and they are not 
 so accurately located about the hairs. In eczema the 
 whole sui-face of the skin is involved and the process 
 tends to extend upon non-hairy parts of the face. While 
 exceptionally eczema is confined to the hairy portions 
 of the face this is always so in sycosis. The duration 
 of the disease will at times help us to a diagnosis, sy- 
 cosis being far more chronic than is eczema. 
 
 In syphilis when the beard is involved we will find 
 pustules upon other portions of the body, and the his- 
 tory will help us to a correct conclusion. The pustules 
 or papules of syphilis are gi'ouped in circles or segments 
 of circles, of peculiar color, and their development is 
 painless and comparatively slow. Pustalar sypliihs 
 more often causes permanent baldness than does 
 sycosis. 
 
 Acne is scattered about the whole face, is usually 
 met with in young persons, comedones are present and 
 its papules, pustules, or tubercles have no definite re- 
 lation to the hair. 
 
 The course and history of lupus are so different 
 from tliat of S3"cosis, that it is hardly possible for 
 them to be confused. In lupus vulgaris we have 
 the characteristic brown tubercles which do not 
 contain pus, are not confined to the hairy poii^ions of 
 the face, generally begin in early hfe, and tend to ul- 
 cerate or to be absorbed and leave behind cicatrices. 
 
 Treatment. — The treatment of sycosis is both gene- 
 ral and local. While many cases will yield to local 
 treatment alone, there are quite as many, if not more, 
 which require general treatment. The surroundings 
 of the patient must be inquired into, and also his mode 
 of hfe. He should be urged to take exercise in the
 
 SYCOSIS. Iftl 
 
 daylight; a powerful means for good if the case hap^ 
 pen to fall upon one constantly employed in badly ven- 
 tilated rooms, such as tailors and the like. He should 
 be advised against exposing himself to dust and wind, 
 and even against smoking, especially in the wind where 
 the smoke blows against the face. The proper regula- 
 tion of the diet is important. Many cases will improve 
 if we stop their tea, coffee, hot drinks of all sorts, ale, 
 beer, and spirits. If the digestive process seem at all 
 embarrassed, it is well to put the patient on a light 
 diet for morning and evening, and direct him to take 
 his principal meal at noon, eating meat only at that 
 time. Anything that is known to him to be indigesti- 
 ble must of course be prohibited. In a word the diet 
 and hygiene of the patient should be regulated. 
 
 What medicines we should administer wiU depend 
 upon the stage of the disease. In the acute stage, when 
 there is much swelHng and inflammation, a good dose 
 of blue pill, calomel, or some other active cathaiiic is 
 to be ordered, to be foUowed by an alkahne diuretic. 
 When pustulation is active the sulphide of calcium or 
 calx sulphurata will do good. Piffard (399) recom- 
 mends this very highly, giving one-tenth of a grain 
 two or three times a day. Care must be exercised that 
 our patient obtain the drug fresh. I have found the 
 exhibition of the drug in the form of the tablet tritu- 
 rate by far the most active way. Small doses of calo- 
 mel, as one-tenth of a grain three times a day for two 
 or three days at a time, are useful in relieving the 
 congestion of the skin. In chronic cases, iron, cod- 
 liver oil, and other tonics are indicated if there is a 
 state of debility. Arsenic is advised in very obstinate 
 cases. If indigestion is present we must address our 
 remedies to its relief before we give calcium, arsenic, 
 or other remedy for the disease proper.
 
 192 DISEASES OF THE HAIR AND SCALP. 
 
 The local treatment is more important than the gen- 
 eral, and is required in every case. It must vary vrith 
 the condition found, whether it be acute or sub -acute. 
 When the disease attacks the upper lip the nose must 
 be examined for evidences of catarrh^ and that condi- 
 tion treated if found. I have had, at times, good re- 
 sults from the subnitrate of bismuth or powdered cu- 
 bebs, used as a snuff in this condition, but it is best 
 for each physician to use for this, that which experi- 
 ence has taught him to be most useful. 
 
 In the management of an acute case of sycosis sooth- 
 ing remedies are needed. Hot water should be soj^ped 
 on the part for some five or ten minutes once or twice 
 a day, and this should be followed, if the beard is grow- 
 ing, by the use of a simple oil such as olive oil or sweet 
 almond oil, or if the face is shaved the zinc oxide oint- 
 ment or cold cream may be used; or better stiU, Las- 
 sar's paste, as foUows: 
 
 Amyli, 
 
 Zinci oxidi. aa . . . .3 ij — 8. 
 VaseHne, ad . . . » 5 j — 32 
 M. 
 
 Powdering the part with corn starch, or bismuth and 
 talc, after smearing on a little vaseline, wiU at times 
 give ease and comfoi-t. If the i^rocess is attended 
 by a good deal of oedema and the inflammatory 
 symptoms are severe, warm poultices wiU relieve the 
 disagreeable sensations of the patient and reduce the 
 inflammation. In some cases cold starch poultices wiU 
 be better borne. Devergie (387) recommends steam- 
 ing the inflamed parts every second day, and covering 
 the affected parts constantly with cold or almost cold 
 thin flaxseed poultices. Even in the early stage, if the 
 inflammatory symf)toms are not very intense, a mild 
 white precipitate ointment wiU sometimes check the
 
 Sycosis. i93 
 
 disease. Duhrixg (10) recommends bathing the face 
 with " black wash " followed by zinc oxide ointment 
 with a drachm of alcohol or half a drachm of camphor 
 to the ounce, spread on cloths and bound on ; and 
 speaks well of the oxide of zinc ointment with fifteen 
 to thirty grains of calomel to the ounce. Tumenol oil 
 has yielded surprising results in some cases. The chief 
 objection to it is its color. It may be used pure or 
 diluted with vaseline or other oil. When the disease 
 has reached the pustular stage, and there is more or 
 less crusting, the crusts are to be removed by the free 
 use of olive oil, or oil of sweet almonds, letting it soak 
 in thoroughly over night and washing the part with 
 soap and warm water the next morning. If the 
 crusts are thick, it is a good plan to tie up the bearded 
 face in a towel after anointing it with oil. A poultice 
 may be used for the purpose of removing the crusts. 
 After the crusts are gotten rid of, puU the hairs out of 
 the pustules, and insist upon the patient shaving him- 
 self every second day. At first he may rebel against 
 the use of the razor, but if plenty of warm water and 
 soap is used, and a good lather formed, the shaving 
 wiU not be very painful, and it is only the first shave 
 that is painful. Epilation of the hair from all the pus 
 tules and papules is to be continued until they cease to 
 form. Shaving is to be continued until some months 
 after the skin is apparently well. It is ])ossible to cure 
 a case without shaving, but the cure will be more diffi- 
 cult to effect. The patient must be made to under 
 stand that epilation is necessary, both for the cure of 
 the affection and the salvation of the hair. After epi- 
 latingjthe oxide of zinc ointment, Lassar's paste, or 
 diachylon ointment is to be used. Sulphur in the form 
 of an ointment, half a drachm to a drachm to the ounce, 
 or in powder, will sometimes do good, but often will 
 prove too irritating. Tilbury Fox (390) recommends 
 the use of the following ointment after shaving:
 
 TJi DISEASES OF THK HAIR AND SCALP. 
 
 Zinc oxide, 
 
 Zinc carbonate aa . . . 3 j — 4. 
 Hose ointment ad . . . 3] — 32. 
 M. 
 
 Instead of an ointment we may use oxide of zinc one 
 drachtn to the ounce of linseed or other oil. Shoe- 
 maker (i02) advises the api>lication of equal parts of 
 oleate of mercury and olive oil. 
 
 In sub-acate and chronic cases a more active treat- 
 ment is necessary. Here our aim is not so much to 
 allay inflammation as to stimulate the skin. To this 
 end we may use the soap and salve treatment of Hebra, 
 which renders such good service in chronic cases of ec- 
 zema. It consists of frictions with green soap, soft 
 soap, or better the tincture of green soap, composed of 
 two parts of the soap and one part of alcohol, followed 
 by a soothing ointment, such as the oxide of zinc oint- 
 ment. Some of the soap is poured or placed upon a 
 piece of flannel, this dipped in hot water, and then 
 rubbed actively upon the part to remove all the tops 
 of the pustules or papules, and leave the surface a lit- 
 tle raw. Then the soap is aU washed off, and the part 
 covered with the ointment spread thickly upon old 
 linen or cheese-cloth. The dressing is firmly bomid 
 down with a roUer bandage. The ointment is to be 
 changed two or three times a day, but the soap is to 
 be used but once a day or every other day. In some 
 cases better results wiU be attained by the use of di- 
 achylon ointment, or Lassar's paste, with ten or fif- 
 teen grains of salicylic acid to tJie ounce. In very ob- 
 stinate cases where there is much thickening of the 
 skin, the soap may be kept applied to the part like an 
 ointment. When sufficient inflammatory reaction is 
 produced, emollient measures, as in the acute stage, 
 should be used. The use of a strong tincture of tar 
 after Pick's formula of forty parts of tar and twenty
 
 SYCOSIS. 195 
 
 parts of alcohol sometimes answers well. In some 
 cases where there is a good deal of pustulation and 
 the patient is shaven, it is a good plan to curette the 
 patches, tearing off the tops of the pustules and letting 
 out the pus. This procedure is to he followed by the 
 application of Lassar's paste with salicylic acid. 
 
 Our success in treating these cases, will vary with 
 the thoroughness with which the dressings are applied. 
 All ointments must be spread on cloths, not on the skin, 
 and the dressings must be kept continuously in close 
 contact with the affected part. Sometimes a sulphur 
 ointment, one half a drachm to two drachms to the 
 ounce; an ointment of iodide of sulphur; the ointment 
 of the ammoniate (gr. xv-xxx. ad 3 j), or the red 
 oxide (gr. v-xv. ad 3 j) of mercury will prove useful. 
 Robinson (33) recommends the following ointment: 
 
 Ungt. diachyli (Hebra) 
 
 Ungt. zinci oxidi, . . aa 3 iss — 50. 
 
 Ungt. hydrarg. ammon. . 3 iij — 10. 
 
 Bismuth subnitrat. . . 3 iss — 5. 
 
 M. 
 
 He has found cod-hver oil the best local application 
 in strumous subjects. Veiel (10)" advises painting the 
 affected parts twice a day with a two per cent, solu- 
 tion of pyrogallol in alcohol, and applying during the 
 night: 
 
 Sulphur, lact. . . . 
 
 Alcohol, 
 
 Aquee rosae aa 30. 
 
 Mucilag. gum acacise, . . tti xx-xxxx. 
 
 M. 
 
 Hans von Hebra's (394) plan of treatment is to epilate 
 and shave, and then with a stiff brush to rub in once 
 or twice a day some of the following ointment : 
 
 * Ziemssen's Handbuch des Speciellen Path. u. Therap. p. 235.
 
 19(3 DISEASES OF THE HAIR AND SCALP. 
 
 01. fagi, 
 
 Flor. sulpli., aa 10. 
 
 Pulv. cretse alb., . . . . 5. 
 
 Adeps, 
 
 Sapo. viridis., . . . . aa 20. 
 M. 
 and cover with flannel. Devergie (387) recommends 
 painting the part every fourth or fifth day with a so- 
 lution of nitrate of silver, one part, in five of water by 
 weight. 
 
 Behrend (12) has obtained good results by scraping 
 the affected parts with the dermal curette, and dressing 
 with a simple ointment or oil. All abscesses must be 
 opened. Brooke (205 ap.) recommends the applica- 
 tion, after epilation, of an ointment of 
 
 ^ Hydrarg. oleat. (2 J per cent), . "f, i. 
 
 Ichthyol. s. amnion., . . . tt[ xx. 
 
 Ac. salicyL, . . . . . gr. x. 
 
 01. lavandulae, .... gtt.ij. 
 M. 
 
 which is to be kept applied on strijjs of linen, or mixed 
 with enough zinc oxide and Armenian bole to make a 
 skin-colored paste, and smeared on. 
 
 Our rule of treatment then is in acute cases to aUay 
 inflammation by emollient dressings; in chronic cases 
 to stimulate. In all cases to epilate, at least from pus- 
 tules, and where possible to have the patient shave. 
 The dry and reddened skin sometimes left after the 
 disease has run its course is to be treated with hot 
 water sopped on for five minutes once or twice a day, 
 and some simple ointment to protect the skin from 
 dust and exposure to the weather. 
 
 Sycosis affecting other locations than the beard is 
 to be treated by epilation and emollient ointments. 
 When the hairs within the nose are affected Harda-
 
 FOLLICULITIS DEC A L VANS. 197 
 
 WAY (299 ap.) Jias found the best plan of treatment to 
 be to foment the parts several times a day, to apply 
 glycerin both to the inside and outside of the nose, 
 and to pluck the hair from the follicles. When pain 
 and tension have subsided he uses the following: 
 5 Squire's glycerol, plumb, sub- 
 
 acetat., 3 ss. 2. 
 
 Glycerin., 3iss. 6. 
 
 Ungt. aqua3 rosae, . . . 1 i. 32. 
 
 Cera3 albee, . . . . q. s. 
 M. 
 
 Prognosis. — This is one of the most obstinate of dis- 
 eases, specially in such cases as are due to occupation. 
 Left to itself, when once under headway, it sliows no 
 tendency to get well, and has been known to last 
 twenty or thirty years. Even under the most judi- 
 cious treatment it is an obstinate disease, taking weeks 
 or months before a cure is effected. Eelapses are ex- 
 ceedingly liable to occur, and these sometimes show a 
 disposition to recur at certain seasons. Unless the hair 
 is carefully withdrawn from the inflamed follicles per- 
 manent baldness may be caused. But the disease is 
 not dangerous to life, and it is curable. 
 
 FOLLICULITIS DECALVANS. 
 
 Within the past few years there has been described 
 by French writers a group of diseases of hairy parts 
 that is characterized by, 1, a follicular and perifolli- 
 cular inflammatory process ; 2, a complete destruction 
 of the hair-papillae, causing absolute baldness ; 3, the 
 f rmation of apparently cicatricial tissue ; and 4, a 
 tendency of the lesions to agminate or group. This 
 group of diseases has been named by Brocq ' ' follicu- 
 litis et perifolliculitis decalvans."
 
 198 DISEASES OF THE HAIR AND SCALP. 
 
 The disease has been described under many names 
 apphed by different observers to different phases or 
 locations of the malady. It has been called " lupoid 
 sycosis" by Milton; '^alopecie cicatricielle innomi- 
 nee " and ''acne pilaire cicatricielle depilante" by Bes- 
 nier; ''foUiculite epilante" by Quinquaud; "Acne 
 decalvante" by Lailler and Eobert; ''Ulerythema 
 sycosiforme " by Unna ; sycosis chronique. Brocq 
 would also include under it Kaposi's " dermatitis papil- 
 laris capillitii." 
 
 The disease may show itself either as a sycotic affec- 
 tion of the beard, pubic and axillary hairs, passing 
 over at times to the scalp; or as a bald area upon the 
 scalp, which, upon more careful examination, will be 
 found to be due to a follicular and perifollicular in- 
 flammation of the hair-follicles. 
 
 Folliculitis decalvans of the bearded portion of the 
 face has its seat of predilection upon the cheeks, from 
 whence it may invade the temporal region of the 
 scalp. It begins as a redness of the skin, which is soon 
 followed by the appearance of little vesico pustules 
 at the mouths of the hair folHcles, foi*ming isolated 
 islets of disease. The patches soon become crusted 
 and appear eczematous. When the acute process 
 subsides the pustulation ceases, and the surface of 
 the patches becomes red and scaly. It will then be 
 noted that the skin is cicatricial and the hair is perma- 
 nently destroyed. There may be but one patch or a 
 number of them. The patches may be symmetrical 
 or non- symmetrical. They tend to spread slowly, 
 serpiginously, and peripherally. The disease is ex- 
 ceedingly chronic in its course, and after it has lasted 
 a number of years, unless it has been of very limited 
 extent, the bearded portion of the face, and perhaps 
 the temporal regions of the scalp, wiU be found sown 
 over with cicatricial spots which may be depressed, 
 bridled, or keloidal
 
 FOLLICULITIS DECALVANS. 199 
 
 Folliculitis decalvaiis of the scalp alone simulates 
 alopecia areata so closely as often to be mistaken for 
 that disease. Usually the first thing noted is the 
 appearance of one or more bald spots, and, attention 
 being thus attracted to the scalp, further search will 
 reveal evidences of folliculitis. It assumes one of two 
 forms: 1. The alojjecle innomineeot Besniev, in which 
 we find on the scalp irregular, ill-defined bald patches 
 bounded by bouquets of sound hairs, or by tufts of 
 hair which has partially fallen out, or by neighboring 
 bald patches. The scalp appears cicatricial, thinned, 
 slightly depressed, smooth or stippled over with the 
 follicular mouth-openings, and with or without pig- 
 mentation. There may be no evidences of dermatitis 
 or traces of it about the follicular orifices. Often there 
 is a slight, diffused, ill-defined redness with furfura- 
 ceous desquamation ; or some very small and super- 
 ficial pustules occupying the inf undibula of the hair, 
 which in a short time are transformed into depressions 
 in the epidermis, out of which the hair deprived of its 
 sheaths falls or is readily plucked. As soon as the hair 
 falls the inflammation subsides, but the hair has been 
 permanently destroyed. The disease spreads in a very 
 erratic manner, and there frequently are many isolated 
 spots scattered over the scalp. 
 
 2. This is the folliciilite epilante of Quinquaud. 
 While usually affecting the scalp, it may affect the 
 beard, pubes, and axillcB. It resembles the first variety 
 in producing bald, smooth, irregular- shaped cicatricial 
 patches, but is preceded or attended by a more marked 
 folliculitis. The patches are disseminated; about the 
 size of a silver quarter of a dollar or a franc piece; pale, 
 with a few red points in them, while about their peri- 
 pheries and in the hair of neighboring parts are various 
 evidences of folliculitis, such as purulent points, punc- 
 tiform miliary abscesses, with hair in their centres. 
 When these hairs fall or are plucked they leave a redj
 
 200 DISEASES OF THE HAIR AND SCALP. 
 
 scarcely moist point. Instead of pustules there may 
 beonlypunctiform redness, with or vdthout secondary 
 desquamation, or red follicular papules. The succes- 
 sive loss of a number of hairs produces bald patches 
 of large size, which are separated from each other by 
 tufts of sound hair. There is never any appearance 
 simulating that of eczema. 
 
 Etiology axd Pathology. — We do not know any- 
 thing positive about the cause of the disease. Quix- 
 QUAUD describes a micrococcus as the cause of his 
 folliculite epilante, which occurs as a monococcus, 
 diplococcus, and in series of four in the follicles, the 
 blood, and in the inflamed skin. The fluid from the 
 cultivation, when rubbed into animals and man, pro- 
 duced a disease apparently identical with the parent 
 disease. In all forms of folliculitis decalvans there is 
 atrophy of the hair-follicles and sebaceous glands. It 
 has been surmised that some of the cases are due to 
 syphilis. 
 
 Diagnosis. — Folliculitis decalvans affecting the 
 bearded portion of the face differs from sycosis chiefly 
 in causing cicatricial destruction of the skin and per- 
 manent loss of hair. Moreover, its pustules are 
 more superficial and its surface is never so crusted. 
 It occurs in patches, and not so disseminated through 
 the hair, and affects primarily the skin between the 
 hairs rather than the hair-follicles themselves. Fol- 
 liculitis decalvans affecting the scalp produces bald 
 spots that are to be distinguished from those of alo- 
 pecia areata by the presence of inflammatory symp- 
 toms. Without a well-marked history of the occurrence 
 of favic crusts it would be impossible to distinguish 
 alopecia from old f avus from an alopecia of this disease 
 in quiescence. 
 
 Treatment thus far has been inadequate to the cure 
 of the disease. The scalp should be kept clean and 
 some mild antiseptic lotion or ointment used.
 
 FOLLICULITIS DECALVANS. 201 
 
 The Prognosis is bad. The course of the disease is 
 slow, and permanent baldness follows. After a time 
 the disease may reach a quiescent stage.
 
 PART III. 
 
 PARASITIC DISEASES OF THE HAIR. 
 
 Trichophytosis. — Favus. — Pediculosis. —Beigel's 
 Disease. — Trichomycosis Nodosa.
 
 CHAPTEE XII. 
 
 TRICHOPHYTOSIS CAPITIS. 
 
 Synonyms. — Herpes tonsurans; Herpes circinatus; 
 Herpes squamosus (Cazenave); Tinea tonsurans; 
 Tinea tondens (Malion); Trichonosis furfuracea (De- 
 vergie); Porrigo furfurans (Devergie); Porrigo tonsoria 
 (Alibert); Trichosis tonsurans (Wilson); Trichosis 
 pityriasica seu furfuracea (Wilson) ; Trichoniykosis 
 (Gruby); Dermatomykosis trichophytina; Phytoalope- 
 cia seu Trichomyces tonsurans (Malmsten); Ehizo- 
 phyto-alopecia (Gruby); Dermatomykosis tonsurans 
 (Kobner); Squarus tondens (Mahon); French, Herpes 
 tonsurante, Teigne tondante (Mahon); Teigne tonsu- 
 rante, Teigne annulaire (Payer) ; Teigne herpetique f ur^ 
 furacee (Gibert); Trichophytie tonsurante (Hardy); 
 Trichophytie (Gruby); Porrigine tonsurantie (Alibert); 
 Dartre furfuracee arrondie (Alibert); L'herpes circine 
 parasitaire; German, Scherende Flechte; English, 
 Eingworm of the scalp; Slew. Eingskurv. 
 
 Definition.— A contagious parasitic disease of the 
 hairy scalp, due to its invasion by the Trichophyton 
 fungus; and characterized by the formation of partially 
 bald, scaly, more or less circular patches, in which 
 ''stumps" of broken- off hair will be found. It is a 
 disease peculiar to children and runs a chronic course. 
 
 Symptoms. — Eingworm of the hairy scalp begins, like 
 ringworm of the body, by the formation of a small, 
 round erythematous spot upon which ephemeral vesi- 
 cles and pustules soon form, which rapidly go on to 
 desquamation. Or the spot may become covered with 
 furfuraceous scales without the appearance of vesicles
 
 son 
 
 DISEASES OF THE HAIR AND SCALP. 
 
 or pustules. This stage is so rapid in its course, and 
 gives SO little ainioyance to the patient, that it is sel- 
 dom brought to the notice of the physician. The patch 
 spreads, the hairs become early affected, and then we 
 have the typical patch of the disease before us. This 
 is circular in shape; denuded of hair, though not com- 
 pletely l)ald; covered with a greater or lesser amount of 
 scales; and more or less raised above the surface of 
 
 Ringworm. 
 
 the scalp. There may be only one patch upon the 
 head, or there may be a number of them. The size of 
 the individual patch may be quite small or it may be 
 as large as a silver dollar. If several patches occur 
 close to each other, they may coalesce and form a huge 
 patch, which may involve the whole top of the head. 
 The color of the patch varies somewhat; it may be 
 reddish, gray, slate, greenish, bluish or even blackish. 
 The color depends upon the amount of scaling present,
 
 TRICHOPHYTOSIS CAPITIS. 207 
 
 upon the complexion of the individual, upon the ex- 
 tent to which the inflammatory process has gone, and 
 upon the admixture of dirt or foreign matter. If the 
 inflammation is but shght, and the complexion is 
 medimii, the patch will be grayish or reddish. In 
 dark-skinned subjects the color is apt to be slate. If 
 in a strumous subject, and pustulation has taken place, 
 we wiU meet with greenish or blackish patches. A. 
 R. Robinson (33) draws attention to the fact that some- 
 times the central part of a patch may be gray or slate 
 color, and the periphery yellowish or blackish brown 
 from the drying up of the vesicles at the margin. 
 Probably '^slaty-gray" wifl best describe the color of 
 the majority of the patches. 
 
 The amount of scaling is rarely excessive, and, 
 though at times abundant, never reaches to the for- 
 mation of thick mortar-like crusts such as we meet with 
 in favus. In a case complicated with eczema, arising 
 either spontaneously or from over treatment, thick pur- 
 ulent crusts may form, but, of course, quite independ- 
 ently of the ringworm. Upon the removal of the scales, 
 the exposed scalp will be found reddened, swollen, 
 and, it may be, oedematous and tender. In chronic 
 cases the scalp will be merely reddened and scaly, and 
 sometimes of goose-flesh appearance. 
 
 The condition of the hairs is characteristic. They 
 are affected very early in the course of the disease, be- 
 coming dry, lustreless, opaque, brittle, twisted, and 
 readily breaking off upon the slightest traction, or of 
 their own accord. They lose their elasticity, as shown 
 by taking a hair and pressing it with the nail, when it 
 will readily bend at an angle which it will retain. If 
 a healthy hair is subjected to the same treatment it 
 will soon regain its usual form. Another proof of the 
 loss of elasticity, is that when the hair is combed the 
 wrong way upon the head, while the healthy haiis will
 
 20S DISEASES OF THE HAIR AXD SCALP. 
 
 immediately fall iiito their former position, the affected 
 ones will stand up for a moment, and then slowly fall. 
 The hairs breaking off leave their roots and a small 
 portion of their shafts, it may be only one or two hnes 
 in length, in the seal}). These are known as ' 'stumps, ' ' 
 and are pathognomonic of the disease. A stump, then, 
 is the broken-off shaft and root of a ringworm hair, a 
 few lines in length, with a ragged, nibbled-off -looking 
 end, which is spht and frayed out, and laden with 
 spores. It may present itself as only a minute dark- 
 colored dot on the scalp. They are met with in this 
 disease alone, and must not be confounded with the 
 ends of cut or accidentally broken-off healthy hairs, 
 which are not spht or ragged, and do not contain spores. 
 The amount of hair present in a patch of ringworm 
 varies. Sometimes there will be quite a number of 
 long though diseased hairs; sometimes there will be 
 only stumps; and sometimes both are present, the 
 stumps being superabundant. In a typical patch there 
 will be mostly stumps, which give to it the appearance 
 of having had the hair cut off clumsily with a dull 
 pair of scissors. In some cases, as the result of treat- 
 ment, or when the disease has taken an exceptional 
 course, the hairs will entu^ely fall out, and thus there 
 will be formed a completely bald spot. 
 
 Ringworm affects by preference the vertex and the 
 parietal regions, though it may occm* anywhere upon 
 the head, and at times may pass over upon the skin of 
 the face or neck. The only subjective symptom w^hich 
 it presents is itching, which is often the first thing 
 noticed, and leads to investigation of the scalp. It is 
 usually slight. The disease, though chronic in its 
 course, and obstinate to treatment, is yet self-hmited, 
 and does not of itself cause baldness. 
 
 Besides this typical form of trichophytosis capitis, 
 the one which we meet ^\ith in the vast majority
 
 TRICHOPHYTOSIS CAPITIS. 209 
 
 of cases, there are several other forms or varieties. 
 These are pustular ringworm, disseminated ringworm, 
 and kerion. The last differs very much from the other 
 varieties, and is not always due to the trichophyton 
 fungus; therefore it will be reserved for special treat- 
 ment. 
 
 The pushilar form of ringworm occurs chiefly in ill- 
 nourished or scrofulous children. Instead of a scurfy 
 place forming, we have pustules produced, and green- 
 ish crusts. Sometimes this form may be caused by 
 treatment, too strong remedies being used, or remedies 
 being improperly applied, and it is especially prone to 
 occur in eczematous subjects. It is indeed an impeti- 
 ginous eczema, complicating a ringworm of the scalp, 
 and may involve a large portion of the scalp. The pro- 
 cess is superficial, and if the crusts are removed, under 
 them will be found the characteristic stumps. Alder 
 Smith (79) regards this form as especially liable to spread 
 amongst schools. It is not the same disease as is the 
 deep inflammatory process called kerion. Sometimes 
 we meet with a chronic pustular ringworm, which 
 presents pustules pierced by hairs. 
 
 Disseminated ringivorm is that form in which, in- 
 stead of a single patch or a number of patches occur- 
 ring on the scalp, the disease involves more or less of 
 the whole scalp, not in the form of patches, but diffused 
 throughout the hair. The hair may seem to be growing 
 weU, but when the scalp is inspected, we will find it 
 scurfy, as in eczema or pityriasis; most of the hair will 
 be of normal length and appearance, but here and there 
 wiU be found a number of stumps, either isolated or in 
 groups, or there may be only black dots on the surface, 
 the roots of broken-off stumps. The long hair may 
 be firmly fixed or may come out easily. This form is 
 seen most frequently in chronic cases ; and is often over- 
 looked. It will sometimes last in this sluggish condi-
 
 210 DISEASES OF THE HAIR AXD SCALP. 
 
 tion for years after the well-defined patches have dis- 
 appeared, and tlie case is considered by the physician 
 and the friends as cured. 
 
 Chronic squamous ringworm is that form in which 
 we meet ^^^th a patch or patches of the disease which do 
 ' not spread, and which are pai-tiaUy covered with appar- 
 ently healthy hair. The patch is stiU scurfy, and the 
 hair may look a little dry, as it is commonly met Tvath 
 in seborrhoea, but that may be all wiiich arouses our 
 suspicions. Upon careful examination stumps will be 
 found close to the scalp, hidden by the long hair. 
 
 The incubation period of ringworm has been shown 
 by experiment to be about three days. Its rate of 
 growth is rapid, a spot as large as a ten- cent piece may 
 develop in forty-eight houi^s, and attain the size of a 
 fifty-cent piece in twenty-four hours more. When it 
 has reached the size of a silver dollar, it, in most cases, 
 ceases to enlarge. The hfe of the fungus is also lim- 
 ited. Though the disease may have lasted many years 
 in a cliild, it tends to get well as the child reaches the 
 age of puberty. 
 
 The scalp is not the only hairy region affected by 
 the trichoph\i:on fungus. The beard is its frequent 
 habitat. It may also occur upon the pubes and in the 
 axiUa, and give rise to appearances somewhat similar 
 to those met ^vith in ringworm of the beard. 
 
 Etiology. — Trichophytosis capitis is due to a single 
 cause, the implantation and growth of the trichophy- 
 ton fungus. This view is one now accepted by aU 
 dermatologists, though up to quite recent years, there 
 were some eminent ones who beheved it to be a disease 
 of nutritive debihty . Thus Wilson (33) taught ' ' that it 
 was essentially an aiTest of development of the hair- 
 cells and the cells of the rete mucosum. That the cells 
 retained their primitive molecular character, and the 
 gi-anules taking on a proliferous growth are converted
 
 TRICHOPHYTOSIS CAPITIS. 211 
 
 into a tissue closely resembling a mucedinous vegeta- 
 tion." 
 
 The fungus gains lodgment in the upper layers 
 of the epidermis, after the most superficial layers 
 are removed in some v^ay, and from its point of 
 entrance, spreads. Liveing (452) thinks that the fun- 
 gus is not the essence of the disease, but plays a sec- 
 ondary, though important part, in its development. 
 His reasons are the following: First. — The food of 
 this kind of vegetable parasite is dead or dying struc- 
 tures. Secondly. — The development of the fungus is 
 not always in proportion to the changes present in the 
 skin and hair, showing that other causes are at w^ork. 
 Thirdly. — In many cases the comparatively healthy 
 hair of the whole scalp loses its lustre and becomes 
 harsh, dry, brittle and more opaque than in health, 
 without the growth of the fungus beyond the ring- 
 worm patches, and this condition may persist for 
 months after the parasitic growth has disappeared. 
 Fourthly. — If the fungus were the essence of the dis- 
 ease we should expect the malady to be less capricious 
 in its nature. 
 
 The disease is very contagious, much more so than 
 is favus. It is nearly always endemic and sometimes 
 epidemic. When it gains entrance into a school or 
 children's hospital or asylum, it spreads with great 
 rapidity, and such institutions are the most important 
 agents in keeping it alive. Bergeron (45) has shown 
 that in France it is more common in cities than in the 
 country. It attacks children almost exclusively. It 
 is rare to meet with it after puberty, excessively rare 
 to see it on the head of an adult, and very infrequent 
 in infants. This shows that it requires, like other 
 parasites, some peculiar condition of the soil for its 
 growth, though what that condition may be is not yet 
 determined. It attacks all classes of children, the rich
 
 212 DISEASES OF THE HAIR AND SCALP. 
 
 and the poor, the clean and the uncared for. It occurs 
 often amongst strumous children, and those who are 
 badly nomished; but as these cliildi-en are found most 
 frequently in those classes which hve under other con- 
 ditions favorable to infection, it is difficult to determine 
 the exact predisposing force of the diathesis. When 
 the disease gains entrance into asylums and schools it 
 shows no disposition to spare the healthy and robust 
 children. Tilbury Fox (12) taught that cliildren of 
 lymphatic temperament w^ere j^rone to the disease. 
 
 The means of infection are mediate and intermedi- 
 ate. Thus^ it is readily conveyed directly from the 
 body or head of one infected pei-son to the head of 
 another, or from the body of a cluld to its own head, 
 ringworms sometimes passing over from the non-hairy 
 to the hairy parts. It may also be communicated 
 from animals, the disease being common in cats and 
 dogs, and it is met with in cows, horses, rabbits, squir- 
 rels and other domestic or pet animals. In epidemics 
 of ringworm in children's hospitals, the au' of the 
 room has been found loaded T\ith floating spores. The 
 most common means of mediate contagion are hats, 
 caps, bi-ushes, and combs. 
 
 Pathology. — The disease is caused by the vegeta- 
 ble fungus called tricophyton tonsurans or acliorion 
 Lebertii. This consists of myceha and conidia, which 
 bear a close resemblance to those of the peniciUium 
 glaucum. It is, without doubt, a distinct species of 
 vegetable growi;h, resembhng (though not the same as) 
 the acliorion Schoenleinii, as inoculations made with 
 pure cultures produce ringworm alone. On the other 
 hand inoculations with pui'e cultui'es of the achorion 
 Schoenleinii give rise to favus alone. It is aerobic. 
 
 In the hair the conidia are far more numerous than 
 the myceha, and sometimes are present in such num-
 
 TRICHOPHYTOSIS CAPITIS. 
 
 213 
 
 bers as apparently to burst the hair, 
 often found arranged in 
 rows parallel with the 
 long axis of the hair. 
 Sometimes they are scat- 
 tered irregularly through 
 the hair; usually they 
 are so numerous about 
 the bulb and root as to 
 appeared crammed to- 
 gether. They are round, 
 highly refractive bodies, 
 of a grayish or pale green 
 color, and a diameter of 
 from .0021 mm. to .0035 
 mm. 
 
 The mycelia are often 
 absent from specimens 
 examined. When pre- 
 sent they run through the 
 hair in its long diameter, 
 and are long, jointed and 
 wavy. Their diameter 
 varies from .0018 mm. to 
 .0026 mm. 
 
 Bacteriologists, by their 
 more advanced methods 
 of staining and cultiva- 
 tion, are striving to ad- 
 vance our knowledge of 
 the micro-organisms of 
 the skin. Furthmann 
 and Neebe (329 ap.) be- 
 lieve that they have found 
 no less than four different 
 worm, resembling each other very 
 
 The conidia are 
 
 fi|iff|t 
 
 Trichophyton (Smith). 
 
 finigi as causes of 
 closely, 
 
 rmg- 
 and
 
 214 DISEASES OF THE HAIR AND SCALP. 
 
 distingiiislied one from the other mostly by their 
 cultures. It is probable that the fungus of ringworm, 
 like other fungi, varies in form and manner of growth 
 according to the physical and chemical properties of 
 the soil in which it grows, and that after all there is 
 but one micro-organism in ringworm. Quincke (:^48 
 ap.) has found that the fungus of ringworm has many 
 points of resemblance to his ^-fungus of favus, but 
 differed also in many respects. It grows slower on 
 gelatin, with greater tendency to grow downward; and 
 more rapidly on agar-agar. Under the microscope its 
 mycelia were simply rounded and not tapering, and 
 were straighter. It would not grow on potato. 
 
 In 1S02 Sabouraud (354 ap.) pubhshed what seems 
 to me to be one of the most important contributions 
 to our knowledge of ringworm. He beheves that the 
 fungus belongs to the botanical species of Botrytis, of 
 ^\'hich there are probably a number of distinct species 
 capable of causing trichophytosis in different animals. 
 In the human there are two principal varieties, viz.: 
 1. This has small spores and is found only on the 
 scalp. It is the constant cause of the disease on the 
 infant's scalp and of all the obstinate cases. Under 
 the microscoj^e it has a spore of 3 /< in diameter, with 
 no mycelia. The hairs are full of the spores, and they 
 escape from it to form a sheath about it. 2. The 
 other species has large spores. It may cause tricho- 
 phytosis capitis, and is found in thirty five per cent. 
 of the cases, and these are easy to cure. It is the 
 common cause of trichophytosis barbae, and, with 
 another special large-spore species, is the cause of 
 trichophytosis corporis, specially when that follows 
 upon the disease in the beard. It has a spore of 7-8 >u 
 diameter, T\ith visible myceha. 
 
 A case with one species of spores produces by con- 
 tagion a case with the same species, and no case pre-
 
 TRICHOPHYTOSIS CAPITIS. 215 
 
 sents both varieties at the same time. The patches 
 caused by the small spores are round or obloiig, and 
 usually not more than 5 cm. in diameter. At the be- 
 ginning they are raised and the scalp feels thickened 
 and infiltrated. The affected hairs are usually fine, 
 and they are almost constantly broken off at more than 
 3 mm. from the mouth of the follicle. The jjatches 
 caused by the large spores are more often large than 
 small, irregular in shape, Avitli tufts of healthy hair 
 that encroach on the circumference of the patch. It 
 looks almost completely bald because the diseased 
 hairs are cut off very short. The hairs are often of 
 large size and appear as black points at the follicular 
 orifices. Besides these common species Sabouraud 
 has found two more rare types. One of these has 
 large spores and occurs in trichophytosis corporis. It 
 differs from the other large spore species in its more 
 vigorous and rapid growth with a fluffy centre in 
 cultures. The other species presents large and un- 
 equally-sized spores. He also found in one cultivation 
 bliick, and in another rose-colored, spores that are 
 th jught to be forms found only in animals. 
 
 He found that he would have to make many at- 
 tempts before succeeding in inoculating some subjects, 
 and that the patient must have an alkaline reaction 
 to his sweat before success can be obtained. 
 
 The hair in ringworm of the scalp is early affected, 
 the first point attacked being, according to Taylor (4Sn> 
 that portion of the shaft immediately on a level with 
 the surface of the skin, from which point it spreads 
 up and down. The cortical substance in its peripheral 
 part is the most frequent and earliest seat of the fun- 
 gus; but the whole hair is frequently involved. Ac- 
 cording to most observers the bulb is invaded to only 
 a slight extent and the papilla and root-sheaths are 
 spared. A. R. Robinson (33) has met with the spores
 
 216 DISEASES OF THE HAIR AND SCALP. 
 
 and mycelia in the root-sheath and even in the perifol- 
 liculai' tissue. However, as a inile it may be stated 
 that the part of the hair most infected is above the 
 neck of the folhcle. It grows up to a long distance in 
 the shaft, but seldom if ever to the point of the hair. 
 When present in the hair, in small amount, the hair 
 preserves its cuticle entire, and looks scarcely altered. 
 When present to such an extent as to cause fracture 
 of the hair and the formation of stumps, the cuticle 
 will be broken, the whole stump wiU be disorganized, 
 and its end frayed out. Often the hair under the 
 microscope seems as if it had burst at many points 
 and allowed the spores to escape. In such a case the 
 spores will be found lying along the outside of the hair- 
 shaft, and grouped and scattered about the fractured 
 portion. In some cases some hairs in a patch will es- 
 cape for some time, but eventually all will become 
 involved. 
 
 The amount of irritation caused by the fungus wiU 
 vary with the amount of the fungus and its seat. 
 W^hen only a few spores are present, and these are 
 su])erficially seated, the scalp will be only shghtly red- 
 dened and scaly, or there may be some vesiculation. 
 When the spores are present in greater number, and 
 have penetrated into the hair-foUicles, they will cause 
 more redness of the scalp, a greater or less amount of 
 perifollicular inflammation, and tumefaction of the 
 scalp. The extreme degree of irritation is that met 
 with in kerion, as we shall learn in another place. 
 Behrend (3) well points out the difference between the 
 growth of the fungus in ringworm and favus, when 
 he says: ^' The achorion remains for a long time con- 
 fined to the superficial layers of the hair, growing 
 quite high up in the shaft, while the trichophyton 
 involves in a few days the whole thickness of the hair 
 and makes it brittle, so that it breaks upon the shght-
 
 TRICHOPHYTOSIS CAPITIS. 217 
 
 est traction. On this account the hairs of favus pre- 
 serve their normal hastre and consistence, while those 
 of ringworm very soon lose the same." 
 
 Diagnosis. — The diagnosis of atypical patch presents 
 no difficulty, as there is no other disease which occurs 
 in the form of round, partially bald, scaly patches, 
 with disorganized hairs and "stumps" growing in 
 them. But at times cases do occur which are not so 
 easily made out. Seborrhoea, psoriasis, favus. lupus 
 erythematosus, and eczema occur upon the scalp in 
 the form of scaly patches; alopecia areata causes cir- 
 cular bald patches; and the other forms of alopecia 
 denude the scalp of hair. From these, then, under 
 certain conditions, ringworm of the scalp must be 
 differentiated. 
 
 1. From seborrJicea sicca capitis. — Seborrhoea may 
 appear at any time of life. Ringworm is almost ex- 
 clusively confined to childhood. Seborrhoea has no 
 history of contagion, and is variable in its course, 
 getting better and worse of itself. In ringworm it is 
 generally easy to trace the case back to its source of 
 contagion, and the disease once started is progressive, 
 showing little tendency to get well of itself until pu- 
 berty is reached, when it generally disappears com- 
 pletely, never to return. Seborrhoea involves the scalp 
 pretty generally and uniformly; if it form patches 
 they are irregular and not sharply defined. Ringworm 
 usually occurs in one or more isolated sharply defined 
 patches, affecting by preference the vertex. The scales 
 of seborrhoea are prone to heap up into thick masses, 
 and are tenacious and greasy to the feel. In ring- 
 worm they are seldom heaped up, are readily detached, 
 and are not so greasy. Seborrhoea may cause bald- 
 ness, this condition being usually preceded by a progres- 
 ■sive thinning of the hair-calibre over a series of years, 
 and affecting the top of the head. With the increase
 
 218 DISEASES OF THE HAIR AND SCALP. 
 
 of the baldness there will be a decrease of the sebor- 
 rhoea, and the baldness \\ill be complete and permanent. 
 In seborrhoea there is a complete absence of the 
 tichoph}i:on fimgiis, and ''stumps." 
 
 2. From j^soriasis. — Psoriasis occui^s in the form of 
 thick, crusted patches scattered more or less over the 
 whole scalp, and tending to form a row of characteristic 
 lesions along the margin of the hair upon the forehead. 
 Ringworm is more apt to be confined to the vertex, its 
 patches are scaly, and if it encroaches upon the non- 
 hairy paris, it vriM form a characteristic patch of ring- 
 worm of the body. Psoriasis does not affect the hair; 
 ringworm causes partial alopecia In psoriasis there 
 will be a history of relapses in many cases; this is 
 entirely absent in ringworm. In psoriasis there is no 
 histoiy of contagion; in ringworm there is such a 
 history in the majority of cases. Psoriasis rarely if 
 ever occurs on the scalp alone, and therefore charac- 
 teristic patches of the disease wiU be found upon the 
 arms or elsewhere; ringworm is quite commonly con- 
 fined to the scalp. 
 
 3. From favus. — Favus is an impoi-ted disease in 
 this country in the vast majority of cases, and hence 
 is seen mostly in foreigners; ringworm is endemic 
 and often epidemic. Favus presents either the path- 
 ognomonic cupped cimsts, or else thick masses of mor- 
 tar or asbestos-hke, grayish, friable crusts; ringworm 
 has no cupped ciTists, and the scaling is but slight. 
 Favus causes distinct, irregular, perfectly smooth, 
 atrophic-looking, red, bald patches, scattered over the 
 whole scalp; ringworm causes only partially bald, 
 shghtly scaly, circular, grayish patches, confined most 
 often to the vertex or side of the head, and the scalp 
 is not atrophic. In favus .the hair is affected second- 
 arily, and readily pulls out ientire with its root; in 
 ringworm the hair is early affected, and when pulled
 
 TRICHOPHYTOSIS CAPITIS. 210 
 
 on it breaks easily and leaves its root behind in the 
 scalp, forming the '^ stump." Favus is a very chronic 
 disease, shows little tendency to get well of itself, and 
 often lasts until late in life; ringworm is not so chronic, 
 is most often seen in children, tends to get well of it- 
 self as its subject reaches puberty, and is rarely met 
 with in adults. Under the microscope the mycelia 
 and conidia of favus scales are seen to be slightly larger 
 than those of ringworm. Its conidia are more mani- 
 fold in shape, being ovoid, often elongated, and some- 
 times dumb-bell shaped, while the conidia of ringworm 
 are uniformly round. In favus the hairs are mostly 
 invaded by mycelia which may be seen as long fila- 
 ments in the hair; in ringworm the conidia are found 
 in superabundance, often exclusively, and so numerous 
 at times as to burst the hair. It must, however, be 
 said that it is very difficult for any but the most 
 expert microscopist to always distinguish between the 
 fungi of the two diseases, as they at times resemble 
 each other very closely. Cultivation of the fungus is 
 the only sure method of diagnosis. 
 
 4. From lupus erythematosus. — The only resemblance 
 it has to ringworm is the formation of a scaly bald 
 patch; but there is no history of contagion, the course 
 of the disease is slower, the hair is affected secondarily, 
 the patch has a cicatricial depression in the centre, and 
 is of irregular outline. There is no fungus to be found. 
 
 5. From eczema. — Squamous eczema is the form 
 which is most apt to be confounded with ringworm. 
 At times a pustular eczema may complicate a case of 
 ringworm, or a case of disseminated ringworm may 
 simulate a pustular eczema. 
 
 Squajnous eczema. — Squamous eczema has no his- 
 tory of contagion; in ringworm the history of contagion 
 can generally be made out. Squamous eczema attacks 
 all ages from infancy to old age; ringworm is usually
 
 220 DISEASES OF THE HAIR AND SCALP. 
 
 met with in childhood alone, sparing infants and not 
 lasting after puberty is reached. Squamous eczema 
 often is diffused over the whole scalp, and when it 
 does occur in patches they are not sharply defined; 
 ringworm occm's in more or less circular, sharply de 
 fined patches. Squamous eczema is very itchy and the 
 scalp shows scratch-marks; ringworm is but slightly 
 itchy and scratch-marks are not commonly found. The 
 scales of squamous eczema can be removed in plates 
 though they are thin; the scales of ringworm are more 
 powdery and bulky. The hau* in squamous eczema is 
 not affected, is firmly implanted in the scalp, and when 
 epilation is attempted, it is painful; in ringworm the hair 
 is early affected, dry, lustreless, and either comes out 
 readily and painlessly on slight traction, or breaks off. 
 In squamous eczema there are no " stumps; " in ring- 
 worm they are always present, and give the diagnosis, 
 even if eczema occurs as a comphcation of the ring- 
 worm. 
 
 PHsfulm^ eczema. — A pustular eczema will only 
 need to be differentiated from that rare form of dis- 
 seminated and pustular ringworm. Here the condi- 
 tion is one of ringworm plus eczema. The diagnosis 
 is made by the presence or absence of the characteristic 
 hairs and stumps of ringworm. In doubtful cases the 
 microscope will decide. 
 
 G. Ft'om alopecia areata. — In t}^ical examples of 
 this disease there should be no mistake in diagnosis. 
 The perfectly smooth, non-scaly, non-pruriginous, per- 
 fectly bald patch of alopecia areata is in strong contrast 
 to the rough, scaly, more or less itchy, partially bald 
 patch of ringworm in which are stumps and diseased 
 hairs. Alopecia areata comes on suddenly, often A\ath 
 antecedent symptoms of headache and pain in the scalp, 
 and the patch is formed at once. Eingworm comes on 
 with comparative slo%\Tiess, and Tvithout antecedent
 
 TRICHOPHYTOSIS CAPITIS. ^21 
 
 symptoms. Alopecia areata occm^s at a later period of 
 life than does ringworm, as a rule; and if a circular, 
 circumscribed bald spot occur in an adult, it is far more 
 likely to be one of alopecia areata than of ringworm. 
 Sometimes a patch of alopecia areata will present a 
 number of black dots, the unf alien roots of hair, which 
 may bear some resemblance to the stumps of ringworm, 
 but if they are examined under the microscope, the 
 root will appear shrunken and atrophied, and there 
 will be an entire absence of the spores and mycelia of 
 ringworm. Sometimes a patch of ringworm will be 
 perfectly smooth and without stumps. This is usually 
 the result of treatment. Stumps will be found else- 
 where on the scalp, or diseased hairs, if the disease be 
 ringworm, and the fungus will be fomid in the scales 
 from the border of the patch. 
 
 7. From other forms of alopecia. — The history and 
 course of other forms of baldness, as well as the time of 
 their appearance, are so different from wdiat ol)tains 
 in ringworm, as hardly to give rise to any difficulty. 
 
 The recognition of the presence of the fungus in the 
 hair by the aid of the microscope is easy after a Httle 
 practice. All that is needed is a microscope with a 
 lense magnifying some 25() diameters, a slide and cov- 
 eiing glass, and a drop of hquor potassae with or with- 
 out glycerine. After dropping the liq. potass, upon 
 the hair, (a stump is the best one to examine,) and put- 
 ting on the covering glass, wait a few minutes before 
 looking at the specimen. The mycelia will be recog- 
 nized as long, branched, jointed threads rumiing up the 
 hair-shaft, and the spores will be seen as small, round, 
 refracting bodies in rows or closely packed together. 
 Care must be exercised not to mistake air-bubbles for 
 spores. Air-bubbles are recognized by their change of 
 color upon changing the focus of the microscope. It 
 is also possible to mistake the striated condition of the
 
 222 DISEASES OF THE HAIR AXD SCALP. 
 
 hair for the mycelia, but a httle care and practice will 
 prevent this. 
 
 Dyce Duckworth (421) has pointed out a ready means 
 of determining the presence of fungus in hair, which 
 is by laying the suspected hair in chloroform, and al- 
 lowing the chloroform to evaporate. If fungus is pre- 
 sent the hair will become white or primrose yellow 
 where the fungus is. But this reaction is not pecu- 
 liar to ringworm, as it is also found in favus and 
 pityriasis versicolor. 
 
 The recognition of the disseminated form of ring- 
 worm is often a most difficult task, but it is most 
 important for the physician to recognize it, as one such 
 unsuspected case may be the cause of fresh epidemics. 
 To examine these cases the child should be placed with 
 its face to the light and its back to the physician 
 Then the hair is to be turned back on the head in the 
 opposite direction to its gi'OT\i:h. By carefully watching 
 the scalp, some stumps will be found here and there; 
 and Tilbury Fox has shoT\Ti that, if there are any 
 diseased hairs present, they will stand out from the 
 head after the normal hairs have fallen into their 
 places. 
 
 Treatment. — That nothing is easier to cure than a 
 recent case of ringworm of the body all will agree. 
 That a chronic case of ringworm of the scalp is very 
 difficult to cure all writers and observers attest. Our 
 treatment must vary with the stage of the disease. 
 External applications are far more valuable than in- 
 ternal medication; and indeed the former may be relied 
 on in the vast majority of cases for the cure of the 
 disease without recourse to the latter. 
 
 General Treatment. — If the patient is evidently 
 strumous or any way out of health, of course he 
 should be given the internal treatment best -fitted 
 to his case, such as cod-liver oil, iron, arsenic,
 
 TRICHOPHYTOSIS CAPITIS. ^23 
 
 etc. Attention to the patient's general surround- 
 ings is in most cases of more service than giving 
 medicines. An infected child should be isolated as 
 much as possible, and by all means kept out of school. 
 Isolation can and ought to be rigidly practiced in all 
 children's asylums, and the attending physician should 
 see to it that the infected children do not come in 
 contact with the healthy ones. In private families 
 isolation cannot be so readily accomplished, but much 
 may be done to prevent the disease spreading to other 
 children in the family by having the infected child 
 sleep by itself; by providing towels, brush and comb 
 for its special use; and letting it wear a close-fitting 
 linen cap. Other children should not wear the infected 
 one's clothing, for not only do caps carry the conta- 
 gion, but also the collars of jackets and coats. The 
 patient's head must be kept saturated \\ath an antipar- 
 asitic oil, lotion, or ointment during the whole course 
 of treatment, to kiU the loose spores and prevent them 
 from being earned to other heads. For this purpose 
 we may use either a two per cent, salicylated oil, that 
 is salicylic acid in castor oil; a saturated solution of 
 boracic acid; a two to five per cent, carbolized oil; a 
 solution of hyposulphite of soda, two drachms to the 
 ounce; or an ointment of sulphur, one drachm to the 
 ounce; or one of the ammoniate of mercury. Of course 
 this does not exhaust the list of useful applications, 
 but the ones mentioned are probably the best. My 
 own preference is for the salicylated oil, as it is odor- 
 less and efficient. 
 
 Local Treatment. — In the local treatment of the dis- 
 ease our chief reliance is upon the use of parasiticides, 
 to which in some cases epilation must be added. The 
 remedies that we caU parasiticides, such as mercury, 
 chrysarobin, pyrogallol, and the like, have been sup- 
 posed by some observers to do good, not by any speci-
 
 224 DISEASES OF THE HAIR AND SCALP. 
 
 fic action, but by tbe production of inflammation and 
 scaling. (We know that the fungus cannot live in the 
 presence of pus, and for that reason we employ, in 
 very chronic cases, croton oil to produce acute pustu- 
 lation. Here the good done is due to the inflamma- 
 tion produced by the remedy.) It is true that many 
 of them do have this action, but as ring-^vorm can be 
 cured by these remedies, without the production of 
 inflammation, and as no exfoliation of the epidermis 
 caused by them could account for the cure of tricho- 
 phytosis pilaris, we must hold that they do act by vir- 
 tue of their specific action upon the fungus. 
 
 The first step in the treatment of all cases is to have 
 the head well washed with soap and water, and all 
 crusts removed. After washing, the parasiticide is to 
 be applied at once,. miless epilation is practised. The 
 frequency with which shampooing of the scalp is to 
 be repeated will vary with the remedial apphcation 
 iised. As a rule it may be stated that the longer a 
 l^arasiticide ointment or oil is kept in contact A\dth the 
 scalp the better, and it is only to be washed off when 
 there is an accumulation of scales, or for pm^poses of 
 cleanliness. But, as we shall see, some plans of treat- 
 ment require daily washing of the scalp. 
 
 Ejyilat ion.— 'Epilation is mmecessary in recent cases, 
 but serviceable in chronic cases, and should always be 
 practised in the pustular form. It is by no means as 
 effectual in ringworm as in favus, because the hair is 
 so brittle that it breaks off when palled on and leaves 
 its spore-laden root in the scalp. Still, a certain num- 
 ber of the roots will be extracted, and this wiU have 
 two good effects, namely; 1. The removal of a cer- 
 tain amount of fungus from the scalp; and, 2. The 
 mouth of the follicle will be open so that the parasiti- 
 cide may gain more ready access to its deeper portion. 
 In pustular ringworm the hair comes away readily,
 
 I'RICHOPHYTOSIS CAPITIS. 225 
 
 and thus relief is afforded to the perifolUcuh'tis. Epila- 
 tion should be immediately followed by the application 
 of the parasiticide. 
 
 Treatment of recent cases. — If we are so fortunate 
 as to see the case in its early stage, when it is still 
 superficial, it will be easy to effect a speedy cure. It 
 is in such cases that many vaunted remedies have 
 made their reputations. One of the most reliable 
 parasiticides is the bichloride of mercury in alcohol, 
 gr. i — iii. ad 1 j ; or even stronger, if used by the physi- 
 cian, sopped on three or four times a day. Here as 
 elsewhere the best means of applying the solution is a 
 little absorbent cotton on a wooden toothpick, or any 
 small stick. Caution must be had to use a fresh swab 
 each time, otherwise a remnant from the previous 
 application will dry on the swab, and we soon wiU. 
 have a much stronger solution than we want. Levi- 
 SEUR (336 ap.) uses the bichloride in tincture of ben- 
 zoin, 1 in 300, rubbing it in with a tooth-brush, after 
 epilation. As soon as irritation subsides he applies a 
 ten-per-cent salicylic acid ointment. Epilation and 
 the bichloride are to be used once a week, and the 
 ointment daily, the strength of each to be slowly in- 
 creased to double that used at first. Kerley (335 ap.) 
 uses two grains of the bichloride dissolved in alcohol 
 and added to a half ounce each of kerosene and olive 
 oil, followed by vaseline or simple ointment, and re- 
 peated when irritation subsides. The scalp is to be 
 frequently washed with soap and water. More rapid 
 results were obtained by alternating a saturated tinc- 
 ture of iodine with the bichloride solution. These meth- 
 ods are also useful in the more chronic cases. Vari- 
 ous other remedies are useful, such as sulphurous acid 
 in full strength; sulphuret of potassium, 3 ss-j, water 
 3 j ; hyposulphite of soda 3 iij, water 3 j ; sulphite of 
 soda 3 j-ii, lard 3 i; salicylic acid, two to five per cent.
 
 226 DISEASES OF THE HAIR AND SCALP. 
 
 in castor oil; a saturated solution of boracic acid; car- 
 bolic acid, ten to twenty per cent, in glycerine, varying 
 with the age of the child; sulphur ointment; tinct. of 
 iodine, and others. "V^^ien the disease is still recent, 
 but the hairs have become invaded and a characteristic 
 patch has formed, the hair is to be cut from the patches 
 and a sHght area around them. In this stage any of 
 the just mentioned remedies may be used. It is in 
 such cases that chrysarobin (chrysophanic acid) effects 
 its most briUiant cures. Fayrer (-I^G) w^as the first, in 
 
 1874, to di^aw the attention of European physicians 
 to its use in the treatment of ringworm as occurring in 
 India, where it was used under the name of Goa pow- 
 der, araroba, or po'de Baliia. It was fii-st used in 
 the form of an ointment, and Da Silya Lbia (4 7-1) in 
 
 1875, reported excellent results from one composed of 
 Goa powder, 2(i gi^ains, acetic acid, 10 drops, ointment 
 of benzoin, one ounce. It has since then been used 
 successfully in the form of an ointment of five to 
 twenty per cent, strength. But this manner of apply- 
 ing the drug on the scalp is objectionable, as it is 
 exceedingly irritating, and frequently causes intense 
 oedema and cellulitis of the scalp and face. The best 
 method of using it is in the form of a ''pigment" 
 composed of 
 
 Chiysarobin, 
 
 , 
 
 10 parts, 
 
 Flexible coUodion, 
 
 , 
 
 90 " 
 
 Castor oil. 
 
 • 
 
 3 drops. 
 
 This is to be painted on the scalp with a stiff brush, 
 and renewed as often as the film loosens or scales off. 
 
 The oleates of mercury or copper in five to ten per 
 cent, strengths according to the age of the child are 
 often useful, especially the first. The ointments of 
 the ammoniate and red oxide of mercury are favorites
 
 TRICHOPHYTOSIS CAPITIS. 227 
 
 with many. Tineture of iodine will sometimes act 
 brilliantly in these cases, and the combination of equal 
 parts of iodine, carbolic acid, and chloral hydrate, as 
 recommended by Cutler (166 ap.), is excellent both in 
 this stage and in the more chronic ones. 
 
 Treatment of chronic cases. — The chronic cases are ex- 
 ceedingly hard to cure, and medical literature is rich in 
 methods of treatment. The first requisite to success is 
 patience both on the part of physician and patient. As 
 there frequently is need for changing from one method 
 of treatment to another before the case is cured, it has 
 seemed advisable to give below a number of plans 
 which have been found useful by competent observers. 
 Tilbury Fox (473 and 12) recommends epilation fol- 
 lowed by 
 
 01. cadini 3 iij. 
 
 Sulphur, 3 iij, 
 
 Lard . . . . ad Ij. 
 
 M. 
 He directs that the parasiticide be well rubbed in for 
 fifteen or twenty minutes every morning and night. 
 He also recommends the following ointments: 
 
 Sulphate of copper, 
 
 Ammoniate of mercury, aa gr.xx =• 1.50 
 
 Oil of cade. 
 
 Sulphur, . . aa 3iij = 12 
 
 Lard, . . . ad 33 = 30 
 
 M. 
 If this is too strong the strength is to be reduced by 
 adding more lard. Another ointment is: 
 
 Oil of cade. 
 Sulphur, 
 
 Tinct. iodine, . aa 3 iij = 12. 
 
 Carbolic acid, . . . gr.xl = 3. 
 Lard, . . . . 3J =30. 
 
 M.
 
 22 S DISEASES OF THE HAIR AND SCALP. 
 
 He aims at producing irritation almost to the point 
 of suppuration, and if the ahove ohitments do not ef- 
 fect this, he prescribes either: 
 
 Corrosive subhmate, gi\ iv-vi. = .25-. 565 
 
 Acetic acid, . 3 j — 4. 
 
 Lard, . ad. 3 j =30 
 
 M. 
 or: 
 
 Corrosive subhmate, gr. vj = .565 
 
 Tinct. of cantharides, 3 ss = 16. 
 
 Nitric acid, . . 3 j =4. 
 
 Distilled water, ad 3 vj = 200. 
 
 M. 
 
 When there are but a few small spots, he blistei-s 
 them, and continues the treatment mitil the growth 
 of diseased hairs is checked. For bhstering fluids he 
 uses acetic acid, or Costar's paste (iodine 3 iij, color- 
 less oil of tar ad 3 j), applied sparingly to small sur- 
 faces and blotted oif when they begin to smart. If 
 much irritation, pain and swelling follow their use, he 
 uses a poultice for one or two hours. Blistering may 
 be repeated every four to six days. Then epilation 
 and one of the above ointments, or the lotion is contin- 
 ued until the disease is cmed. During the treatment 
 the hair is kept either well greased, or soaked with 
 dilute sulphurous acid, and covered ^\'ith a silk cap. In 
 the wards of children's hospitals he directs that sul- 
 phur be burned to disinfect the air. 
 
 E. A. Browx (41 J:) treats his cases by rubbing the 
 patches with rectified oil of tar and covering them 
 with a layer, one eighth of an inch thick, of a paste 
 composed of tamiin, iodine, gum arable and a few 
 drops of oil. This is to be left on for three or four 
 days, then scraped off, and re-applied. 
 
 Sa3IL. Gee (434) gives the following directions for
 
 TRICHOPHYTOSIS CAPITIS. 229 
 
 treatment. 1. Cut the hair everywhere quite close, 
 and keep it cropped close. 2. Wash the scalp twice a 
 day with warm water and soap. 3. After drying inib 
 well into the scalp. 
 
 Sulphocyanide of potassium, ? ss = 15. 
 Glycerine, . . . ij =30. 
 
 Water, . . . , ad 3 vij = 200. 
 M. 
 
 4. Keep a piece of lint soaked in the same lotion on 
 the scalp day and night, covering it with oiled silk 
 and a calico cap. 
 
 Ladreit de Lacharriere (446) uses in chronic cases 
 croton oil followed by poultices, only a small place 
 at a time being treated. He employs a cosmetic pencil 
 composed of equal parts of croton oil and white wax; 
 or of equal parts of cocoa butter and white wax with 
 fifty per cent, of croton oil. The mass is melted and 
 poured into hollow cylinders with a diameter of half 
 an inch. A cure is said to be effected in from six to 
 eight weeks. 
 
 Liveing (453) applies the tincture of iodine in double 
 strength every day in extensive cases, and follows it 
 with the ointment of the nitrate of mercury; or the red 
 or white precipitate ointment with sulphur; or a ten 
 per cent, oleate of mercury. 
 
 Startin (481) advises washing the part with soap 
 and water, drying and applying a blistering fluid. After 
 inflammation has subsided, apply equal i)arts of oil of 
 cade, creosote, and tincture of iodine, and a lotion of 
 hyposulphite of soda ( 3 ij ad 3 j). If the skin is sore 
 from the use of the above, apply equal parts of white 
 precipitate ointment and vaseline. 
 
 Cottle (416) has had most success by using ^ ^liniment 
 crotonis " to produce pustulation, after which an oint- 
 ment or lotion of salicylic acid, ten to forty grains to
 
 230 DISEASES OF THE HAIU AND SCALP. 
 
 the ounce, is applied two or three times a day. Some- 
 times he combines oil of cade or carbolic acid with the 
 salicylic acid. If an eczematous condition is present, 
 he combines one of the soothing salts of zinc or mer- 
 cury with the salicylic acid. 
 
 KiCHARDSON (400) has used ethylate of sodium suc- 
 cessfully in a case of chronic ringworm. 
 
 Morris (460) has been very successful wdth the fol- 
 lowing: 
 
 Thymol, . . 3 ss = 2. 
 
 Chloroform, . 3 i j = 8. 
 
 Olive oil, . . 3 vj = ad 30. 
 
 M. 
 The amount both of the thymol and chloroform is to 
 be reduced in young children and w hen the disease 
 tends to become pustular. The oil is to be rubbed in 
 gently two or three times a day. The part is to be 
 w^ashed w ith soap and water, before the first applica- 
 tion, but not subsequently. If at any time there is 
 the slightest irritation the rubbing is to be stopped and 
 the oil merely smeared on. No cap should be w^orn in 
 the house, as the head is to be kept cool. 
 
 Harrison (430) by a series of experiments upon the 
 comparative power of various substances to penetrate 
 the scalp, found that the most powerful combination 
 of remedies was to apply to a small parf of the diseased 
 scalp for a few days Solution No. 1., as follows; 
 
 Iodide of potassium, 3 ss = 2. 
 
 Liquor potassae, . 3 j = 30. 
 
 M. 
 on pledgets of cotton. This is followed by Solution 
 No. 2. 
 
 Corrosive sublimate, gr. iij = .2 
 
 Sweet spirits of nitre, vel. 
 
 Water, . . . 33 =30. 
 
 M.
 
 TRICHOPHYTOSIS CAPITIS. 231 
 
 In this way the head is gone over several times. He 
 has treated thirty cases hy this plan, curing them in 
 about two months. His theory is that the hquor 
 potassa3 softens the hair and conveys the iodide of 
 potassium to its root and bulb; then the mercury pene- 
 trates to the same place, meets the iodide of potassium 
 and forms the biniodide of mercury just w^here it is 
 wanted. In 1889 Harrison modified his procedure on 
 account of its being a troublesome one, and recom- 
 mended that the patches be rubbed every night and 
 morning with the following : 
 
 Potass, caustic, 
 
 , . gr ix, say 2. 
 
 Ac. carbolici. 
 
 gr. xxiv, '' 5. 
 
 Lanolini, 
 
 
 01. cocois, 
 
 . fill 3SS, " 50. 
 
 say 
 
 33.33 
 1. 
 
 a 
 
 100. 
 
 M. 
 
 And the whole scalp anointed with : 
 
 1^ Ungt. boricis, 
 
 Ungt. eucalypti. . aa I ij, 
 01. caryophilli, . 3 ss, 
 
 01. cocois, . .ad 5 vi, 
 
 M. 
 FouLis (428) claims to cure his cases in seven days by 
 cutting the hair short over the affected parts, or off 
 the whole head, if the disease is extensive, and then 
 rubbing in a liberal quantity of spirits of turpentine. 
 When the scalp begins to smart it is to be washed 
 with warm w^ater and a ten per cent, carbolic soap 
 It is then to be dried and painted with two or three 
 coats of the tincture of iodine. When the scalp is dry 
 the whole head is to be anointed with carbohzed oil, 
 1 in 20. The treatment is to be repeated once or twice 
 a day. In very severe cases it is well to use a solution 
 of ten grains of iodine in one ounce of turpentine. 
 
 Geo.T. Elliot (421:) recommends painting the part 
 with the following:
 
 232 DISEASES OF THE HAIR AND SCALP. 
 
 Pyrogallol (pyrogallic acid), 3 ss-ij = 2-S. 
 
 Salicylic acid, . . 3 ss =2. 
 
 Flexible collodion, . 3 ij = 60. 
 M. 
 
 Lesser (451) has found a ten per cent, solution of 
 corrosive sublimate applied twice a day the most use- 
 ful parasiticide. 
 
 Kaposi (19) regards as specially useful the following: 
 
 Oil of birch, . .' . . . 15. 
 
 Tinct. of green soap, ... 25. 
 
 Precipitated sulphur, ... 10. 
 
 Spirits of lavender, ... 50. 
 
 Balsam of peru, . . . . 1.50 
 M. 
 
 Gamberini (59) recommends. 
 
 Flowers of sulphur, . . . 10. 
 
 Camphor, 10. 
 
 Lard, 30. 
 
 M. 
 Alder Smith (Y9) has often been successful in treat- 
 ing ringworm with, 
 
 Boracic acid, . 3 iv vel q.s. = 16. 
 
 Common ether, § v . =.150. 
 
 Alcohol, . ad Ixx . = 600. 
 
 I M. 
 
 which forms a saturated solution of boracic acid. The 
 hair is to be cut, and all scurf and sebaceous matter 
 washed from the patches with hot water and soap. 
 This washing is to be repeated every morning. After 
 drying the head, the solution is to be well dabbed and 
 pressed into the hair follicles with a small fine sponge 
 for ten minutes. Eepeat three to six times a day. 
 During the first few weeks of treatment the solution 
 is to be apphed over the whole head. No pomade 
 should be used during this treatment. Sometimes un- 
 der this plan the scalp becomes so dry that the hair
 
 TRICHOPHYTOSIS CAPITIS. 233 
 
 falls out of itself, and leaves bald smooth patches, sini 
 ilar to what is seen in alopecia areata. In very chronic 
 cases, and especially in disseminated ringworm, his 
 chief reliance is upon croton oil. In the disseminated 
 variety, a minute drop is placed upon every stump, or 
 black dot. If there are only a limited number of these, 
 the oil is to be pressed into the follicles by means of a 
 line, blunt gold pin. A pustule results, the hair loosens 
 and can be readily pulled out. If the hair breaks off, 
 the oil is to be re-applied when the pustule has healed. 
 A large thin poultice worn day and night under an oil- 
 skin cap will hasten suppuration and aid in extracting 
 the hair. In a chronic case, which has resisted aU 
 other forms of treatment, croton oil is to be applied to 
 a smaU place, not much larger than a ten cent piece, 
 at a time and followed by a poultice. If one applica- 
 tion does not give rise to suppuration, repeat until arti- 
 ficial kerion is produced, the scalp being swollen, ten- 
 der, puffy^ and pustular. The hairs are now loosened 
 and are to be removed, and soothing remedies applied, 
 as in kerion. A second patch is to be attacked as soon 
 as the first one is progressmg favorably, and so all dis- 
 eased portions are to be treated. This plan is to be 
 kept for a last resort. If a bald spot remain after the 
 use of croton oil, a stimulating lotion is to be ordered. 
 
 The same author recommends the removal of obsti- 
 nate disseminated diseased hairs by electrolysis, which 
 of course destroys the follicle. 
 
 Leftwich (450) advises cutting the hau- close from and 
 around the patch, and painting the scalp with an alco- 
 holic solution of the iodide of mercury, made by add- 
 ing calomel to tincture of iodine, and using the super- 
 natant colorless fluid. When the soreness caused by 
 it has passed off, an iodine plaster is to be applied, and 
 left on for a week or so. This plaster is made by add- 
 ing a half drachm of soHd iodine to an ounce of plaster
 
 234 DISEASES OF THE HAIR AND SCALP. 
 
 mass, and spreading it on kid. By this treatment the 
 doctor expects to cure his cases in a month. 
 
 Charon and Gevaert (321 ap.) commend the treat- 
 ment by galvanism proposed by Eeynolds, of Chi- 
 cago — that is, by saturating the electrode of the posi- 
 tive pole v/ith a three- to five- per cent, solution of 
 bichloride of mercury, anil applying it to the diseased 
 spot for ten or fifteen minutes. Pukdon has used 
 ^ith benefit an ethereal tincture of the seeds of cro- 
 ton tiglium with sahcylic acid. A neat and often 
 rehable method of treatment is that devised by DocK- 
 RELL (322 ap.). The patch is to be shaved and washed 
 with a five-per cent, hydronapthol soap and hot wa- 
 ter. After drying the patch it is to be covered with 
 narrow strips of ten-per-cent. hydronapthol plaster, 
 overlapping at the edges and going beyond the peri- 
 phery of the patch. This is to be covered with ten 
 per cent, hydronapthol gelatin. After four days the 
 plaster is to be removed, the washing and drying re- 
 peated, and a twenty-per-cent. plaster used in the 
 same way. This is to be left on for one week, and 
 followed by a ten-per-cent plaster for ten days. 
 
 Hutchinson (332 ap.) has the scalp washed twice a 
 Aveek with one drachm of liquor carbonis detergens in 
 one pint of hot water. He shaves tlie patch, or has 
 the hair cut close, and applies every morning and 
 evening, or only in the evening : 
 
 I^ Chrysarobin, . . 3i, 
 
 Hydrarg. ammon., . gr. xx. 
 
 Lanolin i, . . 3 i, 
 
 Adipis benzoat., . ad 3 ij, 
 
 Liq. carbonis detergens, ^x, 
 M. 
 
 "XMien the case seems to be cured the same ointment, 
 of less strength, is to be continued for six months. 
 
 say 
 
 12. 
 
 i( 
 
 4. 
 
 u 
 
 12. 
 
 ii 
 
 100. 
 
 ii 
 
 2.
 
 TRICHOPHYTOSIS CAPITIS. 235 
 
 Butte (320 ap.) has the scalp washed every second 
 day with a spray of hot water, and then apphes proto- 
 chloride of iodine (ten per cent.) in lanohne. If epi- 
 lation is thought to be necessary he paints the patch 
 with many layers of the following : 
 
 n Alcohol at 95°, .... 12. 
 
 Iodine, . . . . . .75 
 
 Dissolve, and add : 
 
 Collodion, 35. 
 
 Venetian turpentine, . . . 1.50 
 
 Castor oil, 2. 
 
 M. 
 
 This is to be repeated every day for three or four 
 days ; then the border of the artificial skin is to be 
 loosened and the whole gently torn away. Then 
 parasiticides are to be used until another epilation is 
 necessary. 
 
 QuiNQUAUD (350, 351 ap.) recommends lightly scrap- 
 ing the patches with a curette at intervals of five to 
 eight days, and applying twice a day : 
 
 Hydrarg. biniod.. 
 
 20 
 
 Hydrarg. bichlorid., . 
 
 1 
 
 Alcohol at 90°, . 
 
 40 
 
 Aquae dest.. 
 
 . 250, 
 
 M. 
 
 On the fifth or sixth day, after scraping, apply to 
 patches and all over the scalp : 
 
 1^ Chrysarobin, 
 
 Ac. salicylici, 
 
 Ac. boricis, . . . . aa 2. 
 
 Vaselini, .... 100. 
 
 M.
 
 236 DISEASES OF THE HAIR AND SCALP. 
 
 The head is to be kept covered with a rubber or 
 cloth cap held in place by a zinc or bismuth gelatin 
 paste. The ointment is to be used for one or two 
 days, and then the lotion as before. 
 
 Yidal's method, according to Eloy (327 ap.), is to 
 bathe with spirits of turpentine, and then apply tinc- 
 ture of iodine to a limited portion. The scalp is to be 
 kept anointed with vaseline every other day, and cov- 
 ered with a closely fitting cap. 
 
 Carrere (50 ap.) gives Besnier's treatment as con- 
 sisting in epilating for six to eight millimetres about the 
 patch, curetting it, washing wath tar, salicylic acid, or 
 sulphur soap, and covering with emplastrum Vigo. 
 Hallopeau has the patches washed with sapo viridis, 
 and then rubs in 
 
 5 Alcohol, 125. 
 
 Spts. turpentine, ... 25. 
 
 Liq. ammon., .... 5. 
 M. 
 
 and applies half an hour afterward vaseline with one 
 per cent, of iodine. A rubber cap is to be constantly 
 worn, and the vaseline is to be renewed at night. 
 
 D'Audraix (35 ap.) apphes tincture of iodine once a 
 day, or twice if not too irritating. Every second day 
 he removes the destroyed epithelium. AVhen the 
 parts have become smooth he epilates and scrapes 
 them, and makes intradermic injections of the fol- 
 lowing : 
 
 Hydrarg. bichlor., 
 
 .01 
 
 Ac. tartaric, . 
 
 .40 
 
 Cocaini liydrochlorat., 
 Alcohol, 
 
 1. 
 
 Aquae destill., 
 M. 
 
 . aa 30.
 
 TRICHOPHYTOSIS CAPITIS. 237 
 
 The syringe needle is to be directed obliquely and 
 deep under the skin. One drop of the fluid is to be 
 pressed out at each insertion, and the insertions are to 
 be made close together. He has made as many as 
 fifty at one sitting. Twelve days after the injection 
 the patches are white, smooth, and absolutely bald, 
 and he expects the hair to appear within from three 
 to eight weeks. 
 
 The rapidity of cure will depend largely upon the 
 thoroughness w^ith which directions are followed, and 
 the physician should make the applications himself 
 during the first few days, until some one of the family 
 becomes properly trained. The results are often best in 
 hospitals because of the constant supervision of the 
 house physicians and the skillful manipulations of the 
 trained nurses. 
 
 After a case has recovered from trichophytosis a dry 
 and scaly condition of the scalp may be left. This 
 condition may readily be cured by 
 
 Hydrarg. ammon . . . 3ij = 3. 
 
 Hydrarg. chlor. mitis . . 3iv= 6. 
 
 Vasehne . . . . ad §1 =3u. 
 M. 
 
 a favorite formula of Dr. E. B. Bronson of New York. 
 Or a sulphur ointment may be used of the strength of 
 one drachm to the ounce. 
 
 When to stop treatment is a very important matter 
 to determine. The mistake is often made of stopping 
 as soon as the hair is growing fairly. We should sus- 
 pend treatment as soon as the scalp is no longer scurfy, 
 the hair is growing healthily, the microscope no longer 
 shows the presence of fungus in the hair, and there are 
 no stumps to be found in the scalp. The patient should 
 be kept under observation for a few months, and if 
 these same conditions are preserved he may be dis- 
 charged as cured.
 
 238 DISEASES OP THE HAIR AXD SCALP. 
 
 Over-treated cases are sometimes met with, either 
 too strong remedies having been employed, or proper 
 riemedies continued too long. The condition present is 
 usually one of eczema, the original disease perhaps 
 having been cured. By suspending all treatment from 
 time to time we will easily avoid this. 
 
 Progkosis. — The prognosis is good, though the dis- 
 ease is often very rebellious to treatment. A too 
 speedy cure should not be promised, and three to six 
 months must often be given to the treatment of a 
 chronic case. It must be borne in mind that the dis- 
 ease is in most cases self-hmited, and the most mveter- 
 ate cases tend towards spontaneous recovery with the 
 approach of adult yeai*s, rarely lasting later than the 
 fifteenth or sixteenth year. This should prevent us 
 from makuig use of such remedies as croton oil except 
 when other things have failed, as it produces at tunes 
 permanent baldness if not carefully employed. Cases 
 have been known to spontaneouly heal in from one to 
 three years. Baldness rarely follows the disease ex- 
 cepting as the result of ti'eatment. 
 
 Granuloma tricliophyticnm. — Under this title Ma- 
 JOCCHi (458), in 1883, described a form of ringworm at- 
 tacking hairy regions which differed from sycosis and 
 kerion, and consisted oi round tmnors of normal skin- 
 color, painless, non-scaly, surrounded by a colorless 
 areola, of the size of a half walnut, at first elastic, 
 then soft and fluctuating like an abscess. In the middle 
 of each is a trichophytic hair, or a filament of fungus. 
 Histologically the tumors have the charactei^ of a sub- 
 cutaneous gi'anuloma, young granulation cells with 
 blood-vessels and giant ceUs. Majocchi believes that 
 in these cases the fungus penetrated into the corium 
 through the hair foUicle and sebaceous gland.
 
 CHAPTEE XIII. 
 
 KERION. 
 
 Synonyms: — Trichomykosis capillitii (Auspitz); Ves- 
 pajo del Capillizio, Vespajo tricofitico del Capillizio 
 (Ital). Tinea kerion; KerioiiCelsi. 
 
 Definition. — A more or less chronic inflammation 
 of the hairy scalp, characterized hy the formation of a 
 prominent, boggy, uneven swelling, studded with 
 numerous foramina out of which oozes a sticky, 
 mucoid substance. The tumor at times undergoes 
 suppuration, and generally follows upon ringworm of 
 the scalp. 
 
 Symptoms. — Kerion derives its name from a Greek 
 word meaning a honeycomb. The Italian name signi- 
 fies a wasp nest. It has generally been regarded as a 
 stage of ringworm of the scalp, but it is better to look 
 upon it as a form of that disease rather than a stage, 
 as it may be produced artificially and independently 
 of trichophytosis. It is analogous to the nodular 
 swellings met with in trichophytosis barba?. Tilbury 
 Fox (5(12), in ISGG, first identified kerion as a form of 
 ringworm. 
 
 As ordinarily met with the disease or condition fol- 
 lows upon a simple patch of ringworm. The affected 
 part becomes red, oedematous, swollen, and boggy; it 
 may be purplish in color. Its surface is glazed, un- 
 even, and studded with a number of yellowish suppur- 
 ating points, or with foramina out of which oozes a 
 sticky, gelatinous, viscid, transparert fluid. At times 
 if the inflammatory process is more intense, the swell-
 
 240 
 
 DISEASES OF THE HAIR AXD SCALP. 
 
 ing may reach considerable size, and instead of a mu- 
 coid fluid escaping from the foramina, true suppura- 
 tion may take place attended with a sero-purulent dis- 
 charge. The amount of the discharge is in proportion 
 to tlie amount of inflammation present, and the depth 
 to which the process goes. The swelling is rounded or 
 
 
 Kerion. 
 
 oval in shape, and varies in size; usually it is one or 
 two inches in diameter, but it may become as large as 
 a turkey's egg. 
 
 The hair on the affected part at first has the charac- 
 teristic appearances of that of ringworm, when kerion 
 follows that disease, being broken off, and presenting 
 stumps. The pustules of the early stage of the disease 
 form about the hairs at their exit from the scalp. 
 Later the hairs loosen, and are easily plucked; as the 
 inflammation progresses, they fall, and from the open- 
 ings of the hair-foUicles the mucoid or sero-pumlent
 
 KERION. 2il 
 
 discharge takes place. If the disease is not properly 
 managed, or if the inflammation is very intense, per- 
 manent baldness may result from destruction of the 
 hair follicles. 
 
 The subjective symptoms are more or less pain; ten- 
 derness on pressure; at times itching and burning. 
 The course of the disease is chronic, and it may last a 
 very long time. At times the posterior cervical glands 
 are enlarged, as is common in inflammatory diseases of 
 the scalp. 
 
 Etiology. —The disease is rare. I have met with it 
 only three times in six thousand cases. It occurs in 
 all classes of society, but affects children especially. 
 The scrofulous habit or a poor constitution favor this 
 form of inflammation, though it may occur in healthy 
 subjects. The exciting cause is, in most cases, the 
 trichophyton fungus passing deep down into the hair- 
 follicles. It may be produced by over treatment of a 
 case of ringworm of the scalp ; or by the application 
 of irritants to the scalp quite independently of ring- 
 worm; or it may foUow eczema or sycosis of the scalp. 
 According to Majocchi (503) this condition is some- 
 times met with in favus. 
 
 Pathology.— When due to the trichophyton tonsu- 
 rans, the fungus penetrates deeply into the hair-follicles 
 and there sets up an inflammation. This will vary in 
 intensity with the irritation produced. According to 
 Atkinson (499), if the irritation goes only to a certain 
 extent there will result a purely catarrhal inflamma- 
 tion of the hair-follicles, and the production of a mu- 
 coid secretion. If the irritation is greater, a suppura- 
 tive inflammation will be established, and there wiU be 
 a sero-purulent discharge. Eobinson (33) says, that 
 '' in tinea kerion the glands of the skin seem to be af- 
 fected as well as the hair-follicles, and pour out a mu- 
 coid secretion. In this fonn, though there is no true
 
 242 DISEASES OF THE HAIR AND SCALP. 
 
 suppurative process, the inflammation in the given 
 area is so general, deep, and long-continued that the 
 follicles are destroyed, and permanent alopecia results. " 
 Majocchi (503) found the parasite in the hair- follicle, 
 along the hair- shaft, and in the connective tissue 
 ^around the hair-follicle; the folhcles filled with epithe- 
 hal cells, pus corpuscles, spores, and mycelia, and the 
 sebaceous glands and skin in the neighborhood in- 
 flamed. 
 
 We need not here describe the trichophyton fungus, 
 as that has been done in the preceding chapter. If 
 hairs are j^lucked from a non-suppurative patch of 
 kerion the fungus will be found in abundance in them 
 and their sheaths. If suppuration is active in the 
 patch the fungus may be destroyed, and it may not be 
 found in the hairs. 
 
 Diagnosis. — Kerion is most apt to be mistaken for 
 a subcutaneous abscess. It must also be diagnosed 
 from a papilloma of the scalp, from a gummatous 
 tumor, a sebaceous cyst and a fatty tumor. 
 
 An abscess is not preceded by ringworm, has no his- 
 tory of any irritation directly apphed to the part, and 
 may arise without any antecedent disease of the scalp. 
 Kerion is commonly preceded by a ringworm, or there 
 is a history of some antecedent disease, or the applica- 
 tion of some iri'itant to the part. An abscess as a rule 
 is very painful, and the patient experiences a sensa- 
 tion of throbbing in the part. Kerion is nmch less 
 painful and sometimes itchy. Abscesses occur in sub- 
 jects of lowered vitality. Kerion often occurs in the 
 otherwise robust. The formation of an abscess is ac- 
 companied by chilhness, fever, and general malaise. 
 These symptoms are absent in kerion. An abscess 
 when ripe shows fluctuation and contains pus. Kerion 
 is boggy to the feel and generally does not contain pus. 
 There is no discharge from an abscess unless it has
 
 KERION. 243 
 
 been opened either naturally or by the knife, and then 
 it gives exit to pus. Kerion pours out a mucoid secre- 
 tion from numerous foramina. In the hairs pulled 
 from over an abscess the trichophyton fungus is want 
 ing. In the hairs pulled from a kerion the fungus is 
 usually present, or it will be found in hairs from other 
 parts of the head. 
 
 The other diseases mentioned above should not be 
 confounded with kerion. A papilloma is non-inflam- 
 matory, exceedingly chronic, firm to the touch, and 
 has no discharge. A gumma is usually accompanied by 
 other signs of syphilis, and tends to break down and 
 ulcerate. A sebaceous cyst is slow in its groAvth; the 
 skin over it is normal; it shows no great tendency to 
 break down, and if opened it gives vent to a fetid, 
 cheesy mass. A fatty tumor is a chronic swelling, 
 freely movable, rather elastic to the touch, and the 
 skin over it is normal. 
 
 Prognosis. — The disease is curable, although some- 
 times wath difficulty. The chief thing to be feared is 
 the occurrence of permanent baldness, and this will oc- 
 cur in some cases even with the greatest care. 
 
 Treatment. — The first thing to which we should 
 give attention is to the thorough epilation of the af- 
 fected part. This will sometimes save the hair from 
 destruction and prevent baldness. It will remove a 
 certain amount of the fungus from the scalp, and open 
 up the foUicles for the escape of the mucoid or sero- 
 purulent secretion. 
 
 The subsequent treatment wiU depend upon the 
 causation of the case. If it is due to the appHcation of 
 an irritant, such irritant must be stopped, and a poul- 
 tice, hot w^ater, or some mild emollient dressing ap- 
 plied. Mild antiphlogistic remedies are also indicated 
 in cases complicating eczema and sycosis. But as 
 most cases are due to the trichophyton tonsurans we
 
 244 DISEASES OF THE HAIR AND SCALP. 
 
 should at once apply antiparasitics, just as in scabies, 
 for instance, ws use sulphur, no matter how imtated 
 the skin may be. This is advised against by some au- 
 thorities, bift most are in its favor. The antiparasitics 
 mentioned in the chapter on trichophytosis capitis are 
 useful in keiion. Of them dilute sulphurous acid; 
 a solution of bichloride of mercury, a grain to the 
 ounce ; hyposulphite of soda, one or two drachms to 
 the ounce of water ; carbolic acid, twenty to thirty 
 grains to the ounce of water, are perhaps the best. 
 These, joined to epilation, ^ill generally result in a 
 speedy cm^e.
 
 OHAPTEE XIY. 
 
 TRICHOPHYTOSIS BARB^. 
 
 Synonyms. — Tinea sycosis; Sycosis parasitica, seu 
 parasitaria, seu contagiosa, seu menti; Tinea barbae; 
 Trichomykosis barbae (Auspitz); Dermatomykosis bar- 
 bae nodosa; Mentagra; Herpes tonsurans barbae; Tricho- 
 phytie sycosique, Sycosis jmrasitaire (Fr.); Teigne- 
 mentagra, (Bazin); Parasitische Bartfimie, (Ger); Par- 
 asitic mentagra, Ringworm of the beard. Barber's itch 
 (Eng.); Sicosi parasitaria (It.). 
 
 Definition. — A contagious parasitic disease of the 
 hair of the face and neck, caused by the trichophyton 
 tonsurans, which invades the hair foUicles, disinte- 
 grates the hair, sets up a peri-follicuhtis, with inflam- 
 mation of the skin and subcutaneous tissues, and gives 
 rise to the formation of pustules, tubercles and nodular 
 swellings. It runs a chronic course, is rebellious to 
 treatment, and may cause permanent baldness. 
 
 Symptoms.— This is the barber's itch proper, and 
 presents different appearances in accordance with the 
 depth to which the parasite has penetrated and the 
 amount of irritation it causes. It begins as an ordin- 
 ary ringworm of the body, a reddish, more or less circu- 
 lar scaly patch, appearing on the bearded portion of 
 the face, which is either scarcely raised above the 
 surface of the skin, or has its circumference markedly 
 raised, and, it may be, vesicular or pustular, while its 
 centre is scaly. In some cases, under appropriate 
 treatment, the process may go no further; and some- 
 times it stops here spontaneously.
 
 246 
 
 DISEASES OF THE HAIR AND SCALP. 
 
 In most untreated cases the parasite penetrates the 
 hau'-foUicles, sets up a folhcuhtis, and peri-foUicuhtis, 
 and more or less inflammation of the skin and suhcu- 
 taneous tissues, giving rise to the formation of pustules, 
 papules, tubercles, nodular swellings, and, rarely, ab- 
 scesses. According to Behrend (33) it takes about four- 
 teen days for the fungus to penetrate the deeper parts 
 of the skin. The hak is early affected like as in the 
 
 Trichophytosis Barbae. 
 
 other forms of rmgworm, becoming dry, brittle, 
 twisted, and broken off. Over the tubercles and 
 nodules the hair may be extracted with the gi'eatest 
 ease and without pain to the patient, and it may fall 
 spontaneously. The hair roots may be dry, or they 
 may be swollen and boggy. 
 
 A characteristic case of the disease presents the 
 follo^^^ng features: Upon the chin, neck, and sub- 
 maxillary regions, we find a number of tubercles and
 
 TRICHOPHYTOSIS BARB^. 247 
 
 nodules, varying in size from a split pea to a half cherry. 
 These are irregularly shaped, for the most part romided; 
 are prominently raised above the surface of the skin, 
 it may be to the height of half an inch; and show a 
 marked tendency to group in segments of circles and 
 to form patches. There may be one group of nodules 
 or there may be half-a-dozen or more. The nodules 
 themselves have a congested, purphsh look. They are 
 either hard and scaly, or they discharge a thick sticky 
 fluid from many follicular openings, or they suppurate. 
 The hair over them is broken or stubbed, or it has 
 fallen out so that the affected parts are more or less 
 bald. The skin between the separate groups is usually 
 unaffected, as also may be the case between the indi- 
 vidual nodules. But very often the skin over the 
 patches is reddened and crusted, and there are a num- 
 ber of pustules about the hairs at their exit from their 
 foUicles. In some cases the amount of pustulation is 
 so great that the appearances are very hke those found 
 in sycosis, and when the crusts are removed the 
 affected part presents that moist, raw surface, studded 
 ^\ ith numerous points discharging a glutinous material, 
 which suggested the name of <T'jy.o'^, a fig. 
 
 Subjective symptoms may be wanting; commonly 
 some itching and burning are experienced; sometimes, 
 if the inflammation runs high, there will be more or 
 less pain, and even some constitutional distiu'bance in 
 the form of chills, slight fever and loss of appetite. I.i 
 the vast majority of cases, the patients are more trou- 
 bled by the unsightUness of the disease than by any 
 physical discomfort. 
 
 The disease commonly affects the chin, neck, and sub- 
 maxillary regions. In most cases the upper parts of 
 the cheeks are spared, and the upper lip is very rarely 
 invaded even in the worst cases. The malady may 
 bo limited to a single patch, or to one side of the face^
 
 24S DISEASES OF THE HAIR AXD SCALP. 
 
 or may iii\*(3lve the whole bearded portion of the face. 
 It is very chronic in its course when it once becomes 
 deep-seated. At times it may pass over from the 
 hairy to the non-hairy contigaous parts. 
 
 Etiology. — The trichophyton fungus is solely re- 
 sponsible for tliis disease. As it affects the bearded 
 portion of the face, men are naturally its victims. It 
 is most frequently met with in men of early and mid- 
 dle manhood, say from the twentieth to the forty-fifth 
 year. The same idiosyncrasy is shown in the suscep- 
 tibility to this as to other forms of ring-worm, not every 
 man being capable of taking it. Hyde (IS) has met 
 Avith it more often in men with light hair and eyes, and 
 Hght brown, reddish or sandy beard. It occurs most 
 often aniong those who shave, and especially those who 
 are shaved by barbers. All classes are attacked by it, 
 but it is more common amongst the poor. 
 
 The barbe:r's damp towels, and, may be, his fingei^, 
 are the most active agents in spreading the disease. 
 The shaving biTish and razor may convey the fungus, 
 though if the water used in shavmg is hot, the danger 
 is reduced. The razor strop and mug may be mediate 
 carriers of infection. The disease may also be acquired 
 du'ectly from animals, from cases occumng on other 
 indi\4duals, or may be conveyed from other pai-ts of 
 the body to the beard. The health of the pei^on has 
 no influence upon the disease. 
 
 Trichophytosis barbae is not very common. In 
 Boston, White met with it thirty-eight times in 5,000 
 cases. In Xew York, Bulkley had twenty-four cases 
 in 8,000. In Glasgow, Anderson saw it but eighteen 
 times in 10,000 cases. It is said by Duhrixg (10) to 
 be more common in France, and rare in Vienna. In 
 Germany it is quite common, because, as McCall 
 Anderson (501) says, ' ' the men there kiss each other, 
 and go dailv to be shaved."
 
 TRICHOPHYTOSIS BARB^. 2.1:9 
 
 Pathology. — We need not say anything here about 
 the appearances of the fungus in the hair and scales, 
 as they are the same as in ringworm of the scalp. Kob- 
 INSON, (33) has found it in the matrix of the hair and 
 between the hair-sheaths. If there is much suppura- 
 tion it will destroy the fungus, and none may be found 
 in many hairs examined. There is, as a rule, more 
 mycelia in the hairs of ringworm of the beard than in 
 the same disease of the scalp. At times httle, round, 
 ghstening bodies are seen in the hairs, in their frayed- 
 out ends, and in the remains of the root-sheath, which 
 are regarded by Lang (520) as the product of disorgani- 
 zation, but not of the fungus. He affirms that the 
 proper fungus remnants are cubical, large, glistening 
 masses, either simple or forked. It is curious to note 
 that before the identity of the parasite of tinea sycosis 
 with that of trichophyton tonsurans was proven, it 
 was called the microsporon mentographytes. 
 
 The severity of the symptoms varies with the 
 amount and seat of the fungus, and the manner in 
 which the tissues react to it as a foreign body, which is 
 somewhat a matter of idiosyncrasy. That tubercles 
 and nodular swellings are found here and not in the 
 same disease as it occurs upon the scalp, is due to the 
 amount and looseness of the subcutaneous connective 
 tissue. Lang (520) beheves that their presence is ac- 
 counted for by the inflammation and suppuration of 
 the sebaceous glands, which, in the bearded portion 
 of the face, lie m very loose connective tissue, and are 
 freely supplied with blood-v*essels which anastomose 
 around them. Tilbury Fox (12) has drawn attention 
 to the appearances of trichorrhexis nodosa which the 
 hair sometimes presents in this disease. This, how- 
 ever, is not peculiar to trichophytosis barbae. 
 
 Diagnosis.— The differential diagnosis is, mainly, 
 between trichophytosis barbae, and sycosis and pustular
 
 250 DISEASES OF THE HAIR AND SCALP. 
 
 eczema. Sometimes a large papular or tubercular 
 syphilide, an indurated acne, or an epithelioma will 
 need to be differentiated. If the characteristics of 
 the disease as already given are borne in mind, there 
 should be little difficulty in making a diagnosis. The 
 finding of the fungus in the hair is decisive against 
 any of the diseases mentioned above. 
 
 Si/cosis affects all parts of the face, notably the 
 upper hp, and is entirely devoid of nodular swellings. 
 Trichoj^hytosis barbae affects by preference the chin 
 and submaxillary regions, spares the upper lip as a 
 rule, and has large tubercles and nodules which tend 
 to group. Sycosis is an active inflammation, and pre- 
 sents many pustules pierced by hairs. Trichophytosis 
 barbcB is a more sluggish inflammation, and presents 
 few if any pustules. The hair in sycosis is only 
 affected secondarily, and is firmly planted in the skin, 
 giving rise to pahi on extraction. In trichophytosis 
 barbae it is primarily affected, split, twisted, broken, 
 and is readily extracted without pain. In sycosis there 
 is no fungus; in trichophytosis it is often abundantly 
 present. Sycosis relapses when apparently cured, and 
 often seems to get better and worse with the condition 
 of the patient's health. Trichophytosis barbae is not 
 so prone to relapse, and is not influenced by the condi- 
 tion of the patient's health. 
 
 Eczema barbce is an active inflammation of the skin 
 of the bearded portion of the face; tinea barbce is an 
 inflammation of the hair-folhcles. Eczema develops 
 rapidly; involves large portions of the bearded face, 
 or aU of it; is devoid of nodular swelhngs; and pre- 
 sents a large amount of crusting. Tinea barbae is 
 gradual in its advance, affects the chin and submaxil- 
 lary regions, spares the skin between the tubercles, 
 nodules, and groups of the same, and, as a rule, is not 
 crusted. In eczema the hairs are firmly fixed and
 
 TRICHOPHYTOSIS BARB^. 251 
 
 free of disease; in tinea barbae they are evidently 
 diseased, easily extracted, and often wanting. Eczema 
 is accompanied with far more itching and burning 
 than is tinea barba3, and is not contagious. 
 
 The large papular or tubercular sypliilides tend to 
 group in circles or segments of circles, as do the lesions 
 of trichophytosis barbae. Bub there is generally no 
 more than one group of lesions in syphilis; it has a 
 characteristic color, and a different history; other evi- 
 dence of syphihs may be found, and the lesions tend 
 to ulcerate. 
 
 Acne indurata occurs not only on the hairy but also 
 on the non- hairy parts of the face; does not involve 
 the hair; and if the nodules, which here are cutaneous 
 abscesses, are opened, they give vent to a large amount 
 of pm"ulent sebaceous matter. A parasite is wanting. 
 
 Epithelioma should hardly be mistaken for tricho- 
 phytosis barbae. It occurs in the form of a circuni 
 scribed lesion with waxy margins over which course 
 fine blood-vessels. The whole history of its origin 
 and progress is different from what pertains to tinea 
 barbae, and when the almost inevitable ulceration takes 
 place all doubt as to its nature vanishes. 
 
 The superficial form of tinea harhce presents the 
 same appearances and has the same symptoms as met 
 with in tinea corporis, viz. : a superficial, more or less 
 circular scaly patch, with a vesicular or pustular ad- 
 vancing edge. 
 
 Treatment. — The treatment of trichophytosis barbae 
 is prophylactic and curative. Prophylaxis consists in 
 not being shaved by a barber, or, better, in not shav- 
 ing at all, as the disease rarely affects those who do not 
 shave. If you go to a barber's shop, owning your 
 own brush, cup, and razor will not save you. You do 
 not know that you can always trust your barber not 
 to use your apparatus on other men's faces. Then
 
 25^ DISEASES OF THE HAIR AND SCALP. 
 
 too, as has been said, the damp towels, the razor strop, 
 and perhaps the barber's fingers, may convey the con- 
 tagion. If you do not own your ot\ti utensils, of 
 course, your chances are all the worse. Above all 
 things, the cheaper class of barber's shops are to be 
 avoided. 
 
 The curative treatment follows very much the same 
 line as given in the two preceding chapters. In the 
 early stage, and before the hair-foUicles have become 
 involved, we can often succeed in stopping the pro- 
 gi-ess of the disease by painting the affected part with 
 a solution of four or five grains of the bichloride of 
 mercury to the ounce of alcohol, to whicli may be 
 added a little glycerine. This is to be painted on 
 twice a day with a cotton swab, a fresh one being used 
 for each application. Ihle (515) extols resorcin for 
 this stage, exhibited in the following paste: 
 
 Pure resorcin, .... 10. 
 
 White vasehne, .... 50. 
 Oxide of zinc. 
 
 Starch, aa 25. 
 
 M 
 
 Apply two or three times a day. 
 
 Painting with the tincture of iodine; the apphcation 
 of a chrysarobin pigment, (Chrysarobin 10 per cent, in 
 flexible coUodion); the various mercurial ointments, are 
 all good at this stage. When the hair-foUicles have 
 been invaded, and tubercles formed, a more active 
 treatment must be instituted. Epilation now forms 
 an essential part of the treatment. The hair is to be 
 puUed not only from over the lesions but also for a 
 smaU zone about them. Shaving is also to be prac- 
 tised, and it is often well to shave one day and epilate 
 the second or third day, according to the rapidity with 
 which the hair grows. Ihle claims that by using his
 
 TRICHOPHYTOSIS BARB^. 2^3 
 
 paste, as given above, epilation is not necessary, as 
 the diseased hairs come out of themselves. He advises 
 cutting of the beard and applying the paste two or 
 three times a day, its strength being gradually in- 
 creased if well borne, up to twenty -five or fifty per 
 cent. When pustulation and inflammation begin to 
 lessen, the strength of the resorcin is to be reduced. 
 When apparently well, a three per cent, ointment is 
 to be continued for some time. 
 
 The rule, however, is to epilate and shave, and to 
 apply your parasiticide after either, and re -apply it two 
 or three times a day. A bichloride of mercury solu- 
 tion, gr. i to ij, in water or alcohol 3 j; a solution of 
 hyposulphite of soda 3 j, to water 3 3 ; dilute sulphurous 
 acid; a two to four per cent, carbolized oil; a five to 
 ten per cent salicylated oil (castor oil preferred); a five 
 to ten per cent, oleate of mercury; a saturated solution 
 of boracic acid; tincture of iodine; an ointment of 
 sulphur, or of yellow sulphate of mercury, thymol, 
 or napthol; these are all good parasitics. Tilbury Fox 
 (512) advised the use of an ointment composed of 
 
 Hydrarg. Ammoniate. 
 Hydrarg. oxidat. nitrici, 
 Acidi carbohci, 
 M Adepis, 
 
 Hardy (514) directs that the part be epilated and 
 then bathed with a sublimate solution 1 in 500. The 
 next day an ointment composed of 
 
 gr.v 
 
 = 
 
 .3 
 
 gr.Y 
 
 = 
 
 .3 
 
 gr.x 
 
 = 
 
 .6 
 
 !] 
 
 = 
 
 30. 
 
 
 Hydrarg. sulph. flavae, . 
 
 2 parts 
 
 
 Pulv. camphoris, 
 
 1 part. 
 
 M 
 
 Adepis, 
 
 27 parts 
 
 or of 
 
 
 
 
 Sulphur, subhmat. 
 
 2 parts 
 
 M 
 
 Adepis, 
 
 . 28 ''
 
 254 DISEASES OF THE HAIR AND SCALP. 
 
 is to be constantly worn. When there is much in- 
 flammation he uses emollient dressings until it has 
 subsided, and then employs the above plan. Neumann 
 (27) advises green soap frictions, the opening of pus- 
 tules and multiple scarifications of the patches. When 
 there is deep infiltration he uses a plaster composed 
 of equal parts of mercurial and diachylon plaster, with 
 enough olive oil to make it soft. 
 
 Behrend (3) speaks highly of scraping the patch or 
 patches with the sharp spoon. Gamberini (59) paints the 
 affected parts with a solution of oil of juniper in tinct- 
 ure of iodine. Li the Algemein. Wien. Med. Zeit. 
 (506) for 1881, it is recommended to apply after epila- 
 tion and every morning and evening, the following: 
 
 Hydrarg. bichlor 01.-02 
 
 Sapo-viridis, 
 M 01. cade, . . . aa 5. 
 
 Epilating, shaving, and the careful use of parasiticides 
 will effect a cure. 
 
 Morrow ^ epilates and applies an ointment of iodide 
 of sulphur, thirty or forty grains to the ounce. Unna 
 in superficial cases recommends a ten-per-cent. resor- 
 cin ointment, or a spray of 
 
 5 Eesorcin, . . . .5. 
 
 Hydrarg. bichlor., . . . .01-05 
 
 Aquae Colognien., 
 
 Alcohol, .... 50. 
 
 01. ricini, . . . . 1. 
 M. 
 
 followed by powdering. In the nodular form he binds 
 on plaster-mulls made either of hydrarg. 20, ac. 
 carbol. 7.5; or hydrarg. 10, ac. carbol. 10, corrosive 
 
 * Journal of Cutaneous and Venereal Diseases, 1886, iv., 32.
 
 TRICHOPHYTOSIS BARB.^.. 255 
 
 sublimate 1 ; or the last with two parts of sublimate 
 and ten of oxide of zinc. 
 
 Prognosis. —When left to itself the disease is very 
 chronic. It may end spontaneously, though with per- 
 manent loss of hair. If properly treated it is perfectly 
 curable, and leaves no traces. The prognosis of ring- 
 worm of the beard is indeed the same as that of the 
 head, though it is somewhat easier to cure.
 
 CHAPTER XY. 
 
 FA^TS. 
 
 Derivation: Favus (Lat.) a honeycomb. 
 
 Synonyms. — Porrigo lupinosa OVillax;) Porrigo 
 favosa, Porrigo lavalis; Porrigo scutalata (Lebert); 
 Porrigophyta (Gruby); Tinea favosa; Tinea vera; 
 Tinea ficosa (Pare); Tinea lupinosa (Gui de Chaliac; 
 Tinea maligna; Trichomykosis favosa (Auspitz); Der- 
 matomycosis favosa; Kerion; Teigne faveuse (Ali- 
 bert); Teigne clu pauvre; Crusted or honeycomb 
 ringworm, scall head, true porrigo (Eng.); Erbgrind 
 (Ger.); Kopskurv. (Slav). 
 
 Definition. — A contagious vegetable parasitic dis- 
 ease due to the invasion of the hairy scalp by the 
 Acliorion Schoenleinii. It is characterised by the pres- 
 ence of discrete or confluent, circular, pale, sulphur- 
 yellow cupped crusts perforated by hair, or by asbestos- 
 Hke masses of gi-ayish ciiists; by loss of hair producing 
 irregularly shaped, disseminated, red bald patches; by 
 running a chronic course; and by causing permanent 
 atrophy of the scalp. 
 
 Symptoms.— Favus begins either as one or more 
 scaly erythematous spots, as minute yellowish pmicta 
 or as a group of vesicles smaller than those met with 
 in lingworm. But though this is the mode of origin, 
 the physician seldom sees a case in that stage, except- 
 ing as he may find new points developing upon a scalp 
 akeady bearing the disease in a pronounced form. 
 As usually met with, we find that the hair is dry and 
 lustreless, and in places it has fallen out, leaving irregu- 
 larly shaped bald patches, of all sizes, and of rather 
 brilliant red color. Upon separating the hairs, and
 
 ]PAVUS. 257 
 
 examining the scalp more closely, we will find both 
 upon the bald patches and upon parts of the scalp 
 covered with hair, Uttle, sulphur-yellow, cup or saucer- 
 shaped crusts, with raised or rounded edges, out of the 
 middle of which one or several hairs will be growing. 
 Besides these cups there will be more or less scaling, 
 and if the disease is of some age, thick, mortar-like 
 
 Favus. 
 
 crusts of grayish color. If we approach near enough 
 to the patient, we will appreciate a peculiar odor from 
 the scalp. 
 
 The characteristic features of favus are: 1. Sulphur- 
 yellow cupped crusts. 2. Baldness occurring in irregu- 
 lar patches. 3. Dryness and loss of lustre of the hair. 
 4. A peculiar odor. In a typical case all these symp- 
 toms are present. Let us examine each one by itself. 
 
 1. The cupped cnists. These are present very 
 shortly after the commencement of the disease, and
 
 258 DISEASES OF THE HAIR AND SCALP. 
 
 are to be found at some period in all cases. They are 
 situated about the hair-foUicles. At their beginning 
 tliey are small, about the size of a pin head, but grow- 
 ing rapidly they attain the size of a split pea. These 
 are called favi or scutula. Though usually described 
 as cup-shaped, they seem to me to be more like a sau- 
 cer in form. Their edges are rounded and several 
 lines in thickness. The depression in their centres is 
 well marked. They are round and concavo-convex, 
 the concavity looking upwards. At first they are 
 covered with a thin layer of epidermis, but later the 
 edges are free. When they are picked off fi'om the 
 scalp, which can readily be done, they leave a moist 
 depression, which soon fills up. Or the scalp, under 
 them, may be dry, red and atrophied; or it may be 
 pustular. The color of the crust is pale or sulphur 
 yellow: if of long standing it may become a dirty or 
 greenish yellow from extraneous matter. The surface 
 of the crust is uneven, and its centre is pierced by one 
 or more hairs. These crusts occur discretely and dis- 
 seminated ; sometimes in groups. They are firm in 
 consistence, and when crushed between the fingers 
 they impart a feeling of crumbling, somewhat Uke 
 mortar. Around them is a slight zone of redness. 
 
 In old cases these cupped crusts may not be present. 
 We will then find thick mortar or asbestos -like grayish 
 crumbly masses of scales, or perhaps these may be 
 gi'eenish yellow as if they were composed of dried pus. 
 But if they are cleared off and the scalp left to itself, 
 the scutula will again develop. 
 
 2. Baldness occurring in irregular patches. This is 
 almost as characteristic of fa^ois as are the scutula. 
 The patches are of all shapes, though they show little 
 inclination to become round or oval. There may be 
 only one or two bald spots, or the whole scalp may be 
 so denuded of hair that the condition may be better de-
 
 FAVUS. 259 
 
 scribed as a bald scalp with irregularly shaped and sized 
 patches of hair. In the active stage of the disease the 
 bald patches are covered more or less with scutula and 
 crusts, and here and there will be solitary hairs, or 
 little tufts of hair. Their color is an inflammatory 
 red in the active stage, v/hich pales with time. They 
 have a cicatricial look, due to the atrophy which 
 always takes place. They are wanting in glands and 
 hair -follicles, and are permanent. 
 
 3. Dryness and loss of lustre of the hair are always 
 present. The hair, unlike what obtains in lingworm, 
 is affected secondarily, and grows, though with impaired 
 vigor, for some time after the scutula have formed. 
 Eventually, the growth of the hair is interfered with 
 by the general atrophy of the skin, and by invasion of 
 their roots and shafts by the parasite. They then be- 
 come dry and brittle and, may be, split longitudinally 
 and fall out of themselves, or on account of traction 
 from brushing, scratching, and the like. They are 
 easily pulled out when their roots are invaded and do 
 not break so readily as in ringworm. 
 
 4. The odor is always present in a well-marked un- 
 treated case, and has been variously described as 
 " menagerie like," or " mousey " or, like the urine of 
 cats, or as "stale straw." In doubtful cases it may 
 be an aid in diagnosis as it is quite unlike the smell of 
 pustular eczema or syphilis. 
 
 Itching is the only subjective symptom. Tlie disease 
 may be complicated by eczema, syphilis, pediculosis, 
 or any other disease of the scalp, and these may some- 
 what alter the chnical appearances. In this way we 
 may have a decidedly pustular element added. In 
 Eandall's Island Hospitals there are always some forty 
 or more ringworm and favus cases in the same wards. 
 During four years I have never seen a case of ring- 
 worm and favus on the sair.': scalp, though the children
 
 260 DISEASES OF THE HAIR AND SCALP. 
 
 mingle freely with each other. As in other inflamma- 
 tory diseases of the scalp, enlargement of the glands 
 of the neck are quite commonly encountered. Kaposi 
 (19) says, that in the course of such fevers as typhus, 
 variola, and pneumonia, the favus growth is checked 
 only to begin again in convalescence. 
 
 Various names have been aj^plied to designate the 
 different chnical pictures presented by favus. Thus 
 we have: F. discretus, when confined to one spot; F. 
 confertus, when it extends over large surfaces; F. 
 scutiformis, when in moderate oval patches; F. cohoer- 
 ens, when a number of cups join; F. gran ulatus, when 
 in mortar hke masses; F. urceolaris or dispersus, when 
 disseminated. Charpy (539) has described one form 
 in which the crusts are millet seed sized and dissemi- 
 nated throughout the hair, to wliich he has given the 
 name of F. miliaire. 
 
 Etiology. — The disease is due to the implantation 
 and growth of the acliorion Schomleinii primarily in 
 the scalp and secondarily in the hair. This vegetable 
 fungus was first described by Schoxlein in 1839, in 
 Mueller's Archiv filr Anatomie unci Physiologie. In 
 181:1, Gruby also described it, and at the time he was 
 unaware of the discovery of Schonlein. 
 
 Favus is highly contagious, though not so much so 
 as is ringworm. Its victims are mostly children of 
 the poorer classes, such as Hungarians, Poles, and 
 other foreigners, who neglect the most ordinary rules 
 of h3^giene. It is exceedingly rare to see favus of the 
 scalp in our own people, and in this country it is one 
 of the rarer skin diseases; the statistics of the Ameri- 
 can Dermatological Association in 1885 record only 32 
 cases in 16,863. But while it is not so contagious as 
 is ringworm, it is more persistent. While ringworm
 
 FAVUS. 261 
 
 tends to spontaneous recovery as puberty is reached, 
 and it is exceedingly uncommon to see it in the adult, 
 favus persists indefioitely. I have seem it in a woman 
 well on in her twenties, and in a man in his thirties, 
 not only in the form of permanent bald spots, but with 
 scutula and asbestos crusts. The disease may be ac- 
 quired either mediately or immediately; that is, directly 
 from another individual suffering with the disease, or 
 by wearing the cap or using the brush or comb of a 
 favus patient. Hebra and Kaposi (15) say it is more 
 common in males than females. Bergeron (45) found 
 that it was more prevalent in the country than in the 
 city. It does not affect all individuals, but seems to 
 require some undefined peculiarity of soil for its lodge- 
 ment and growth. How great a role the strumous or 
 other diathesis plays in etiology it is difficult to deter- 
 mine. Many of the children with favus are strumous, 
 but that is a very common condition in this class of 
 children. Aubert (533) asserts that the disease is 
 prone to follow injuries to the scalp, and Kaposi (19) 
 says that the spores must land upon macerated epider- 
 mis or in a hair-follicle, and lie there for some little 
 time before they wiU grow. 
 
 Animals are subject to favus, and from them it may 
 be acquired by mam It occurs in mice, rabbits, dogs, 
 fowls and cats. When occurring in the mouse the 
 pressure of the fungus may cause not only atrophy of 
 the skin but also of the bones of the skull, and kill the 
 animal by exposure of the brain, the bones of the skull 
 being completely destroyed. 
 
 Pathology. — A.R. Eobinson (33), who has carefully 
 investigated the parasitic diseases of the skin, thus 
 describes the appearances of favus: ^' The mass (favus 
 cup) is composed almost wholly of the luxuriant vege- 
 table growth in various stages of development. The 
 most apparent is the mycelium in the shape of flat,
 
 202 DISEASES OF THE HAIR AXD SCALP. 
 
 narrow threads branching and inosculating with one 
 another in various directions . Their diameter is about 
 the -glo- part of an inch, and their color is pale-gray, 
 
 Favus ^Kaposi.) 
 
 sometimes tinged with green. When in a state of 
 fructification these tubes ajt^e divided into numerous 
 smaR compartments by delicate cross lines, sometimes
 
 FAVUS. 263 
 
 with constrictions, giving a chain-like appearance; 
 and in each compartment are seen young spores in 
 various stages of grow^th. The spores or conidia are 
 present in abundance amid the meshes of the ai)parent 
 growth. They are very small, of varying form, round, 
 oval, flask or dumb-bell shaped, and of a pale greenis]) 
 color. Intermediate forms between the spores and 
 mycelia are always present, and fungoid grow^ths of 
 various kinds, as well as micrococci and bacteria, are 
 often accidentally in the field of view. 
 
 '' The parasite first obtains a lodgement in the fun- 
 nel-shaped depression in the epidermis, through wdiich 
 the hair-shaft emerges upon the surface. It grows 
 luxuriantly in the upper part of the hair-sac, and in- 
 sinuates itself on all sides between the superficial layers 
 of the epidermis. When it reaches a short distance 
 on all sides of the foUicle-mouth, it breaks the looser 
 layers and appears on the surface, giving us the 
 familiar cup-shaped bodies. It also invades the hair- 
 shaft itself, though not to the extent that the tricho- 
 phyton does. It penetrates between the cellular layers 
 of the root sheath, and multiplies in the cortical sub- 
 stance of the hair. The nutrition of the hair is inter- 
 fered with by the mechanical pressure of the growth 
 upon the papiUse. The hair falls out, and eventually, 
 in many cases, the papilla atrophies, and a new growth 
 becomes impossible. In cases of any standing the 
 parasite may be demonstrated not only in the cortical, 
 but in the medullary substance of the hair. Splitting 
 of the hair may occur, as in tinea tonsurans, but as a 
 usual thing the hair faUs out before that occurs. 
 
 ^' In the skin itself the pai*asite usually confines itself 
 to the upper corneous cells, and does not extend to the 
 living tissues. In cases where the surface is covered 
 by irregular, moi^tar-like masses of parasite, the entire
 
 204: DISEASES OF THE HAIK AND SCALP. 
 
 upper layer of the epidermis will be foujid infiltrated 
 with the achorion. 
 
 ' ' The coriuni itself is usually in a state of chronic 
 inflammation, and suppuration, which may be quite 
 abundant, often occurs under the crusts. Even where 
 no pus is found, the pressure of the parasite causes 
 atrophy of the skin, and at last pit -like depressions, or 
 more extensive reddened scars are left. When the 
 granular stiiictures are entirely destroyed, the achorion 
 no longer finds a suitable nidus, and the disease at 
 that spot is at an end." 
 
 The fungus of favus does not aftect the hairs so 
 readily as does that of ringworm. Unna (^57*J) has 
 found that the hair is sometimes diseased only in its 
 upper one-third, while the inner root -sheath is diseased 
 throughout. Sometimes, on the other hand, the hair 
 may be diseased throughout and the inner root-sheath 
 unaft'ected. He has found the hau'-bulb uniformly free 
 from fungus, and the cortex generally undiseased till 
 to about the upper border of the lower fourth of the 
 hair-foUicle. The usual point of entrance of the fmi- 
 gus into the hair is at that part of the hair foUicle 
 where the sebaceous glands find entrance, the fungus 
 making its way through the cuticle of the hair. From 
 the point of the entrance into the hair, the fungus 
 grows up and down. The achorion furnishes a cement 
 to the corneous cells in which it lives, so that the cor- 
 neous layers do not scale off but form cups, and, later, 
 mouldy or Ijrittle masses, and the hairs do not break 
 up as in trichophytosis. 
 
 The formation of the yellow cup is accounted for in 
 several ways. 1. The parasite gains entrance into the 
 hair-follicle and grows out in all directions from it as 
 a centre. The outer rings are the newest and more 
 succulent, while those nearer the hair or point of de- 
 parture are the oldest and drier. Hence the latter
 
 FAVUS. 265 
 
 will be depressed by the pressure of the atmosphere. 
 2. The epidermic cells in the immediate neighborhood 
 of the hair are more firmly attached to the hair than 
 are those further away, hence will not so readily give 
 way and bow out under the pressure of the parasitic 
 growth. 3. EoBiNSON (33) has shown that the peripheral 
 portion of the cup consists of a dense collection of my- 
 celia, imbedded in a granular debris, while the central 
 lX)rtion is composed ahiiost entirely of spores which are 
 not very closely packed together. From this it results 
 that the peripheral portion of the cup is much firmer 
 and more resistant to external pressure than the cen- 
 tral part, and does not so readily sink in. 
 
 The objective symptoms of favus are due to the 
 growth of the achorion. The skin is atrophied on 
 account of the pressm^e of the growing fungus upon 
 the constituents of the skin, squeezing, as it were, the 
 life out of them. Whether the achorion Schoenleinii 
 is the only parasite causing favus is a question that is 
 still under discussion. The majority of investigators 
 believe that it is, and inoculation experiments support 
 them in their belief. Grawitz (435) has recently in- 
 oculated several subjects with pure cultures of favus 
 and ringworm, and each has produced the disease pe- 
 culiar to itself alone. Quincke (508) has found in his 
 cultures of favus crusts, that at least three different 
 fungi are capable of producing the clinical picture of 
 favus. In each of the examined cases, one form was 
 found. The three forms he designates only as ^, fi, y 
 fungi. They show marked difference under cultivation. 
 As yet Quincke has not been able to classify them 
 botanically. Unna (402 ap.) has outdone Quincke and 
 describes no less than nine sorts of favus fungus. On 
 the other hand. Pick, supported by Kral (382, 383 ap.), 
 and MiBELLi have found only one fungus. At present 
 the question is far from settled, and it is not possible
 
 266 DISEASES OF THE HAIR AND SCALP. 
 
 to give here the details of the investigations of the 
 bacteriologists. It is probable that the so-called 
 '^forms'' are due to the different methods of the ob- 
 servers in making cultures, and to the different reac- 
 tions of different skins to the favus irritation. 
 
 Diagnosis. — Most cases of favus are easy of diag- 
 nosis, tlieir features of sulphur-yellow cupped crusts ; 
 asbestos-like grayish masses ; red, atrophic bald spots; 
 and peculiar odor, being so well marked. It is to be 
 differentiated from ringworm, eczema, seborrhoea 
 sicca, psoriasis, lupus erythematosus, and baldness 
 arising from various other causes. 
 
 1. From Ringworm. Ringworm is met T\'ith chiefly 
 in children, rarely persisting to the age of puberty. 
 Favus usually begins in early hfe, but often continues 
 into the period of adult life. Ringworm is indigenous; 
 fa^iis is most often an hnpoited disease, and is met 
 vdi\\ in Hungarians, Poles, and other foreign races 
 which are uncleanly in their habits. Ringworm occurs 
 in the form of ch'cular, ch'cumscribed spots, partially 
 denuded of hau-, and covered with grayish scales in 
 moderate amount. It has no cupped crusts, and entire 
 baldness is rare except from the results of treatment. 
 Favus is more multiform and presents to view either 
 discrete or grouped yellow-cupped cnists; or gray 
 mortar -like masses of parasitic debris; or UTegularly 
 shaped bald spots scattered througli the whole head, 
 wdiich are atrophic, devoid of follicles, and either red 
 or white in color, according to then- age. In some 
 cases there wiU be a mixtm-e of all these features. In 
 ringworm the hau's look as if nibbled off, and we find 
 many ^'stumps;" in fa^Tis stumps are not met with, 
 and the ban* though dry and cracked is not broken off. 
 ^lien we attempt to epilate m ring-worm the hair 
 breaks and leaves its root behind; in fa^-us the hair 
 ^Wth its root wiU come out entire. Ring*Avorm has
 
 FAVUS. 267 
 
 no characteristic odor. In a well-marked case of 
 favus the odor of stale straw or mice will be readily 
 appreciated. In doubtful cases we may often decide 
 whether the disease is ringworm or favus by the 
 microscope. The conidia of favus are more mani- 
 fold in shape than those of ringworm and slightly 
 larger. In the hair, in favus, we have chiefly my- 
 celia, which sometimes are exceedingly long; while 
 in ringworm the conidia are found in greater abun- 
 dance. But it is by no means easy to accurately differ- 
 entiate between the two diseases by the microscope 
 alone, and we must trust chiefly to the symptoms 
 and course of the disease in our diagnosis. 
 
 2. From eczema favus needs to be differentiated when 
 it is of long standing and there are no cupped crusts pres- 
 ent. Sometimes the scalp of a patient with favus may be 
 irritated by treatment to such an extent that it may 
 become eczematous ; but this is an accident that need not 
 detain us. We would speak here of the diagnosis from 
 pustular eczema in a doubtful case. In favus we 
 have often a history of contagion, which is not found 
 in eczema. Favus is usually confined to the hairy scalp. 
 Eczema of the scalp is usually accompanied by eczema 
 behind the ears, and quite commonly it extends upon 
 the neck and forehead. The grayish, dirty-looking, 
 thick, friable crusts of favus are in strong contrast 
 with the greenish, tenacious crusts of eczema. On 
 removing a favic crust we leave a dry, red surface. 
 When an eczematous crust is removed, a moist, ex- 
 uding surface is exposed. In favus the hair is dry, 
 lustreless, and more or less spHt longitudinally. In 
 eczema the hair is matted together, and may be dry, 
 but it is not otherwise altered. Favus causes perma- 
 nent bald spots of red and atrophic appearance. Ec- 
 zema as a rule does not cause baldness, and never 
 gives rise to permanent alopecia. The mousey odor
 
 268 DISEASES OF THE HAIR AND SCALP. 
 
 of favus is vastl}^ different from the sickening smell of 
 pustular eczema. 
 
 The pustules of a discrete pustular eczema or im- 
 petigo are rounded, non-umbiUcated, whitish or grayish 
 in color, and contain pus. These should not be con- 
 founded with the straw-colored or yellow cups of favus, 
 which are umbilicated and firm and do not contain 
 pus. 
 
 3. From seborrhcea sicca. Favus affects all parts of 
 the scalp indifferently and irregularly; seborrhcea is 
 most frequently confined to the upper portions of the 
 head, and when present to a sufficient degree to require 
 differentiation from favus, it will form a continuous 
 patch covering the whole top of the head with the hair 
 dry and more or less matted. The crust of favus is diy 
 and brittle and gritty to the feel: that of seborrhcea 
 is friable, but greasy to the feel, and when removed 
 leaves a normal or pale skin. Seborrhcea has no char- 
 acteristic odor, no cups, and if it causes baldness it 
 will be at first a general thimiing of the hair, and 
 with it the amount of seborrhcea will lessen. The bald- 
 ness caused by favus is permanent, and the skin is 
 smooth and atrophic. 
 
 4. From Psoriasis. Psoriasis does not occur upon 
 the scalp alone; when found there, other lesions will 
 be found elsewhere on the body. Favus is quite gen- 
 erally found on the scalp alone. The crusts of psoriasis 
 are scattered about through the whole scalp, are cir- 
 cumscribed and discrete, and when removed the skin 
 underneath will be found reddened but not ati'ophic. 
 Psoriasis presents no lesion like the cupped ciTist of 
 favus, and does not cause permanent baldness. 
 
 5. Ltqnis erythematosus resembles favus only in 
 forming red cicatricial bald areas, wliich are crusted. 
 Its bald patches are really cicatricial, while those of 
 favus are atrophic. The cicatrix of lupus is often de-
 
 FAVUS. 269 
 
 forming. Lupus is much slower than fa\ais in its 
 course, is generally more limited in its distribution, has 
 no cupped crusts, and when crusted the crust is thin 
 and adherent, and never forms the thick mortar-like 
 masses of favus. 
 
 6. From Alopecia. Alopecia areata presents per- 
 fectly bald, smooth, non- scaly, white, circular, cir- 
 cumscribed patches, the skin of which is normal in 
 appearance, though it may be somewhat pale and thin. 
 Its history and course are distinct from what obtains 
 in favus. The baldness arising from syphilis, as 
 seen in the early stages of the disease, and due to the 
 general hydraemia, is more like the baldness arising 
 from favus than is any other form of alopecia. But 
 the hair in syphilis is less affected than in favus, and 
 when it falls it gives the head a ragged appearance, as 
 if the hair had been cut off in an irregular manner 
 with a pair of dull shears. There are no crusts, and 
 there is a history of an initial lesion and a general 
 eruption. When the baldness is due to a late ulcerat- 
 ing lesion the history will be distinct, and the cicatrix 
 well marked. The other forms of baldness will be 
 sufficiently distinguished by the history of their onset 
 and course, and the absence of all the other characteris- 
 tics of favus. 
 
 In doubtful cases the finding of mycelia and conidia 
 in crusts and hair will positively exclude eczema, 
 seborrhoea, psoriasis, lupus, and alopecia. If a case 
 presents itself with thick crusts; or, if b}^ reason of 
 cleanliness, it has only red, bald patches, and we are 
 told that it has lasted for some .time and is very scaly, 
 we can determine the presence or absence of favus 
 by letting the disease follow its own course for a time, 
 and watching it. Of course all the crusts that may 
 be present must be removed. In the course of two 
 or three weeks or less, if the case be one of fa\"us, we
 
 270 DISEASES OF THE HAIR AND SCALP. 
 
 will notice, at first, little red spots upon the scalp, and 
 later the development of cupped crusts. 
 
 Prognosis. — Though the disease is obstinate to treat- 
 ment, still it is perfectly curable when handled with 
 intelligence and perseverance. A promise of speedy 
 cure should never be given, as it is always a matter of 
 months, and sometimes of years. Even after the dis- 
 ease is apparently cured, we should have the patient 
 present himself for inspection at intervals of a few 
 weeks during a year. Unfortunately we can do noth- 
 ing to remedy the damage done to the scalp in the 
 foi'mation of bald patches. These are permanent, 
 though they will become less disfiguring by time, as 
 the redness gradually fades. 
 
 Treatment. — In the treatment of favus patience and 
 method are of more value than any special medica- 
 tion. Without perseverance on the part both of phy- 
 sician and patient it will be impossible to cure a case. 
 Epilation, cleanhness and parasiticides are the means 
 at our command for combating the disease. 
 
 The first thing to be done is to clean the scalp of 
 all crusts. This is accomplished by keeping the whole 
 scalp soaked in oil for a day or two, according to the 
 thickness of the crust, and then washing with an 
 abundance of soap and water. For an oil we may 
 choose either sw^eet or ohve oil, or- oil of sweet almonds, 
 and it is useful to add some parasiticide to the oil, 
 such as carbohc acid gr. xv ad 3 j ; or salicyhc acid, 
 three per cent. Or we may use a poultice to remove 
 the crusts, though this is a more disagreeable method. 
 When the crusts have been got rid of we must epi- 
 late, and prevent the new formation of ci-usts by 
 the use of our chosen parasiticide, and by washing, at 
 intervals, with soft soap or the tincture of green soap. 
 As a rule it is best to allow the parasiticide to remain
 
 FAVUS. 271 
 
 undisturbed upon the scalp, and not to wash the head 
 more than once or twice a week. 
 
 The most important means of cure is epilation, which 
 may be accomplished by one of three methods: 1. By 
 the pincette or epilating forceps; 2. By Kaposi's (19) 
 method; and 3. By the " calotte," or by the epilating 
 stick, which is a modification of the calotte. 
 
 The first method, or that of the forceps, is the one 
 most commonly employed, and when systematically 
 carried out, is thoroughly reliable. Care must be given 
 to the selection of the forceps. They should have an 
 easy spring and their edges should accurately coapt. 
 I prefer to have the blades grooved transversely on 
 their inner face, as the hair is more firmly held by a 
 roughened than by a smooth blade. Each hair must 
 be plucked out from the diseased patch and from a 
 little area around it. The operator should begin at 
 one portion of the patch and clear off a small part 
 every day, each hair whether sound or unsound being 
 pulled out by a rapid jerk of the hand in the direction 
 in which it grows. The chosen parasiticide should be 
 applied immediately to the part epilated. 
 
 Kaposi's (19) method has for its object the epilation 
 of the diseased hairs alone. When the forceps is used, 
 both the sound and the unsound hairs are pulled out. 
 Of course it is desirable to spare the soimd hairs, and 
 Kaposi maintains that if little bmiches of the hair are 
 pulled between the thumb and some firm object, such as 
 a straight spatula, held within the grasp of the fingers 
 enough traction will be exercised to extract the loos- 
 ened and diseased hairs, but not enough to disturb the 
 healthy and firmly seated hairs. This is Kaposi's 
 method, which has given him satisfaction. It is rapid, 
 and less painful than any other mode of epilating. 
 
 The ^' caZo^fe," or pitch -cap, is the most rapid means 
 of epilating, but is i)ainful and sometimes dangerous. 
 The "calotte" is composed of,
 
 272 DISEASES OF THE HAIR AXD SCALP. 
 
 Vinegar, . . . . 150 parts. 
 
 Wheat flour, .... 25 '^ 
 
 Black pitch, .... 25 '^ 
 
 White pitch, . . . . 25 " 
 
 made into a mass and spread on leather. This is ap- 
 plied, while soft, to the whole head, and. when it has set, 
 it is pulled off suddenly hy taking hold of the part over 
 the forehead, and removing it from hef ore hackwards. 
 Its use was abandoned on account of some unfortunate 
 accidents. Since then various epilating sticks have 
 been invented to take its place. One of these much 
 used by Bulkley (53S) is composed of 
 
 CerrP flavae, . . 3 iij say 10. 
 
 Lacc^e in tabuhs, , . 3 iv '' 15. 
 
 Picis burgundicae, . . 3x " 35. 
 
 Gummi damar, . . § iss ^' 40. 
 
 These are made into a mass and cast in sticks from 
 half an inch to an inch in diameter and two inches in 
 length. One end is heated and apphed with a sort of 
 boring movement to the part to be epilated. When 
 cold it is removed by a sudden twisting motion. The 
 hair will be found sticking to the end, and must be re- 
 moved by burning before the stick can be used again. 
 Several sticks may be employed at once to a large 
 patch. For hospital or dispensaiy work these epilat- 
 ing sticks are serviceable, but are rather harsh for 
 private practice. 
 
 Whatever method is used it must be faithfully car- 
 ried out. A skilled nurse should be employed for the 
 work, and where such is not attainable, the physician 
 must make it his duty either to do the epilating him- 
 self, or to train some member of the family for the 
 work.
 
 J^AVUS. 273 
 
 Parasiticides are next in importance to epilation, and 
 should be applied after that procedure, not only to the 
 part epilated but to the whole scalp; the latter in order 
 to prevent the spread of the disease. There are many 
 excellent ones from which to choose, such as a half per 
 cent, solution of bichloride of mercury in ether or 
 alcohol; the oleate of mercury or copper; the essential 
 oils; tar; oil of cade; creosote in ethereal or alcoholic 
 solution, or in oil; sulphurous acid in full strength; 
 carbolic or salicylic acid, 3 to 5 per cent, in oil; the oint- 
 ments of the ammoniate or yellow sulphate of mercury; 
 and various others. Ointments or solutions of thymol, 
 napthol, pyrogallol, or chrysarobin in five to ten per 
 cent, strength, are among the newer remedies. Hyde 
 (18) quotes Lenzberg as saying that he had never failed 
 to cure a case of f avus without epilation by generating 
 sulphur fumes, carrying them to the head by means of 
 a paper cap, and continuing the fumigation for five or 
 ten minutes. Peroni (390 ap.) recommends spraying 
 the scalp with acetic acid. If this causes excoriations 
 they are to be treated with diachylon ointment, and 
 when healed the scalp is to be washed with warm 
 water and sublimate soap. 
 
 Sawicki (572) recommends cutting the hair short and 
 covering the whole scalp, crusts and all, with a paste 
 made out of powdered chalk or gypsum with iive or 
 ten per cent, of carbolic acid. The paste is to be lai 1 
 on 0.5 cm. thick, and the head bound with a damp 
 cloth. In three days the whole is removed, the scalp 
 washed with a potash soap, and the dressing reapplied. 
 Three or four applications are said by him to effect a 
 cure. The oil of naptha has been used from time to 
 time, applied morning and night, after washing the 
 scalp with soap and water. This often proves irritat- 
 ing. Unna (i93a) has recently recommended icthyol 
 in the form of spray for favus. Ihle (55-I-) cured one
 
 274: DISEASES OF THE HAIR AND SCALP. 
 
 case in two mouths by means of a five per cent, resor- 
 cin ointment. I have seen as satisfactory results from 
 epilation and the use either of a three to five per cent, 
 solution of salicylic acid in castor oil, kept constantly 
 applied, or from the constant and persistent use of 
 sulphur ointment, as from any other plans of treat- 
 ment. 
 
 The treatment of fa vus consists then, in 1st. Cleaning 
 the scalp; 2nd. Epilating; 3d. Applying a parasiticide. 
 These procedures must be repeated again and again, 
 and the whole diseased portion of the scalp worked 
 over and over, until the hair is apparently growing in 
 a healthy manu'^r and the scalp is free from reddish 
 points freshly cropping out. Then the scalp should be 
 left entirely alone for a few weeks. At the end of that 
 time it should be mspected, some hairs examined 
 under the microscope, and if there is no sign of the dis- 
 ease present, the case may be discharged. Even then 
 the patient should be examined from month to month 
 for some months, to make sure of the dm-abihty of the 
 cure.
 
 CHAPTER XVI. 
 
 PEDICULOSIS CAPITIS. 
 
 Synonyms: — Phthiriasis; Phtheiriasis; Morbus pedic 
 ularis; Pedicularia; Malis pediculi; Pediculosis cai)il- 
 litii; Lousiness (Eng.); Lausesucht (Ger.); Phthiriase, 
 ou Maladie pediculaire (Fr.). 
 
 Definition. — A contagious disease of the hairy scalp 
 due to its invasion by lice. It is characterized by the 
 presence of the lice and their ova upon the scalp and 
 hair; by the wounds inflicted by their probosces; by 
 pruritus; and by lesions consequent upon scratching. 
 
 Symptoms. — The attention of the patient is first 
 drawn to his disease by itching of the scalp, due to the 
 irritation produced by the louse in its endeavor to ob- 
 tain its nourishment from the skin, which it does by 
 inserting its proboscis into the follicles; and by its 
 moving about on the scalp and hair. The amount of 
 itching varies with the susceptibility of the individual, 
 with the number of the Hce present, and with the ex- 
 tent and duration of the disease. One louse will cause 
 as much itching in one individual as a whole army of 
 them will give rise to in another. In susceptible indi- 
 viduals, and in aggravated cases, the itching may be so 
 intense as to cause loss of sleep, and consequent loss of 
 health, emaciation, and such constitutional symptoms 
 as to constitute a grave disease. The itching always 
 induces scratching, and the inibbing and tearing of the 
 scalp by the nails give 'rise to the lesions of the dis- 
 ease. These are either merely excoriations, or isolated 
 pustules, or a veritable pustular eczema, varying with 
 the individual. People who are in bad hygienic sur-
 
 270 DISEASES OF THE HAIR AND SCALP. 
 
 roimdings, poorly nourished, uncleanly, and of stru- 
 mous habit present the most pronounced lesions. 
 
 The pai-t of the scalp most frequently affected is the 
 occipital region. The parietal regions stand next in 
 order of invasion, but always in conjunction with the 
 occipital region. In the vast majority of cases the 
 disease is hniited to these locahties, but sometimes the 
 whole head is affected, and in bedridden, uncleanly in- 
 dividuals the head-hce may be found on the trunk. 
 
 The picture i^resented by a well-marked case of pedi • 
 culosis capitis is the following: On hfting the hair 
 from the back of the head a reddened, oozing, excori- 
 ated, ciTisted patch of varying size is uncovered, with 
 outlying pustules, and cutaneous abscesses or furun- 
 cles, a veritable pustular eczema of liigh grade. The 
 hak is matted together by the exudation, and myriads 
 of Hce will be seen running around amongst it and 
 crawhng along the hairs. There will be multitudes of 
 ghstening white or yellowish ova firmly attached to 
 the hair shafts, sometimes quite near the scalp, some- 
 times at long distances from it. Over the whole scalp 
 we will find isolated pustules, fmiincles, excoriations, 
 and patches of eczema. The post-cervical glands will 
 be enlarged, there will often be patches of eczema be- 
 hind the ears and upon the face and neck, and, ac- 
 cording to Kaposi (19), pemphigus -like blebs may occur 
 upon the face. 
 
 Pediculosis may occur alone or it may compHcate 
 other diseases of the scalp, such as eczema, favus, and 
 trichophytosis 
 
 Etiology.— The head louse is the only cause of the 
 disease, and this is always derived from some other 
 individual sufferiug with phthiriasis. It used to be 
 thought that hce were the product of an eczema or other 
 disease of the scalp, but this view is no longer tenable. 
 It gained its support from the presence of an eczema
 
 PEDICULOSIS CAPITIS. 277 
 
 in the cases observed. But though eczema does not 
 produce hce, an existing eczema may favor their 
 invasion, providing for them a good and convenient 
 feeding ground. 
 
 The disease is met with most frequently amongst 
 the poor, but the better classes, even those who are 
 most cleanly, are not exempt. Thus Bulkley met with 
 228 cases of the disease in 8,000 cases of skin diseases, 
 of which 7 occurred in private practice. It is more 
 frequent than is pediculosis corporis, as Bulkley 'stables 
 show. He met with but IttT cases of the latter against 
 228 of the former. Children suffer from the disease 
 more than adults, and, among adults, women more 
 frequently harbor the vermin than do men. Infants 
 at the breast are, usually, exempt from the disease; I 
 have seen but few cases in them. The reason for the 
 exemption of infants is found in the scantiness of their 
 hair, and the greater care that is bestowed upon them. 
 Women wear their hair long and their skin is more 
 tender than is that of men; they therefore form a more 
 favorable lodgment for the lice than men do, and are 
 more often affected. 
 
 The cause of the lesions of the scalp in phthiriasis 
 is the scratching, nature's plan for allaying the itching. 
 The swollen glands are sympathetic with the inflam- 
 mation of the scalp; they are commonly met with in 
 all inflammatory diseases of the scalp. 
 
 The louse does not bite, as it has neither mouth nor 
 mandibles, but simply inserts his haustellum into the 
 follicles of the skin and sucks its food from the deeper 
 parts. Thus it is improper to speak of louse-bites. 
 
 Pathology. — The pathology of this disease is con- 
 cerned mainly with the louse itself. The pathology of 
 the lesions of the disease is the same as that of artifi- 
 cial eczema of the scalp, or a common traumatic der- 
 niatitis.
 
 27s DISEASES OF THE HAIR AND SCALP. 
 
 There are three distinct varieties of Uce which infest 
 the human body. 1. The pediculus vestimenti sen 
 corporis. 2. The pediculus capitis. 3. The pediculus 
 pubis. Each has its own province, out of which it 
 rarely passes. 
 
 The body louse resides in the clothing, which it leaves 
 only to draw its food from the wearer of the same. 
 This genus of louse does not concern us here. The 
 pubic louse is found mostly on the pubes, rarely on the 
 scalp, and will be described in the next chapter. We 
 have here to do with the head louse alone. The male 
 pediculus capitis is from 1 to 2 mm. long (according to 
 Neumann (27) it is 3 to 5 mm. long)- 
 ^ V^V_J^ and from 0.6 to 1 mm. broad: the fe- 
 ^"^ ^"^^"^^ male is larger by a few millimetres. 
 It is smaller than the body louse, and 
 larger than the pubic louse. Its head 
 is triangular in shape; its body forms 
 an elongated oval whose outline is 
 scalloped with seven deep notches. It 
 has three pairs of legs, situated well 
 Pediculus capitis, f^^ward at the sides of the thorax, 
 and these have powerful joints and strong claws. 
 The legs are covered sparsely with bristly hairs. Two 
 fine- jointed antennae come off from the head. The color 
 of the louse is gray with black outlines. The color 
 varies ^\ith the race. Thus in the Esquimaux it is 
 white, in the Negro black, and in the Chinese yellow- 
 isli brow^n. The ova or '^ nits" are about one quarter 
 of a line long, are of oval or pear-shape, and of gray 
 color. They are found in great abundance glued to 
 the hair-shaft, one hair bearing anywhere from one 
 to four or more, the lower one being the youngest. 
 They are first laid by the female along the lower part of 
 the hair- shaft, and then are carried further away from 
 the scalp by the growing hair. They are difficult to re-
 
 PEDICULOSIS CAPITIS. 279 
 
 move and are arranged along the hair hke grapes upon 
 a stem. 
 
 The female is very prolific, laying from fifty to sixty 
 eggs. The young hatch out in six days, and within 
 seventeen to twenty days are capable of propagating. 
 This accounts for the rapidity of spread of the disease, 
 one louse being capable of producing 8000 lice in eight 
 weeks. 
 
 Diagnosis.— Pediculosis capitis is most apt to be 
 mistaken for an eczema of the scalp, and is not infre- 
 quently treated with ointments, such as that of the 
 oxide of zinc, wiiich only add the element of rancid 
 lard to the already disgusting condition present. This 
 mistake need never occur if we bear in mind that an 
 eczema of the occipital region is due, in an over- 
 whelming majority of cases, to Hce. In every such 
 case then, look for the vermin, and you will find them 
 or their nits, if the case is one of pediculosis. In some 
 cases where only itching of the scalp is complained of 
 and the patient is very careful of his scalp, we may 
 find neither eczema nor lice, but simply some little 
 grayish bodies fastened on the hairs. These may be 
 epithelial scales or sebaceous masses perforated by 
 hairs, a not uncommon condition; or they may be nits. 
 The doubt is readily settled by attempting to remove 
 them. If they are epithelial or sebaceous particles they 
 will be easily removed by brushing. If they are ova 
 they will resist the brush, and sometimes the comb, 
 and often will require the application of some agent, 
 such as acetic acid, to dissolve their connection with 
 the hair. 
 
 Prognosis. — The disease is rapidly and completely 
 cured by appropriate treatment. 
 
 Treatment. — The promptest, cheapest, and most 
 readily obtainable remedy for pediculosis capitis is 
 crude petroleum or common kerosene oil. The head
 
 280 DISEASES OF THE HAIR AND SCALP. 
 
 is to be saturated with this for a day or two, and then 
 well washed w4th an abundance of soap and water. 
 This will destroy the lice, but will not prevent the 
 hatching out of the ova. Tliese are to be removed by 
 the fine comb, care being taken not to touch the scalp, 
 and by pulling the hair through a towel saturated with 
 vinegar or dilute acetic acid. By patience all the nits 
 may be removed. As a precautionary measure the 
 scalp should be well wetted with kerosene for a few 
 days, after it is apparently well, to insure the death of 
 any louse which may have hatched from a missed nit. 
 The objections to this plan are the danger of fire, and the 
 unpleasant odor. The first objection may be met by 
 cautioning the patient to keep away from the fii'e; or 
 the danger may be reduced by mixing the petroleum 
 with some other oil, such as olive oil. The second 
 objection is overcome by adding some perfume to the 
 oil. But this is only partially effective, and the plan 
 with all its excellencies cannot be used in j^i'i^ate 
 practice. 
 
 It is always preferable to use lotions rather than 
 ointments in treating pediculosis capitis. Ointments 
 are apt to mat the hair together and to become rancid. 
 There are many drugs and chemicals that destroy lice. 
 One of the most desirable for use in private practice, 
 and in adults, is a solution of bicliloride of mercury, two 
 or five gi-ains to the ounce of cologne water or bay 
 rum, sopped on several times a day. This is poisonous 
 and had best not be used on the heads of children, and 
 is contraindicated where there is eczema. In children 
 a good substitute is carbolic acid, ten, twenty or more 
 drops to the ounce of alcohol, to which a little glycerine 
 may be added. Larkspur seed {staphisagria) can be 
 readily obtained, and a strong decoction of it will be 
 found a quick and sure destroyer of hce. Instead of the
 
 PEDICULOSIS CAPITIS. 2S1 
 
 decoction the tincture may be employed. Napthol, 
 five per cent, in oil, is another good remedy. The 
 essential oils will kill lice. The decoction or tincture 
 of cocculus indicus enjoys a repute tion of the same 
 sort. A five or ten per cent, salicylated oil may be 
 used. Instead of a lotion we may use an ointment, 
 especially where there is considerable irritation of the 
 scalp and an artificial eczema. One of the best is that 
 of the ammoniate of mercury made with vaseline in 
 twenty per cent, strength. Where eczema is present, 
 we want to kill the lice first, when it will be an easy 
 matter in most cases to cure the eczema. These ecze- 
 matous heads with lice will often bear kerosene very 
 well. After the vermin has been destroyed by the 
 kerosene, the application of oil of cade, one drachm to 
 olive oil one ounce, will act admirably upon the eczema 
 and at the same time be a parasiticide. 
 
 An ointment of sulphur is efficient, as is also one of 
 sabadilla. The latter should not be used upon a sore 
 head as it may cause dangerous symptoms of poison- 
 ing. All the ointments of mercury will render good 
 service. An ointment of tobacco w^ill destroy the 
 pediculi, but it is too disagreeable for use except when 
 nothing else is available. Chrisma, a derivative of 
 petroleum, has been indorsed by Crane as an active 
 parasiticide. (587.) 
 
 Instead of ointments some recommend powdering 
 the hair with either calomel, pyrethrum roseuni 
 (Persian insect powder), powdered seeds of wormwood, 
 rue, or parsley. But in my judgment ointments and 
 powders are all objectionable. If an ointment must 
 be used, then it is better to have it made with vaseline 
 rather than with lard, as it is less Hable to mat the 
 hair. In all cases soap and water should be used for 
 washing, and this should be done daily, excepting
 
 282 DISEASES OF THE HAIR AND SCALP. 
 
 where eczema is present, when water is contraindi- 
 cated. In all cases the nits are to be removed with the 
 greatest care, and we must impress upon the patient 
 or the attendant, that as long as there is a single nit, 
 there is danger of a new outbreak. The nits may be 
 removed, as already stated, by means of vinegar, or 
 acetic acid, which is the best. To the same end alco- 
 hol, and alkaline solutions, as of borax or soda or the 
 tincture of green soap, may be used.
 
 CHAPTER X\^II. 
 
 PEDICULOSIS PUBIS ET PALPEBRARUM. 
 
 These two diseases are caused by the same species of 
 louse, the Phthirius inguinahs, or, as commonly called, 
 crab louse. We will first consider, 
 
 PEDICULOSIS PUBIS. 
 
 Symptoms. — When the louse has taken up its habita- 
 tion upon the pubes it begins to propagate in the same 
 energetic way we have learned of in the preceding 
 chapter; and to insert its haustellum into the foUicles 
 of the skin and suck its nourishment therefrom. The 
 movements of the lice upon the hair, and the irritation 
 caused by their puncturing the skin, give rise to itching, 
 which the patient tries to allay by scratching. The 
 itching is at times intense, specially at night, but is 
 usually not so violent as in pediculosis capitis, though 
 it is as persistent. As a rule there is no great amount 
 of dermatitis or eczema present, and it is rare to see 
 such a picture presented as we constantly meet with in 
 pediculosis capitis. This may be accounted for by the 
 fact that the pubic region must be scratched for the 
 greater part of the time through the clothes, while 
 the scalp is readily accessible to the nails. If the lice 
 are present in very gi^eat number, or the patient's skin 
 is very vulnerable, we may have a well-marked eczema. 
 The patient usually applies to the physician on account 
 of a pi-uritus of the genital region, and in the majority 
 of cases, is not conscious of having lice on liim. In all
 
 ^84 DISEASES OF THE HAIR AND SCALP. 
 
 cases of itching about the genitals it is imperative to 
 make an examination of the parts. If Hce are present 
 we will And them as small, flat, translucent, brownish 
 or reddish specks close down to the skin and chnging 
 to the roots of the hair. Their position is character- 
 istic. They usually are found with their heads buried 
 in a skin- follicle, their claws firmly fastened about a 
 hair, and their hinder parts sticking up in the air. At 
 times one may be found moving about upon the hair, 
 but they are far less active than the hce which infest 
 the head and clotliing. Besides the lice, we will find 
 their excrement lying amongst the hair-roots in the 
 form of minute reddish particles; and their ova upon 
 the hair. As has already been said, we may find a well 
 marked eczema of the pubic region. This is excep- 
 tional. But we constantly see red, punctate macules 
 or papules scattered about, which are scratch marks. 
 Now and again, but not constantly, we will see dull or 
 slaty gi'ay, or peculiar pale blue macules, varying in 
 size from that of a lentil to that of a split pea or larger, 
 scattered over the regions infested by the lice, as over 
 the pubes, abdomen, and inside of the thighs. These do 
 not disappear on pressure; they last for a few days 
 and then vanish of themselves. They are known as 
 macuJce cerulece or, in French, tdches omhrees. They 
 are unaccompanied by any subjective symptoms. 
 
 Tlie pubic louse is more nomadic than any of its 
 congeners. While it is most frequently found, as its 
 name indicates, upon the pubic region, it is not infre- 
 quently met with upon other parts of the body sup- 
 phed with hair, as upon the thighs, about the anus, on 
 the abdomen, thorax, and arms, in the axillae, occa- 
 sionally upon the eye-brows, eyelashes and beard, and 
 sometimes on the arms. In aU these situations it gives 
 rise to the same symptoms as when on the pubes, and 
 we must be on the watch for it in all cases of pruritus
 
 PEDICULOSIS PUBIS ET PALPEBRARUM. 
 
 1>S5 
 
 in those regions. It is not found on the scalp. Adults 
 are the subjects of the disease in the vast majority of 
 cases. 
 
 Etiology.— The cause of the disease is the infesting 
 of the part with the pubic louse. The infection most 
 commonly is effected during sexual intercourse. It is 
 also acquired by sleeping with an infected individual or 
 in a bed already infected by some one ; and by wearing 
 infected clothing. It is quite possible for the vermin to 
 infest a woman in public conveyances, on account of the 
 peculiar make of her 
 clothing. A man's 
 clothing affords bet 
 ter protection. Pif- 
 FARD (29a) thinks that 
 it is possible to ac- 
 quire the disease in 
 water-closets. It is 
 much rarer than are 
 the other forms of pe- 
 diculosis. BULKLEY 
 records but 8 cases in 
 8,000 cases of skin dis- 
 eases. The tables would indicate that it is proportion- 
 ately more common in private practice than are the 
 other forms, as of the 8 cases met with, three were in 
 private practice and five were in public practice. 
 
 Pathology. --The pathology of this affection is the 
 same as that of pediculosis capitis with but two excep- 
 tions, and those are the characteristics of the louse, 
 and the macula3 ceruleae. These alone will require 
 notice here. 
 
 The Pubic Louse, — synonyms : pediculus pubis sen 
 ferox, phthirius inguinalis, morpio, f oralis pediculus; 
 morpion (Fr.); die Filzlaus (Ger.); Crabs (Eiig.), — 
 has a less triangular and more broad head than the 
 
 Pediculus pubis.
 
 286 DISEASES OF THE HAIR AXD SCALP. 
 
 other species of louse, and a well-marked neck. Its 
 body is heart-shaped, and its eight segments are not 
 clearly indicated by notches in its outhne, as is tlie 
 case with the head louse. It has three pairs of legs 
 which come off from its thorax, of which the anterior 
 pair are proportionately dehcate, and bear only a small 
 claw at their ends. The two other pairs have a stout 
 hook-shaped claw. The male is from 0.8 mm. to 1.0 
 mm. long, and from 0.5 mm. to 0.7 mm. wide; and 
 the female is from 1.0 mm. to 1.5 mm. larger. The 
 female has a triangular-shaped notch at the termina- 
 tion of the abdomen. From the head of the louse 
 project two fine- jointed antennae. The color of the 
 louse is yellowish gray; and it is more or less trans- 
 parent. 
 
 Maculae ceruleae have long been known, but until 
 very recent times their significance has been misunder- 
 stood, and they have been considered as symptomatic 
 of grave fevers, such as typhus fever. 
 
 MouRSON (591) was the first, in 1878, to draw atten- 
 tion to the connection between these spots and the 
 presence of hce. He showed that while everyone who 
 has pediculosis pubis does not have the maculae, yet 
 everyone upon whom the maculae are fomid has the 
 pediculi, or has had them shortly before presenting for 
 examination. They were found more commonly in 
 those who had fine skins and did not wash often. 
 They are fuiiher j^roved to be due to the hce by the 
 fact that if only one axiUa was affected with hce, 
 they would be found in that axiUa alone, the other 
 being free. Most of the cases have been found in 
 patients suffering from some debilitating disease, and 
 their gi^eat rarity,— Gibier (580) failed to find a single 
 case in Iavo hundred subjects of pediculosis, — would in- 
 dicate that some predisposition on the pai-t of the skin 
 is a requisite for their formation. The causal connec-
 
 PEDICULOSIS PUBIS ET PALPEBRARUM. 2S^ 
 
 tion between the pediculi and the maoulai having been 
 estabhshed, it next remained to determine how they 
 were produced. Duguet (588), in 1880, obtained the 
 same appearances by pricking the skin with a lancet 
 point charged with a paste made by rubbing up the 
 bodies of twenty-five hce. Bat he could produce the 
 maculae only in individuals already bearing them ; an- 
 other indication of the part idiosyncrasy plays in the 
 disease. He believes that the maculae are caused by 
 the emptying of the contents of the salivary glands of 
 the louse beneath the epidermis of the human, uncon- 
 nected with any further alterations in the skin. These 
 spots spontaneously disappear in about ten days. 
 
 Diagnosis.— The detection of the louse or its nits 
 will at once give the diagnosis. It is for us only to 
 look for the evidence of pediculi in every case of pruri- 
 tus cutaneous, especially when such pruritus is limited 
 to the pubic or axillary regions. We should suspect 
 and carefully look for lice in all cases of eczema limited 
 to the pubis, and even in eczema of the genitals and 
 thighs. The pediculus pubis is less easy of detection 
 than are the other species of louse on account of its 
 small size, light color, translucency, greater quiescence, 
 and more or less perpendicular position as it lies deep 
 down among the hair-roots. Still if one is but alive to 
 the possibility of the vermin being present, he will 
 have no difficulty in detecting them when present. 
 
 It is important to determine whether we must deal 
 with the pediculus vestimentorum, the so-called body 
 louse, or with the pubic louse, as the two species of 
 louse demand different treatment. The body louse in- 
 habits the clothes alone, and if we search carefully we 
 will find either the lice crawling about the clothing or 
 will see its eggs deposited in groups aloug the seams of 
 the clothing. The pubic louse dwells upon the hairy 
 skin alone, and neither it nor its egg is to be found in
 
 ^S.S DISEASES OF THE HAIR AXD SCALt>. 
 
 the clothing. The scratch marks of pediculosis vesti- 
 mentoruin are found over the shoulders posteriorly, 
 ahout the waist, and along the outer side of the limbs 
 where the seams of the clothing come. The long 
 parallel scratch marks over the shoulders are pathog- 
 nomonic of this form of lice. The scratch marks of 
 pediculosis pubis are limited more to hairy parts, and 
 therefore are seen more commonly on the anterior face 
 of the trunk, and in the axillae. Maculae ceruleae are 
 met with in this form alone. 
 
 Prognosis. — There will be no difficulty in curing the 
 disease if we have once made the diagnosis. 
 
 Treatment.— The quickest and neatest method of 
 treatment, when the patient A\ill allow of it, is to 
 shave the affected parts. By this means we at once 
 destroy the lice, nor need we wait until any compli- 
 cating eczema is cured. One of the most frequently 
 employed remedies is mercurial ointment. It is effica- 
 cious, but very often proves irritating and sets up a 
 pustular eczema. A lotion of the bichloride of mer- 
 cury is better. If there is much excoriation mercurials 
 are to be avoided. Any of the remedies used in pedi- 
 culosis capitis will be useful here, and need not now 
 be detailed. Chloroform may be used to destroy the 
 lice where the skin is uninjured, using the plan pro- 
 posed by Hamal (590) in 1S5T, namely, after washing 
 the part with soap and water, and then with clear 
 water, and drying, pour chloroform on drop by drop and 
 iTib in. Then cover with a folded handkerchief for a 
 half hour, and wash again to remove the debris of 
 pediculi. As the chloroform is irritating it is advisa- 
 ble to protect the skin of neighboring parts w^ith pow- 
 der. Ether will act in the same way as the chloro- 
 form. Hot baths \^ith the free use of soap, and sub- 
 sequent bathing with carbolized water, is a good plan 
 of treatment for a generalized ^pediculosis caused by 
 the pubic louse, care being taken to get rid of the ova.
 
 t>EDICULOSIS PUBIS Et PALPEBRARUM. 28^ 
 
 Mourson caused the maculae ceruleae to disappear 
 promptly with a solution of hypochlorite of soda. 
 
 Pediculosis Palpebrarum is a very rare form of 
 pediculosis, which occurs most frequently in children. 
 It is caused by the pubic louse and is communicated in 
 some cases from the beard of a man in the act of 
 fondling a child. As a rule there is but little itching in 
 this form of pediculosis, though there is enough to 
 cause the patient to rub the eyelids. The irritation by 
 the lice and by the rubbing gives rise to redness of the 
 lids and even eczema. Usually the eyelids will be 
 found reddened, crusted, and scaly, and sometimes 
 some of the eyelashes are broken off. Close examina- 
 tion will show the lice either at the roots of the eye- 
 lashes in the characteristic position, or wandering 
 about, and the eyelashes will have ova upon them. 
 Minute reddish specks of excrement are to be seen on 
 the edge of the lids, especially the lower one. One or 
 both lids may be affected, and the disease is symmetri- 
 cal or unilateral. The whole of a lid may be diseased, 
 or only places here and there. The eyebrows may 
 also be involved with the eyelashes, or be affected inde- 
 pendently of them. 
 
 The treatment consists either in pulling out all dis- 
 eased hairs, and then smearing on mercurial ointment, 
 which is a rapid and radical plan of treatment; or the 
 mercurial ointment may be smeared on, and soap and 
 water used to wash off the lice and remove the ova. 
 As the first plan results in a temporary deformity, and 
 the second is quite as effectual though slovv^er, the 
 latter is to be preferred.
 
 CHAPTER XVIII. 
 
 BEIGEL'S disease, or the CHIGXOX fungus ; PIEDRA ; 
 
 TRICHOMYCOSIS NODOSA ; AND OTHER 
 
 PARASITIC DISEASES. 
 
 Besides favus, ringworm, and pediculosis, there 
 have been described from time to time other parasitic 
 diseases which involve the hair. In this tjhapter will 
 be found Beigel's disease, Piedra, Tinea nodosa, Tri- 
 chomycosis nodosa, and some unclassified parasitic 
 diseases. 
 
 beigel s disease. 
 
 In 1S66, Professor Lixdemaxn of Petersburg first 
 described a parasite that he fomid in artificial hair, 
 and which he considered a species of gregarine, or 
 low form of animal life on the border line between 
 the vegetable and the animal world. Shortly after 
 this Beigel (44) examined a number of samples of arti- 
 ficial hair, and in one, which had been discarded by the 
 hair- workers as unfit for use, he found upon each hair a 
 number of dirty brown knots which adhered very close- 
 ly to it. The hair itself was unaffected, and the knot 
 formed a sort of sheath to it. With considerable care it 
 could be stripped off without damaging the hair. Micro- 
 scopical examination showed that these knots were com- 
 posed of micrococci in chains, and of large round cells 
 containing two to four large nuclei. The fungus groTvi^h 
 was pronoimced by Kuchexmeister as a new species
 
 PIEDRA. 291 
 
 of pleurococcus. Hallier (4:4) subsequently deter- 
 mined that they were a new species of Sclerotium, and 
 a stage in the development of the well-known peni- 
 cillium. Behrend (3) considers the chignon fungus as 
 being a species of Piedra. 
 
 Beigel determined by experiment that the chignon 
 fungus was incapable of producing the slightest ill 
 effect upon the skin. It is therefore simply a scientific 
 curiosity. 
 
 PfEDRA. 
 
 The best description of this is given by Malcolm Mor- 
 ris (293) in his paper upon the subject reported in the 
 Transactions of the Pathological Society of London, 
 1879, vol. XXX., page 441: also in the Lancet, 1879, x., 
 407. It is upon this paper I mainly rely in the follow- 
 ing account of the disease, as from its rarity I have 
 not had an opportunity to study it. 
 
 Description.— Piedra is said to occur only in Cauca, 
 one of the United States of Colombia, and was first 
 described in 1874 by Dr. N. Osorio of the University 
 of Bogota. It consists in the occurrence, along the shaft 
 of the hair, of from one to ten smaU dark-colored nodes 
 which are very hard and gritty, and rattle like stones 
 when the hair is combed or shaken. The stony hard- 
 ness of the nodes gave the disease its name, which in 
 the Spanish language means *' stone." These nodes 
 are always placed at irregular intervals along the hair- 
 shaft, and are first met with at about half an inch 
 from the point of exit of the hair, the root being 
 unaffected. The disease occurs most frequently in 
 women, men being but rarely affected, and it is the 
 scalp-hair alone which exhibits the disease. It is non- 
 contagious and seems to be met with only in warm 
 valleys. The hair has an acid odor.
 
 292 DISEASES OF THE HAIR AXD SCALP. 
 
 Etiology.— Dr. Osorio thought that the nodes were 
 produced by an agglomeration of epithelium in certain 
 parts of the hair. Morris believes that it is a fungoid 
 gro\\i:h, and due to the use of a pecuhar mucilaginous 
 hnseed-hke oil by the natives, especially by the women, 
 to keep the hair smooth and shiny. Another theory 
 is, that it depends upon the use of the watei*s of certain 
 stagnant rivei-s, wliich are very mucilaginous. Heat 
 seems essential for its production, as the use of either 
 the oil or the water fails to cause the disease in cold 
 chmates. 
 
 Pathology. — The hair is formd to be dark, weak, 
 and flaccid. The nodes are very hard to cut, and 
 when considerable force is used they break. Under 
 the microscope the appearance is that of a honey-comb 
 mass consisting of spore-hke bodies, deeply pigmented 
 on their surface. The mass in its early stage seems to 
 oiiginate from one cell that gi^ows by budding in every 
 direction, forming radiating columns of spore -like 
 bodies. As soon as the mass has gT0^^^l to a certain 
 size, the surface cells seem to alter in shape, become 
 darker in color, and form a pseudo-epidermis. Mor- 
 ris, (293). 
 
 Diagnosis. — It is differentiated from trichoiThexis 
 nodosa by the stony hardness of the nodes, by its oc- 
 curring principally upon the scalp-hair, by its probable 
 etiology and by the microscopical appearances it pre- 
 sents. 
 
 The third nodular disease of the hair is 
 
 tinea nodosa. 
 
 This name is selected by Cheadle and Morris (278) 
 to designate a condition of the hair which differs from 
 trichorrhexis nodosa, in the presence of a parasitic 
 growth resembling, though larger than, that of tinea 
 tonsm-ans; in the marked incrustation of the hair-shaft
 
 TINEA NODOSA— LEPOTHRIX. 293 
 
 by this growth; and in the absence of multiform sym- 
 metrical nodosities. It also lacks the stony hardness 
 of Piedra. 
 
 According to their description the hair folhcles and 
 the skin were unaffected, and the hairs were firmly 
 fixed in their foUicles. The affected hairs looked as if 
 incrusted by a granular material around and external 
 to the shaft. In some places sphtting of the hair and 
 incrustation occurred together; in other places incrust- 
 ation was seen alone, the hair- shaft being intact though 
 somewhat cloudy and opaque. The incrustation in- 
 creases toward and reaches its maximum at the free 
 extremity. With high powers the incrustation was 
 seen to consist of an agglomeration of minute, spher- 
 ical, light-refracting bodies of uniform size, and hav- 
 ing all the characters of a vegetable parasite. The 
 sporules adhered, as a rule, in masses like fish-roe; but 
 a few were found scattered about in small groups. As 
 a rule none were found within the hair- shaft. When 
 splitting and fibrillar disintegration were well advanced, 
 a few spore like bodies were seen clinging to the fibrils, 
 or more rarely lodged in the interstices between them. 
 The spores were larger than those of tinea tonsurans. 
 
 LEPOTHRIX. 
 
 This disease was first described by Paxton (295), and 
 received its name from AVilsox. Patteson (418, 419 
 ap.) has studied it carefully and proposed for it the 
 name of Trichomycosis nodosa. 
 
 It affects the hair of the axilla? and scrotum, and 
 assumes two forms, a diffuse and a nodular form. In 
 the first the hairs appear dry and dull, and look as if 
 they had been steamed. Tliey feel rough and knotted, 
 on account of the projection from the side of the 
 shafts of numerous minute concretions. The w^hole 
 hair may be involved, or there may be intervals of
 
 29i DISEASES OF THE HAIK AND SCALP. 
 
 sound hair. The nodular form consists of small, 
 rounded masses, generally most thickly placed on the 
 terminal third of the shaft. Both forms may be pre- 
 sent on the same hair. They are firmly adherent, and 
 cannot be separated from the hair without injury to 
 it. The hairs themselves are usually unaffected and 
 end with fine points. Occasionally they break through 
 a node and their ends split up into fine fibres. The 
 follicles are not implicated. 
 
 The disease is due to the gro\vth of bacilli upon the 
 hairs of individuals who sweat freely. The sweating 
 loosens the epidermic scales of hair and allows of the 
 lodgment of the bacilli. At first these lie in small jDits 
 or depressions on the hair, but by their growth they 
 break the cortical fibres. They also produce a hard, 
 homogeneous, granular substance, which lies between 
 and around the bacteria and forms the nodes, at the 
 same time acting like a cement to prevent the break- 
 ing of the hair. The bacilli are short, fine rods with 
 slightly rounded ends, two or three times as long as 
 broad, and about one-fourth the diameter of a red 
 blood corpuscle. They stain readily with aniline dyes, 
 but best by Gram's method. They are sometimes 
 joined together, but do not form threads. They are 
 not cultivatable by ordinary methods. 
 
 It will be seen that this disease bears a close resem- 
 blance to tinea nodosa. Treatment has not been very 
 successful, but an antiparasitic lotion is indicated and 
 the use of soap and water. 
 
 DISEASES OF THE HAIR CONNECTED ^VITH EXCESSIVE 
 
 SWEATING. 
 
 Various colored nodes surrounding tlie hair are 
 found in subjects who sweat profusely. These are 
 met with most often in the axillae, then upon the
 
 DISEASES CONNECTED WITH EXCESSIVE SWEATING. 295 
 
 chest, genital regions, and inside of thighs. They are 
 of large and small size, completely invest the hair 
 sometimes to a considerable length, and adhere closely. 
 Behkend (3) says that they are found in twenty per 
 cent, of all individuals in Germany. They certainly are 
 much less frequent in this country. They occur most 
 often in Summer and in those who do not bathe fre- 
 quently, and, like Beigel's chignon fungus, are of no 
 pathological significance, excepting that they may be 
 the cause of chromidrosis staining the underclothing 
 red. 
 
 The color of these nodes is grayish, yellowish red or 
 brown. When the hair is dry they are hard, and 
 appear under the microscope as sharply contoured 
 bodies. When plucked from the sweating skin they 
 appear as slimy or gelatinous masses. They are com- 
 posed entirely of micrococci, of which several different 
 forms have been described. Eberth (598) has met 
 with tliem in the form of colonies composed of round, 
 oval and biscuit-shaped bacteria; as ball-shaped, some- 
 what larger, bacteria; and as bacteria in chains. 
 
 The sweat macerates the hair and loosens its cuticle 
 in places. In tliese the micrococci gain lodgment, and 
 their growth being favored by the heat and moisture, 
 they rapidly increase, still further lift up the cuticle, 
 and form nodes. It is possible that they may even 
 penetrate between the cortical fibres, though Waldeyer 
 is inclined to doubt this. 
 
 Under the title of "'Dermatojiiykosis PalmelUna,^'' 
 Pick (000), in 1875, described similar micrococci due to 
 sweating and occurring in the same situations. But he 
 found in his case that the hair was fragile, and in places 
 broken off so as to leave bald spots. Martin (599), 
 in 1862, reported a case in which a patch of hair on 
 the occiput of a girl recovering from typhoid fever be- 
 came golden or yellowish red, and looked as if smeared
 
 29G DISEASES OF THE HAIR AND SCALP. 
 
 with a yellowish red pomade. In one part of the 
 patch the Jiair had dropped out or was broken off, and 
 in other parts it looked as if it had been singed. The 
 pomade-like substance was composed of epiphytes, 
 the ZoogJea Cajnlloruui of Btihl. 
 
 UNCLASSIFIED PARASITIC DISEASES OF THE HAIR. 
 
 DuHRiNG (597), in IS 76, reported a case of parasitic 
 disease of the hair of the head in which ova were found 
 upon the hau', and papules and pustules on the scalp. 
 Xo insect couJd be detected about the scalp or person, 
 and the ova, though watched for some time, did not 
 undergo change. The ova were firmh^ attached to the 
 shaft of the hair, close to the root, and were of elon- 
 gated, elliptical shape. One end was glued to the hair, 
 the othei' terminated in a romided, somewhat tapering 
 form. They were firm in consistence, half a hue in 
 length, and a twelfth of a hne in width. Their color 
 was straw yellow. From four to a dozen ova were 
 fastened to a hair, arranged in rows, close to one an- 
 other and pointing obhquely upwards away from the 
 •scalp. 
 
 Thin (601), in 1882, reported a case of parasitic dis- 
 ease of the moustache occurring in a man of good 
 health, readily cured, but reappearing once a year for 
 five yeai^. It caused a bald strip one quarter of an 
 inch l)road, extending from the upper to the lower 
 border of the moustache. The diseased surface had 
 the characteristic appearances of ringworm. The hair 
 contained spores similar to the trichophyton fungus, 
 but were diseased at their free extremities first, instead 
 of at theii* roots, as is the case in ringworm.
 
 PAET lY. 
 
 DISEASES OF THE HAIR SECONDARY TO 
 DISEASES OF THE SKIN.
 
 CHAPTER XIX. 
 
 DANDRUFF. 
 
 Synonyms: — Seborrhoea sicca capitis; Pityriasis capi- 
 tis; Dandriff ; Eczema seborrhoicum. 
 
 The term dandruff or dandriff has been used to des- 
 ignate at least four distinct diseases of the scalp, name- 
 ly: pityriasis simplex, seborrhoea sicca, eczema ery- 
 tliematosum or squamosum, and psoriasis; and it is 
 probable that a fifth disease, diffuse trichophytosis 
 capitis, has been included under it. Properly speaking, 
 its use should be limited to that scaly condition of the 
 lioad which is due to seborrhoea sicca or pityriasis sim- 
 plex — the seborrhoeal eczema of Unna. 
 
 Whether these latter three diseases are identical or 
 not, is still an unsettled question. By some authori- 
 t ies they are regarded as one and the same disease, but 
 t hey present enough points of difference to entitle them 
 to separate consideration. I have here placed them 
 together for convenience, as they give rise to a some- 
 Avhat similar condition of the scalp, and are amenable 
 to the same treatment, 
 
 Seborrhoea sicca ir., as commonly taught, a functional 
 disease of the sebaceous glands, in which an abnormal 
 amount of sebaceous matter of abnormal consistence 
 is secreted by them. This dries upon the scalp, and 
 cither appears in the form of thin, fatty plates about 
 the mouths of the hair-follicles, or adheres to the hairs 
 ill flakes, or, if very abundant, heaps up into thick, 
 fatty masses or cakes, which cling with a good deal of 
 tenacity to the scalp. This latter form is seen very
 
 300 DISEASES OF THE HAIR AND SCALP. 
 
 frequently in children, during the early months of in- 
 fancy, and is the remains of the vernix caseosa. If 
 portions of these crusts or cakes are rubbed between 
 the thumb and finger, they will impart an unctuous 
 feeling. The scalp in this disease is usually pale or 
 leaden-hued, and when the crusts are removed shows 
 no tendency to moisture, or else exhibits a fatty, glis- 
 tening surface upon which the crust is soon renewed. 
 In some cases more activity is shown, and the scalp 
 is slightly reddened. This affection runs a chronic 
 course, is generally most pronounced on the vertex, 
 but often is distributed quite uniformly over the whole 
 head. Some pruritus at times is present, and in some 
 cases, in consequence of scratching, there will be ex- 
 coriations. Seborrhoea of the scalp may also take the 
 oily form (seborrhoea oleosa), though this is unusual. 
 In that case, instead of the scalp being covered with 
 fatty plates and scales, it will be oily, a»d the hair 
 shiny. 
 
 Pityriasis simplex, sen capillitii, is essentially an 
 interference with the cornification of the upper cell- 
 layers of the skin, on account of which, instead of the 
 normally compact stratum corneum, we have a con- 
 stant shaling off of imperfectly formed epithehal scales. 
 The whole scalp may be quite uniformly affected, or 
 the disease may be hmited to the vertex, or it may 
 occur in circumscribed patches. The scales are thin, 
 easily detached from the scalp, sometimes so easily as 
 to be readily blown off, and they do not pile up into 
 crusts. When rubbed between the thumb and finger 
 these scales do not impart the same unctuous feeling 
 as do those of seborrhoea sicca, though there is usually 
 a certain amount of sebaceous matter present, just as 
 in seborrlioea sicca there is always an admixture of 
 epithelial scales. Usually the scalp is of normal color, 
 though often it is shghtly reddened from hyperaemia.
 
 DANDRUFF. 301 
 
 There is never any moisture of the scalp. Pruritus 
 often annoys the patient, especially when he is over- 
 heated or is using his brain actively, and this inviting 
 scratching, excoriations are often met with. 
 
 Unna, of Hamburg, and Elliot, of New York, to- 
 gether with some other authorities, would do away 
 with both of the names seborrhoea and pityriasis, and 
 substitute that of sehorrh(xal eczema, as they regard 
 both of the former as but degrees of the latter, and 
 both of them as inflammatory diseases of the scalp. 
 
 These two diseases, differing mainly in their essen- 
 tial lesion and constituting dandruff, cause annoyance 
 by the constant falling of the scales upon the shoulders 
 of the patient, thus ruining the clothing, or giving it 
 the appearance of being powdered; and by the pruri- 
 tus which attends them. The hair, too, is generally 
 dry, and will not stay smooth after brushing. It is 
 for these reasons, in most cases, that the patients ap- 
 ply to us for relief. But dandruff is in many cases the 
 forerunner of baldness, and the fact that a long con- 
 tinued seborrhoea sicca, or pityriasis, is the most fre- 
 quent cause of premature alopecia, should stimulate us 
 to use our best efforts to cure the disease. 
 
 Etiology. — Dandruff is one of the most common of 
 skin diseases. Statistical tables would not show this, 
 as it is seldom so bad as to demand medical aid. It 
 frequently occurs in strumous individuals who are 
 anaemic and have a sluggish circulation niarked by 
 cold hands and feet. Adolescence is its peculiar time 
 of appearance, and chlorotic girls are apt to be annoyed 
 by it. It is an attendant upon chronic debilitating dis- 
 eases, such as rheumatism, syphilis, phtliisis, and the 
 like, and comes on after profound disturbances of the 
 constitution, such as fevers and parturition. Dyspep- 
 sia and constipation are very common exciting causes 
 or aggravants of the disease. Improper care of the
 
 302 DISEASES OF THE HAIR AXD SCALP. 
 
 scalp, the use of the fine-toothed comb, and of pomades, 
 hair "tonics," and hair-dyes, will give rise to the dis- 
 order. In some cases there is apparently no cause for 
 the disease, but careful inquiry, even in these cases, 
 will usually bring out some latent cause, such as 
 worry, overwork, mental or nervous strain, and the 
 like. Malassez, Thix, Chtncholle, and some others, 
 claim to have found a parasite as the origin of the 
 trouble; and recent experiments by Lassar and Bish- 
 op would seem to prove that the disease, at least pity- 
 riasis simplex, is contagious." The jDarasitic and con- 
 tagious theory of its origin is gaining ground. 
 
 Pathology. — Seborrhoea sicca is a functional disease 
 of the sebaceous glands, no structm^al derangement of 
 them having been found. The normal change of the 
 hning cells of the glands into oil globules, which escape 
 through the gland ducts as an oily secretion, is miper- 
 fectly performed, and instead of an oily fluid we have 
 an inspissated fat. ^licroscopical examination shows 
 the ciiist of seboiThoea sicca to be composed of a gran- 
 ular mass of epithehal cells in various stages of fatty 
 degeneration, and some oil globules. 
 
 Pityriasis is a consequence of imperfect comification, a 
 condition that sometimes follows a squamous eczema. 
 By some authorities, as is stated mider etiology, a par- 
 asite is maintained to be the reason of the desquama- 
 tion. Both Malassez (169) and Chixcholle (OOJ:), in 
 lb 74, described parasites found in the scales from cases 
 of pityriasis capitis, and asseiied that they were the 
 cause of tlie disease. They described them as oval or 
 spherical in shape, and from 2 to 5 mm. in length, 
 without myceha, and forming more or less extended 
 sheets upon the surface of the corneous layer of the 
 
 * The experiments of Lassar and Bishop wiU be found in Chapter 
 VI., page 97, of this work.
 
 DANDRUFF. 303 
 
 Skin, splitting it intolayers: These spores of Malassp:z 
 and Chincholle are probably identical with the sac- 
 charomyces sphoericus et ovalis of Bizzozero (603), 
 which according to him are found quite generally upon 
 the normal human skin. The question of the parasitic 
 or non -parasitic nature of pityriasis capitis cannot be 
 considered settled as yet. 
 
 Diagnosis. — Before we can intelligently treat a case 
 of scurfiness of the scalp we must arrive at a correct 
 diagnosis, and must differentiate between dandruff on 
 tlie one hand and eczema, psoriasis, and diffuse trich- 
 ophytosis capitis on the other. 
 
 Eczema is distinguished by the scales not being so 
 abundant nor so greasy as in dandruff; by their being 
 more parchment like, as if formed rather of dried 
 serum than inspissated fat, and more adherent to the 
 scalp; by the disease not being so diffuse, but more hm- 
 ited to certain patches, or to one side of the head, and 
 implicating contiguous non-hairy parts; by the 
 greater amount of hyperaemia; by the moisture which 
 is either present or readily induced by scratching; by 
 its being far more pruriginous, and by its history. 
 If thick crusts are present they will usually be of a 
 greenish-yellow color and when removed will expose a 
 reddened oozing surface. In eczema there will usually 
 be a patch of the disease behind the ears. 
 
 Psoriasis rarely occurs upon the scalp without be- 
 ing found on other parts of the body. It occurs in the 
 form of circumscribed, round, or oval, reddish, infil- 
 trated patches, which if of large size are seen to be 
 composed of a number of smaller round patches which 
 have joined together at their edges. These patches are 
 covered with a thick mass of gi-ayish or white glisten- 
 ing scales which are not greasy, and on being removed 
 expose a number of minute bleeding points or red dots; 
 and they do not reform as quickly as those of sebor-
 
 304 DISEASES OF THE IIAIR AXD SCALP. 
 
 rhoea. Tlie disease tends to form a fringe under the 
 hair on the forehead, and sometimes to push its white, 
 ghstening, scaly surface doT\'n upon it, and often pre- 
 sents a characteristic patch just in front of the ear. 
 
 Trichophytosis capitis (tinea tonsurans), when oc- 
 cuning as a " ring-worm,^' should offer no difficulty in 
 diagnosis, its circular shape and the presence of 
 broken and gnawed-off hau's being pathognomonic. 
 The diffuse form is rare, and is to be diagnosed by its 
 history of gradual spread from numerous reddish 
 points Or papules, l)y its scales not being greasy, by the 
 hair being broken oft' and fragile, and by the micro- 
 scopical examination of the hair and scales, which 
 will reveal the trichophyton fungus in abimdance. 
 
 Besides these three diseases, lupus erythematosus 
 may sometimes call for differentiation. It is rarely 
 met with upon the scalp, and then occui^s in the form 
 of a sharply detuied patch, with an infiltrated reddened 
 base covered by a thin adlierent scale, which being 
 raised shows on its under side a number of prolong- 
 ations, the sebum plugs withdrawn from the folhcles. 
 It causes loss of hair and well -marked atrophic changes 
 in the scalp. 
 
 Treatment. — A good deal in the way of preventive 
 treatment of dandruff can be accomphshed by the pro- 
 per care of the scalp and of the general health. More 
 care than is usual should be bestowed upon the oper- 
 ations of brushing and combing the hair, washing the 
 scalp, and upon the selection of the bi-ush and comb.* 
 Do not wash the head too much. I beheve that the 
 so-commonly practised daily sousing of the head in 
 water is hurtful to the hair and scalp, especially if they 
 are not carefully and thoroughly dried afterward, and 
 
 * Full dii-ectious as to these mattei-s will be fouud iu Chapter TTT., 
 of this work.
 
 DANDRUFF. 305 
 
 a little oil or vaseline nibbed into the scalp. It is not 
 the daily sousing which is objectionable, but the in- 
 sufficient after-care. Water renders the hair dry, and 
 the daily sousing only washes the head superficially. 
 A good shampoo every week or ten days for those per- 
 sons exposed to a good deal of dust, and every two or 
 three weeks for other people, is sufficient for clean- 
 liness. A shampoo composed of soap and water, 
 borax and water, or of the yolk of an egg beaten 
 up in hme-water, is simple and good, but it must 
 not be forgotten to wash out these materials with 
 plenty of clean water and to thoroughly dry the hair 
 and scalp. 
 
 Patent hair "tonics," pomades, washes, and dyes 
 are to be avoided. Those containing grease, the 
 pomades, are, to use an Anglicism, "nasty," give the 
 hair an unnatural lustre, smear the hat-band and 
 whatever the hair touches, and, becoming rancid, act as 
 local irritants. None of these dressings are needed by 
 the healthy scalp, and the proper care of the scalp as 
 above indicated wjU preserve the hair in better condition 
 than they will. 
 
 The nearer the body can be kept to the standard of 
 perfect health by means of bathing, exercise, and good 
 diet, the less likely is dandruff to develop. When, 
 therefore, the disease has appeared, and we are applied 
 to for relief, one of our first inquiries should be con - 
 cerning the general health, and our first efforts ad- 
 dressed to remedying anything found to be wrong. 
 For, important as our local measures are in relieving 
 the local disorder, in most cases we must depend upon 
 internal treatment to render the cure permanent. The 
 internal treatment must be along the lines marked out 
 in works upon general medicine — tonics, as cod-liver oil 
 and iron, for the debilitated; the acids and bitters for
 
 306 DISEASES OF THE HAIR AXD SCALP. 
 
 the neui'otic and dyspeptic; mercurials, podophylliu, 
 and the hke for the bihous, etc. Duhrixg (10) recom- 
 mends sulphur and the sulphide of calcium as of special 
 efficacy; and arsenic sometimes acts well. We should 
 insist upon our patient obeying the laws of general 
 hygiene and instruct him as to the proper care of the 
 scalp. 
 
 Various substances, all of a more or less irritating 
 nature, have been recommended for the local treat- 
 ment of dandruff. Such are tincture of cantharides, 3 j. 
 to s j. ; tincture of capsicmii, 3 j. to 3 j- ; tincture of nux 
 vomica, 3 j. to 3 j. ; chloral, 3 j. to 3 j. ; bichloride of mer- 
 cmy, gr. ij. to iij. to 3 j. ; the oleate and other mercurials 
 in proportionate strength; sulphur, 3 j. to 3 j. ; carboHc 
 acid, gr. x. to xx. to 3]'.; sahcylic acidgr. x. to xx. ad 
 3 j ; tar or oil of cade 3 j. to 3 iv. ad 3 j ; quima, strychnia, 
 etc. These are used either in solution in alcohol, water, 
 or the oil of olive, castor, rosemary, bene, etc. ; or as oint- 
 ments. A good menstruum for their exliibition is com- 
 posed of glycerine, 3 j. to ij.,to dilute alcohol, 3 j. Yase- 
 Hne forms the best medium for their exlnbition as oint- 
 ments. Excepting where the hair is decidedly thin, 
 so stiff an ointment as the ungt. zinci oxid. should not 
 be used, and lard itself is apt to become rancid. Lano- 
 lin is too stiff a base unless very much diluted with 
 vaseline or oil. Tlie tincture of benzoin is made a con- 
 stituent of many lotions for the scalp, and resorcin 
 and icthyol have both been commended as remedies in 
 seborrhoa\ Thus Fourxier {^OT) recommends the fol- 
 lowing lotion: 
 
 Beef marrow, 60. 
 
 Oil of sweet alriionds, .... 20. 
 
 Flower of sulphur, . . . . 1. 
 
 Tinct. of benzoin, .... 6. 
 
 Ihle's (150) formula for resorcin is:
 
 DANDRUFF. 307 
 
 Resorcin, . . . . 5 to 10. 
 
 Castor oil, . . ... 45. 
 
 Alcohol, 150. 
 
 Balsam of Peru, .5 
 
 Sig. Daily rubbed in with a piece of flannel. 
 Unna has had good results from icthyol iii ointment 
 form, ten to twenty per cent strength. 
 
 Heitzmann (608) expects a rapid cure of his cases by 
 the appHcation to the scalf) of the following ointment: 
 Oleum rusci . . . 3ss=15. 
 
 Ungt. aquae rosae ad . . liv=100. 
 01. rosae .... gt. xtoxx=:l. 
 M. 
 
 This is to be used at night, and the superfluity is to 
 be rubbed off with a dry rag in the morning. Twice 
 a week the head is to be shampooed with castile soap 
 and water. 
 
 Before using any remedy for the dandruff the scalp 
 must be cleaned. If there is enough accumulation of 
 fat scales to form crusts, the head must be saturated 
 with oil, preferably sweet almond oil, for from twelve 
 to twenty-four hours, and then washed with soap and 
 water. After the hair and scalp have been well dried 
 the chosen remedy is to be apphed. In shght cases of 
 dandruff the soaking with the oil may be omitted. 
 
 Of aU the above remedies, I have been led by experi- 
 ence to place my main reliance upon sulphur and the 
 mercurials, and would advise the following plan of local 
 treatment. If the case presents itself with a decided 
 accumulation of scales, or if crusts are present, direct the 
 patient to saturate his head with oil, preferably sweet 
 almond oil, before going to bed, and place over his 
 head a flannel cloth soaked in the oil, and outside of 
 all an oiled silk cap. The next morning he should 
 shampoo his head thoroughly with soap and water,
 
 308 DISEASES OF THE HAIli AND SCALP. 
 
 using by preference the tincture of green soap or the 
 tincture of prepared ohv^e soap, and wash out the soap 
 with plenty of water. The scalp is then to be dried by 
 vigorous rubbing with a coarse towel, and the hair by 
 pulling it through a soft towel. If the crusts are not 
 completely removed by this method, a little oil should 
 be kept on during the day, the head soaked again at 
 night and washed with soap and water in the morn- 
 ing. If the scalp should appear very hyperaemic after 
 the crusts are removed, apply vaseline or simple oint- 
 ment, such as rose ointment, until the hyperaemia is les- 
 sened. When the crusts are removed and the hyper- 
 aemia overcome, have an ointment composed of one 
 drachm of sulphur loti to one ounce of vasehne, or, 
 better, the sulphur cream whose formula is given under 
 Alopecia furfuracea, applied once a day to the scalp. 
 If the scales form rapidly, apply the oil every night and 
 the sulphur ointment every morning, and wash the 
 head every second or third day. As soon as scaling is 
 lessened stop the use of the oil, but continue the oint- 
 ment, at first using it every second morning, then 
 gradually reducing its apphcation to once a week. 
 Throughout this plan of treatment the head should be 
 shampooed about once a week with the tincture of 
 green soap, borax and water, or the yolks of three 
 eggs beaten up in one pint of lime-water, to which a 
 half ounce of alcohol is added. Another excellent 
 ointment for these cases, for the formula of which I 
 am indebted to Prof. Bronson, of the New York Poly- 
 clinic, is composed as follows; 
 
 IJ Hydrarg. amnion., . . . gr. xx. 
 
 Hydrarg. chlor. mitis, . . . gr. xl. 
 
 Petrolati, |j. 
 
 M. 
 
 This applied once or twice a day has yielded most
 
 DANDRUFF. 309 
 
 admirable results in a number of cases in simple dan- 
 diTiff . Its consistence being that of a Mayonaise dress- 
 ing, renders it an elegant pomade for private practice. 
 Its use should be combined with the occasional sham- 
 poo, as directed above. 
 
 Prognosis. — Dandruff is curable, though Hable to 
 relapse. In some cases the disease will disappear never 
 to come back; but these are the exceptions. Quite com- 
 monly the condition wiU return whenever the health 
 becomes deteriorated. We should inform our patients 
 of this fact, and tell them that they will obtain sl cure 
 only by persistent, long-continued, and oft-repeated 
 effort.
 
 CHAPTER XX. 
 
 KERATOSIS PILARIS. 
 
 Synonyms. — Lichen pilaris; Pityriasis pilaris; Icthy- 
 osis seu hyperkeratosis foUicularis; Cacotrophia folli- 
 culorum (T. Fox.) 
 
 Keratosis pilaris, as its name indicates, is a disorder 
 of cornification. It is characterised by a heaping up 
 of the corneous cells about the mouths of the hah"-f olh- 
 cles in the form of small conical whitish or grayish ele- 
 vations, the skin between them being normal in color and 
 texture, though often of a grayish or brownish shade 
 from lack of cleanhness and hyperpigmentation. It is 
 met with principally upon the extensor surfaces of the 
 hmbs, the upper arm and thigh being most often affect- 
 ed, though it may occur almost anywhere on the body 
 and not infrequently on the scalp. To the eye, the 
 skin has the appearance of what is commonly called 
 goose flesh, ^" cutis anserina.^^ It is seen to be dotted 
 aU over with httle pinhead to small pea-sized, conical, 
 whitish, grayish, blackish, or pinkish papules, each of 
 which is either pierced by a hair or has at its summit 
 a small black dot, indicating the mouth of a hair- 
 foUicle. These papules are often scaly, sometimes 
 surmoimted by a scale. Sometimes the hairs gi'ow 
 vigorously from the papules, sometimes they are 
 broken off, and sometimes are to be found only by 
 opening the papule, when they will be seen cmied up 
 inside of it. To the touch the skin feels dry, and harsh 
 and somewhat like a fine nutmeg grater. 
 
 Subjective symptoms are wanting in most cases, but 
 there often is more or less prmitus, especially in chil-
 
 KERATOSIS PILARIS. 311 
 
 dren; and in them tliere may be a slight degree of ec- 
 zema on account of the scratching. Occurring on the 
 scalp it sometimes produces baldness. 
 
 Etiology. — The disease is most often met with after 
 puberty, though it may be congenital. It is a very 
 common affection of the skin, but, as it gives little or 
 no trouble, we are seldom called upon to treat it. It 
 is the result of an inactive state of the skin, and is 
 seen most often in those who do not bathe with suffi- 
 cient frequence. It is met with in connection with 
 icthyosis and prurigo, and is said to follow pityriasis 
 rubra. It was formerly regarded as a species of papu- 
 lar eczema. 
 
 Pathology. — It is simply an anomaly of cornifica- 
 tion, a thickening of the corneous layer of the skin 
 about the mouths of the hair-follicles, by which the 
 epithelial ceUs are heaped up into conical papules. It 
 has nothing to do with any disorder of the sebaceous 
 glands or of the hair-follicle itself. When this condition 
 is congenital and constant in spite of treatment it has 
 l)een named icthyosis follicularis, and corresponds to 
 T. Fox's cacotrophia folliculorum. 
 
 Diagnosis. — It is necessary for us to differentiate 
 keratosis pilaris from cutis anserina; the miliary papu- 
 lar syphilide; lichen scrofulosus; papular eczema; 
 lichen planus, and icthyosis. 
 
 Cutis anserina is a passing condition of the skin in 
 which the arrectores pill muscles contract imder the 
 stimulus of cold, and raise up the hair and immediately 
 contiguous parts into papules. Keratosis pilaris is 
 constant and uninfluenced by temperature. 
 
 The miliary papular syphilide has its papules 
 grouped; they are of a dark red or raw ham color, and 
 deep seated, and are only slightly scaly. The syphilitic 
 eruption is more apt to be a general one, and fades 
 away of itself in a few weeks. The papules of kera- 
 tosis are whitish, gTayish or blackish, supeificial so
 
 312 DISEASES OF THE HAIR AND SCALP. 
 
 that they are readily removable by soap and water, 
 scaly, and usually confined to the arms and thighs. It 
 does not tend to get well of itself. 
 
 Lichen scrofulosus, as generally seen, is in the form 
 of well-marked circular or crescentic patches of yellow- 
 ish-brown papules upon the trunk, usually upon the 
 abdomen. The papules are shghtly scaly, and the sub- 
 jects generally present other symptoms of struma. 
 Keratosis pilaris does not have grouped papules; its pap- 
 ules are whitish or grayish, and its subjects are not 
 necessarily strumous. 
 
 Papular eczema occurs as an eruption of bright red 
 inflammatory papules which tend to run together and 
 form patches. It is very itchy, and shows no predilec- 
 tion for the upper arm and thigh. 
 
 Lichen planus occurs especially on the anterior face 
 of the wrists as a group of duU red or Ulac tinted, an- 
 gular, shghtly umbilicated, flat papules, and is attended 
 with a good deal of pruritus. 
 
 Icthyosis is a congenital affection of the general in- 
 tegument, though most marked upon the arms and 
 legs. The skin is dry and scaly, and marked off into 
 polygonal spaces, and the disease is incurable. Kera- 
 tosis pilaris rarely occurs before puberty, is limited to 
 the mouths of the lanugo hak-follicles, and is perfect- 
 ly curable. 
 
 Treatment. — The vigorous use of soap and water 
 in an alkaline bath will promptly remove the papules. 
 The best soap for the purpose is the sapo viridis or 
 soft soap, and this may be used in the form of a tinc- 
 ture. 
 
 ' A vapor or Russian bath may be used for the same 
 purpose. After the bath the skin should be anointed 
 with oil, vaseline, lanohn, or any emollient. In some 
 obstinate cases it may be necessary to use a mercurial 
 such as:
 
 KERATOSIS PILARIS. 313 
 
 ^ Hydrarg. ammon. . . . 3 j— ii 
 
 Hydrarg. chlor. mitis, . . . 3ij — iv 
 
 Vaseline, . ad . . . . 5j 
 M. 
 
 In congenital cases cod-liver oil should be given by 
 the mouth and also rubbed into the affected skin. 
 
 Prognosis. — The disease is perfectly and easily cur- 
 able, but without treatment it may last indefinitely. 
 It is subject to relapses.
 
 CHAPTER XXL 
 
 ECZEMA CAPITIS ET B.ARB^. 
 
 The hairy parts of the body are affected with eczema 
 eithei* in connection with or independently of eczema 
 of other regions. Owing to the presence of the hair, 
 and, in some places, as the scalp, to a difference in the 
 structure of the under-lying tissues, the disease in 
 hairy regions has some pecuhar symptoms. We will 
 describe eczema of the scalp, of the bearded portions 
 of the face, and of the edges of the eyehds. The 
 symptoms of the disease, as met with in these regions, 
 include all that are to be encountered in any hairy 
 region. 
 
 eczema capitis. 
 
 Synonyms: — Crusta lactea; Impetigo figurata, seu 
 lactantia, seu mucosa, seu muciflaa; Porrigo; Tinea 
 amiantacea, seu furfuracea, seu granulata, seu asbes- 
 tina; Melitagra; Achor; Eczema capiUitii; Erythema 
 ichorosum; Gourme (Fr.); Vesicular or running scall, 
 scalled head, milk crust (Eng). 
 
 Symptoms. —By the above and a number of other 
 names this very common disease of the hairy scalp 
 has been designated. The vesicular, pustular and 
 erythematous varieties of eczema occur upon the scalp 
 as primary forms far more frequently than the papu- 
 lar variety, which is exceedingly rare: squamous ec- 
 zema is met with as a sequella of the other forms. 
 Eczema may affect the whole scalp or only a portion 
 of it; and it may run an acute or chronic course. It
 
 ECZEMA CAPITIS ET BARB^. 315 
 
 may occur either in connection with eczema of other 
 parts of the body, or independently. 
 
 Vesicular Eczema. — Eczema vesiculosum is an 
 acute disease which breaks out either upon a part or 
 the whole of the scalp. The vesicles are so short lived 
 that the physician hardly ever sees them excepting 
 upon newly formed patches. When the case presents 
 itself, the scalp is seen to be swollen, at times so much 
 so as to give a boggy sensation to the touch; it is 
 moist, and in bad cases exuding so freely that it is 
 covered with a sticky, yellowish, mucilaginous fluid. 
 The hair is always stuck together in little bundles, and 
 if it is long it will be matted. The head emits a sick- 
 ening odor. The exudation dries into light -yellow ad- 
 herent crusts; when these are removed a moist exud- 
 ing surface is exposed that soon becomes again crusted. 
 This form of eczema may change into the pustular 
 form, or it may become squamous. It runs an acute 
 course in most cases. 
 
 Pustular Eczema.— FiCzema. pustulosum occurs as an 
 eruption of discrete pustules affecting a part or the 
 whole of the scalp. The pustules soon become con- 
 fluent, break down and discharge their purulent con- 
 tents. The hair is matted together. The exudation 
 dries into thick yellowish green or blackish adherent 
 crusts and the head emits a foul odor. When the 
 crusts are removed a moist exuding surface is left, 
 which soon becomes covered with a fresh crust. After 
 lasting an indefinite time the pustular form is ex- 
 changed for the squamous. 
 
 The pustular form differs from the vesicular form 
 in having pustules rather than vesicles; in the char- 
 acter of the exudate; in its crusts being darker colored; 
 and in having a more disgusting odor. Sometimes 
 the pustules are located only about the hair- follicles 
 and the disease will assume the form of sycosis. At
 
 316 DISEASES OF THE HAIR AND SCALP. 
 
 times there T^ill be marked swelling of the cervical 
 glands; and, especially in children, abscesses of the 
 scalp may form. 
 
 Erythematous E'cze ???«.— Eczema erythematosum 
 usually occurs in patches upon one side of the head 
 but may affect the whole scalp. The patches are of 
 irregular form, bright red in color, perfectly dry and 
 slightly scaly. Sometimes the skin may be a little swol- 
 len or thickened. If the scales are removed with soap 
 and water or slight friction, the skin will become moist 
 and exude serum from innumerable pores. This form 
 of eczema either gets well rapidly or changes to the 
 squamous form. 
 
 Squamous Eczema. — Eczema squamosum on the 
 scalp as elsewhere is the final stage through which the 
 other varieties of eczema pass on their way to recovery. 
 The whole scalp may be affected or only a patch here 
 and there, depending upon the nature and location of 
 the preceding primary form. It also presents several 
 forms. It may be of only slight intensity when the 
 scalp will be but slightly thickened, of light-red color, 
 and covered with whitish or grayish scales, which come 
 off readily in the form of flakes. Or it may be more 
 severe, when the scalp will be decidedly thickened, of 
 deep -red color, and covered with more or less adherent 
 white or gray scales in the form of plates. Or the 
 thickening of the skin and the inflammation may be 
 yet more severe, and the scalp will be red, scaly and 
 cracked. This form of eczema may last indefinitely 
 as a chronic eczema of the scalp. 
 
 These are the four varieties of eczema as commonly 
 met with on the scalp. The pustular and the squa- 
 mous forms are the most frequent, the former especially 
 in children, where it constitutes the "milk crust." 
 The erythematous form is seen chiefly in adults. At 
 times there wiU be several varieties of eczema upon the
 
 ECZEMA CAPITIS ET BARB^. 317 
 
 scalp at once— for example, the pustular variety in one 
 place and the squamous in another. With eczema of 
 the scalp we usually will find a patch of the same 
 disease behind or upon the ears, upon the back of the 
 neck, or on the face. Sometimes other hairy regions 
 will be affected at the same time, as the pubes or axilla. 
 
 The hair is unaffected as a rule, excepting that it is 
 glued together by the serous or sero-purulent exuda- 
 tion of the vesicular and pustular forms, and is dry in 
 the erythematous and squamous forms. It is only 
 when the disease is very chronic that there is baldness, 
 wiiich is not permanent; the hair in most all cases 
 growing again when the eczema is cured. It is not 
 uncommon to meet with baldness on the back of the 
 head in children with eczema, the hair being rubbed 
 off by the constant scratching of the head against the 
 pillow or the nurse's arm. 
 
 Itching is present in gi^eater or less degree in all 
 cases. It is often intense in the erythematous and 
 squamous varieties; less marked in the pustular and 
 vesicular forms. In the acute stages of the disease 
 the scalp will feel drawn, and, may be, painful, and 
 there will be more or less of a burning sensation. 
 
 The sebaceous glands are usually functionally 
 diseased in a case of eczema giving rise to a seborrhoea. 
 In the crusts of eczema of the scalp oil globules are 
 generally found, and in a chronic eczema the dry 
 and lustreless appearance of the hair is in part due to a 
 deficiency of the oily secretion of the sebaceous glands. 
 
 In neglected cases among people who are unclean in 
 their habits pediculi find lodgment in the hair; and in 
 some aggravated cases of uncleanliness we have devel- 
 oped that condition which is described in the next 
 chapter as Plica Polonica. 
 
 Etiology.— The etiology of eczema of the scalp is no 
 more settled than is the etiology of eczema in general. 
 Some authorities, as in the Vienna school, insist upon
 
 318 DISEASES OF THE HAIR AND SCALP. 
 
 the disease being local in all cases ; some of the French 
 school are equally positive that eczema is an expres- 
 sion of a diathesis; while some, and perhaps these now 
 are in the majority, take the safer middle course and 
 teach that some cases are due to local causes, and some 
 to constitutional conditions. By the use of croton oil 
 an artificial eczema can be produced on any skin; but 
 that does not prove that eczema is always due to a 
 local cause. Water, with or without strong alkalies, 
 may be used by a person for years with impunity; then 
 there may come a time when it will cause an intense 
 eczema of the hands. This seems to show clearly that 
 there has arisen in the person some constitutional con- 
 dition which renders the skin obnoxious to the use of 
 water. Eczema, I believe, may be in some few cases 
 a purely local disease; then it has rather the nature of 
 a dermatitis and is of short duration. In most cases, 
 however, there exists a predisposition to the disease, 
 and when the predisposing causes -are very pronounced 
 and not easily removable, the disease will be very 
 chronic and obstinate to treatment. This predisposi- 
 tion may be so pronounced that we may speak of the 
 person having it as being eczematous, just as we would 
 speak of another being rheumatic or gouty. 
 
 The causes of eczema of the scalp are predisposing 
 and exciting. Here I do not intend to enter upon a 
 discussion of all the causes of eczema as given by dif- 
 ferent authors, but shall content myself by giving such 
 as have special relation to eczema of the scalp. 
 
 The predisposing causes of eczema capitis are in- 
 fancy and a debilitated condition of the s^^stem arising 
 from any cause. 
 
 Age is an important element in etiology. Children 
 under five years of age furnish nearly one-quarter of 
 all cases of eczema, - and in them the scalp is more fre- 
 
 *Bulkley's Eczema and its Treatment, New York, 1884
 
 ECZEMA CAPrnS ET BARB^. 319 
 
 quently attacked both independently and in connection 
 with the disease elsewhere, than is the case in adults. 
 In forty-nine personal cases of eczema of the scalp, 
 thirty-five occurred in children under five years of age, 
 and of these twenty-seven were in connection with ec 
 zema on other parts of the body, mostly of the ears and 
 face. In the remaining fourteen cases wliich occurred 
 in adults six were on the head alone. That children 
 should be more predisposed to eczema than are adults 
 is due to their skin being more delicate and hence more 
 vulnerable. In them, too, we more often see evidences 
 of struma, and vices of constitution either inherited or 
 acquired. 
 
 A debilitated condition of the system predisposes to 
 eczema in general, and hence to eczema of the head. 
 Fat anaemic babies are prone to eczema. Over-fed or 
 under-fed children, who live in bad hygienic surround- 
 ings and are uncared for, furnish some of our most ob 
 stinate cases. Disturbances of the digestion, expressed 
 either as nausea, vomiting, diarrhoea, constipation, or 
 simply as malassimilation without any tangible symp- 
 tom, by their effect upon the constitution of the blood, 
 and hence on the nutrition of the skin, predispose to 
 eczema. Gout and rheumatism, nervous exhaustion, 
 the chlorotic state, predispose to the disease. In al- 
 most every case there will be found some deviation 
 from the standard of health. 
 
 The exciting causes of eczema capitis are all injuries 
 to or irritations of the scalp. In children a very fre- 
 quent exciting cause is well meant, but badly directed 
 efforts at cleanliness. The vernix caseosa is attacked 
 too vigorously with soap and water before it is prop- 
 erly soaked with oil; the fine-toothed comb is em- 
 ployed for the removal of dandruff and the scalp is 
 scratched by it; or a too stiff bmsh is used for the ten- 
 der scalp. In both children and adults all cutaneous
 
 S20 DISEASES OF THE HAIR AND SCALP. 
 
 irritants may give rise to eczema, such as mercurial 
 ointments applied for the destruction of lice, and the 
 like; tincture of arnica for hruises; water fomentations; 
 too strong applications for the cure of sehorrhoea or 
 loss of hair, and the like. Pedicuh are very frequently 
 the cause of eczema, especially of the occipital region. 
 The too vigorous use of the comh and hrush may act 
 like any other irritant in causing the disease. It is also 
 possible that in an infant the growing hair may irri 
 tate the scalp. 
 
 Diagnosis. — A moist eczema of the scalp is easy of 
 diagnosis if we remember that in it the scalp is red- 
 dened; more or less thickened; exuding in some places 
 and crusted in others; itchy; and the hair is stuck to- 
 gether as if by mucilage. Only one other disease sim- 
 ulates it and that is pediculosis. On the other hand 
 the erythematous and squamous forms are at times 
 difficult of diagnosis froin pityriasis, ringworm, ery- 
 sipelas, lupus erythematosus, or a simple dermatitis; 
 and pustular eczema of the scalp in its more chronic 
 form when it occurs in patches may be mistaken for 
 psoriasis, sehorrhoea sicca, favus, or syphihs. 
 
 A moist, exuding eczema is to be differentiated from 
 pediciilosishy its occurrence generally all over the scalp, 
 while pediculosis is more limited to the occipital and 
 temporal regions. In eczema there are no pediculi 
 or ova, while iu pediculosis they are readily to be 
 found. When pediculosis is well marked there is al- 
 ways a pustular eczema, and in a pustular eczema of 
 any continuance there are liable to be pediculi. But 
 then the diagnosis is not essential, the indication for 
 parasiticides being so plain, that in treatment they are 
 to be used first, and afterw^ards remedies for the ec- 
 zema. 
 
 li\ pityriasis the scalp is but slightly reddened, not 
 at aU thickened, the scales are abundant, readily de-
 
 ECZEMA CAPITIS ET BAKB^. c2l 
 
 tached and furfuraceous, the hairs are not stuck to- 
 gether, but frequently are found piercing a small scale. 
 In eczema the scalp is decidedly red and more or less 
 thickened; the scales are moderate in amount, often 
 quite adherent, and come off in the form of plates; and 
 the hairs here and there may be found stuck together, 
 if there are any moist spots on the head. 
 
 Ringworm occurs in one or more circumscribed, 
 round, scaly patches. The patches of eczema are not 
 sharply circumscribed. In ringworm the hairs are 
 brittle, broken off, twisted, and come out readily. 
 In eczema the hairs are merely stuck together. In 
 ringworm we have stumps of broken hair, which are 
 pathognomonic of the disease. The crusts of ring- 
 worm are grayish in color, those of eczema are yellow- 
 ish or greenish. Eingworm is never moist, has a well- 
 marked history of contagion, the patches spread from 
 one point peripherally, and it is not very itchy. Ec- 
 zema is generally moist at some time, is not contagious, 
 does not develop from one focus, and is very itchy. 
 In ringworm the trichophyton fungus is readily de- 
 monstrable by the microscope. In eczema there is no 
 fungus. 
 
 Erysipelas creeps over the scalp w^ith a sharply cut 
 advancing outline; there is a considerable swelling of 
 the integument, and marked fever and cc^nstitufional 
 disturbance. It runs its course rapidly. Eczema has 
 an ill-defined border, less swelhng of the scalp, and 
 sHght if any constitutional disturbance. 
 
 Lupus erythematosus develops slowly in the form of 
 a dry, sharply defined, scaly, red patch. In a short time 
 there will be loss of hair, and marked cicatrisation in 
 the old parts of the patch. The scales are adherent 
 and in close relation to the sebaceous glands. In ec- 
 zema the patches are »ot sharply defined, there is no 
 cicatrisation nor baldness, and the scales bear no rela-
 
 oi'2 DISEASES OF THE HAIR AND SCALP. 
 
 tion to the sebaceous glands. Lupus is far more 
 chronic than is eczema, and less amenable to treatment. 
 
 A simple dermatitis is an acute redness and swelling 
 of the skin, arising from some readily ascertainable 
 cause, and soon passes away. Should it continue for a 
 few days it will pass over into an eczema with the 
 characteristics of the latter disease. 
 
 Impetigo is regarded by many authorities as merely 
 a pustular eczema, but there is at times an eruption of 
 discrete pustules upon the head, which show no ten- 
 dency to form patches, being isolated throughout their 
 course. To this eruption the name of impetigo is 
 given. It is less itchy than is eczema and the pustules 
 are larger. 
 
 Psoriasis never occurs upon the scalp alone; char- 
 acteristic patches will always be found elsewhere upon 
 the trunk or extremities, and often there is a line of 
 scahng papules on the forehead along the edge of the 
 hair. Eczema is often hmited to the scalp, with at most 
 a patch of disease behind the ear. Psoriasis is dry and 
 occurs as circumscribed, rounded, discrete, small 
 patches, or larger ones evidently made up of separate 
 smaller ones, and covered with thick whitish or dirty 
 grayish crusts composed of heaped- up epidermic scales. 
 When the crusts are removed the under-lying skin is 
 dry or shghtly moist, with a few minute bleeding 
 points. The patches of eczema are larger, and less well 
 defined; its ciiists are made up of scales, dried pus and 
 sebaceous matter, matting the hairs together, and when 
 they are removed a moist exuding surface is exposed. 
 Psoriasis is less itchy, and there is in it a well-marked 
 history of relapses. 
 
 Sehorrhcea sicca affects by preference the vertex; 
 eczema has no sites of preference. In seborrhoea the 
 scalp is normal in color or pale, in eczema it is always 
 red. The scales and crusts of sebon-hoea are greasy
 
 ECZEMA CAPITIS ET BARB^. 323 
 
 to the touch, and gray or yellow in color; those of ec- 
 zema are harder, and yellowish green or even black. 
 Seborrhoea is a dry disease, eczema is a moist one. 
 Seborrhoea is less itchy than is eczema, and in it the 
 hair is dry and, may be, powdery, while in eczema it is 
 stuck together. Seborrhoea is followed frequently by 
 permanent baldness. Alopecia may follow eczema 
 but in most all cases it is transient. 
 
 Favus has yellowy cupped crusts which are never met 
 with in eczema. Favus has a history of contagion, 
 and of spreading from one or two foci; causes bald 
 atrophic patches of a peculiar red color; is dry through- 
 out its course; only shghtly itchy; and has a stale 
 straw or mousey odor. Eczema has no history of con- 
 tagion; forms rapidly into moist patches; is exceed- 
 ingly itchy; does not cause atrophy of the scalp nor 
 baldness; and has a sickening odor. 
 
 Syphilis differs from eczema in its whole history and 
 course. Its pustules and papules are discrete and unat- 
 tended by itching. Its pustules tend to break down and 
 ulcerate, and then are covered with striated crusts, 
 which being removed expose circular deep ulcers, 
 which heal and leave scars. Nothing like this is met 
 with in eczema. 
 
 Treatment. — Constitutional Treatment. — The 
 treatment of eczema capitis is both constitutional and lo- 
 cal. Excepting where there is some evident local cause, 
 such as the presence of pediculi or the use of some irritat- 
 ing application to the scalp, it is necessary to enquire 
 very carefully as to the action of the various organs of 
 the patient, and to use our best endeavors to aid them in 
 properly performing their several functions. We must 
 regard the patient as a sick man quite apart from his 
 sick skin. There is no specific for eczema; each case 
 must be treated on its own merits according to the 
 principles of general medicine. Arsenic is one drug
 
 324: DISEASES OF THE HAIR AND SCALP. 
 
 that is commonly administered in a routine way. In 
 most cases it wiU do no good; in some cases it will do 
 harm; and in a very few cases it will render excel- 
 lent service. It should be kept as a last resort. The 
 acetate of potash is another drug that is used in a rou- 
 tine way. It may do good; it probably wiU do no 
 harm. I have seen but little if any benefit from its 
 use in this affection, excepting where there is a rheu- 
 matic or gouty condition. Tonics, such as iron, 
 strychnine and cod-liver oil, are of great service in de- 
 bilitated, neurotic, and aucemic subjects, and will often 
 aid us materially, especially in infants and children. 
 
 The care of the digestive and aUied processes is all 
 important. If we question mothers with eczematous 
 babies we wiU find in most cases that the cliildren are 
 nursed every time they cry, and consequently at most 
 iiTegular hours; or they are improperly fed either as 
 to quantity, quahty, or frequency, being allowed to 
 eat " aoything that is on the table," besides numerous 
 apples, bananas and cakes between meals, and to 
 drink beer, coffee, tea and the like. In adults we wiU 
 find quite as frequently great indiscretions in eating 
 and drinking. Now this is all wrong. We must in- 
 sist upon an infant being fed at regular intervals and 
 with the food proper to its age. We should inquire as 
 to the quantity and quaUty of the breast milk, and the 
 health of the mother. Children should not be allowed 
 to eat " what is going " for the first few years of their 
 life, and cakes, confectionery, pastry, beer, coffee, and 
 tea should l)e ligorously excluded from their dietary. 
 In children, as in adults, it is often weU to forbid meat 
 for a time, especially in the Summer. Children as weU 
 as adults must not drink beer, coffee or tea; it is best to 
 hmit their fluids to milk and water. It is not possi- 
 ble here and now to lay down any hard and fast lades 
 as to diet; my object at present is to insist upon the
 
 ECZEMA CAPITIS ET BARB.E. 325 
 
 importance of regulating the diet of an eczematous 
 patient. 
 
 The action of the bowels is to be regulated, prefer- 
 ably by diet and exercise; by drugs if we must. In an 
 acute case, a sharp purgative will be found useful, and 
 my preference is for the old-fashioned remedy, calomel. 
 It is best given in small, repeated doses, say to an adult 
 one or two grains repeated every two hours till two or 
 three doses are given. It unloads the bowels, and stimu- 
 lates the liver. Byford ^' lays special stress upon this lat- 
 ter action in explanation of its good effect in eczema of 
 children, and beheves that as in them the liver is larger in 
 proportion than in the adult, liver indigestion is proba- 
 bly an important etiological factor in the disease. He 
 gives a quarter to an eighth of a grain of calomel twice 
 a day to an infant until slight purgation is caused, and 
 afterwards as often as the bowels need it. In children 
 over two and one half years of age he gives a single 
 purgative dose every six to eight days. The adminis- 
 tration of calomel is also of service in chronic cases in 
 adults, and I often give it in the form of tablet tritu- 
 rates in doses of from a tenth to a fifth of a grain three 
 or four times a day for three or four days and then stop 
 for a few days. Podophyllin may be used in propor- 
 tionate doses and for the same purpose, and also with 
 good results. Acids and alkalies are useful in appro- 
 priate cases for the regulation of the digestion. 
 
 Local Treatment.— The indications to be met by 
 the local treatment of eczema are to soothe an acutely 
 inflamed skin; to stimulate it when in a state of sub- 
 acute or chronic inflammation; and to protect it when 
 it is endeavoring to reassume its normal condition. 
 To know what we want to accomplish is of more im- 
 portance in this disease than to know Avhat is the lat- 
 
 * Jour. Amer. Med. Assoc, 1885, V. 317.
 
 326 DISEASES OF THE HAIR AND SCALP. 
 
 est drug that is ^' good for eczema. " Before using any 
 remedy all ciTists and scales must be removed by soap 
 and water, and after that is accompUshed no water 
 should be used upon the scalp excepting at intervals. 
 If om- remedies are properly used, crusts will not re- 
 form. Stiff ointments should not be used on hairy parts 
 where the hair is thick, as it mats the hair and makes 
 the scalp more miclean than before. Alcohol, water, 
 oil and vasehne are our best excipients. The hair need 
 never be cut, and should never be sacrificed in women. 
 In young children and in boys our treatment is ren- 
 dered easier by cutting the hair, but it is not neces- 
 sary. In applymg remedies to the scalp they should 
 be worked in, and not merely smeared over it. 
 
 In an acute moist eczema of the scalp, the head 
 should be satm-ated with olive or sweet ahnond oil, and 
 covered with a linen cap. The oil should be reapplied 
 until the acuteness of the inflammation has subsided. 
 Sometimes the addition of an alkah to the oil will be 
 useful, such as the bicarbonate of soda or borax ( 3 iv to. 
 viii. ad. Oj); or hme- water in equal parts with oil. A 
 weak carbolized oil, say one per cent, of carbolic acid, or 
 glycerine diluted with water, answers admirably in some 
 cases. In a few clays the acuteness of the disease will sub- 
 side under this soothing plan of treatment. Then the 
 scalp is to be thoroughly cleaned ^\'ith soap and water, 
 and the treatment proper to the condition of the scalp 
 used. The scalp will bear stimulating applications much 
 better than the rest of the integument; so as soon as the 
 acuteness of the disease is past we can use a weak tar 
 lotion, say half a drachm of oil of cade to the ounce 
 of ohve oil. 
 
 In acute erythematous and papular eczema, besides 
 carbohzed oil or vaseline we may use black wash, or 
 a weak white precipitate ointment, say ten to twenty 
 grains to the oimce. The squamous stage wiU soon
 
 ECZETJA CAPITIS ET BARB^. 327 
 
 be reached and more stimulating measures called for. 
 The treatment for acute moist eczema will be appro- 
 priate for an acute pustular eczema when it occurs in 
 a violent outbreak of pustules forming patches and 
 discharging freely As generally met with, this form 
 of eczema occurs in patches covered with crusts. The 
 crusts must be first removed by soaking them in oil 
 for twelve or twenty-four hours, and then washing the 
 head with soap and water. After the scalp is clean it 
 is to be freely anointed with oil either carbohzed, or, 
 better, with oil of cade, half a drachm to one drachm 
 to the ounce. Sometimes sulphur one drachm in vase- 
 line one ounce will do good service in this form of ec- 
 zema; but it is uncertain, and apt to prove irritating. 
 Mercurial ointments, say of calomel twenty to thirty 
 grains to vaseline one ounce, or that of the white pre- 
 cipitate ointment already spoken of will be beneficial. 
 
 When the squamous stage is reached we need stim- 
 ulation, and for this the best remedies are frictions 
 with soap and water, and preparations of tar. Once 
 or twice a week the scalp is to be washed with the 
 tincture of green soap, or equal parts of soft soap and 
 alcohol, or if the scalp is very tender and irritable a 
 milder soap such as Sarg's liquid glycerine soap, or 
 pure castile soap may be used. The washings should 
 be repeated at intervals of a few days to a week or 
 more according to their effect on the scalp. If they 
 prove very irritating they are to be less frequently 
 used. After washing, the scalp is to be carefully dried 
 and anointed with some oil or soft ointment contain- 
 ing tar such ae; 
 
 01. Cade, . . 3 ss— ij=2 to 16. 
 
 01. Olivae ad, . . 3 j = 30. 
 M. 
 
 raid this is to be applied every morning and evening.
 
 32S DISEASES OF THE HAIR AND SCALP. 
 
 Instead of the olive oil as a vehicle we may use vase- 
 line, oil of sweet almonds, or agnine or lanoline di- 
 luted, as with castor oil, sufficiently to make tliem 
 supple. This has proved itself to be in my hands the 
 most efficient mode of treating subacute and chronic 
 eczema of the scalp. Its only objectionable feature is 
 its odor, and this is so pungent and persistent that 
 many patients will not use it. Unfortunately we have 
 no means of successfully disg-uismg the odor. Instead 
 of the oil of cade we may use pix hquida or the oleum 
 iTisci, but there is no particular advantage in these 
 other forms of tar, and the odor is the same or worse. 
 The oil of cajeput may be substituted for the tar in 
 five to ten per cent, strength, but it is not so good. Car- 
 bolic acid five to fifteen grains to the ounce may be 
 used, and sahcyhc acid in three to five per cent, 
 strengths. 
 
 Instead of using oily applications we may sometimes 
 do better with oil of cade or pix liquida exhibited in 
 alcohol, one to two drachms to the ounce. Bulkley 
 (5) recommends a lotion composed as follows: 
 
 Acetate of lead. 
 
 gi\ viij. 
 
 . .5 
 
 Oil of bergamot, 
 
 3ss 
 
 2. 
 
 Castor oil. 
 
 . 3iv . 
 
 . 16. 
 
 Alcohol ad, 
 
 siv 
 
 120. 
 
 M. 
 
 
 
 Napthol /5, napthalin, pyrogallol, in the strength of 
 five to ten per cent, may be tried if other things fail. 
 Kesorcm has of late been highly commended by Ihle - 
 and others; and icthyol by UNNA.f In many cases of 
 eczema in which the scalp is much thickened, the 
 treatment is best begun by having the patient wear a 
 close-fitting cap made of sheet rubber, and its use con- 
 
 * Monatshft f. prakt. Derm. 1885, IV. 430. 
 
 f Monatshft f. prakt. Derm. 1886, V. Erganzungsheft No. 2, in Mai.
 
 ECZEMA CAPITIS ET BAKB^. 329 
 
 tinued till the scalp becomes moist and less thick. 
 Then tar may be employed. 
 
 After the eczema has been cured the scalp may be 
 left dry and scaly, and then it should be treated ac- 
 cording to the principles given in Chapter XIX. on Dan- 
 druff. 
 
 Prognosis. — Though eczema capitis is a very obstin- 
 ate disease at times, still it is perfectly curable. Some 
 cases yield readily to treatment, while others will tax 
 our patience and resources to the utmost. 
 
 ECZEMA BARB^. 
 
 Synonyms: — Impetigo sycosiforme; Achor barbatus; 
 Barber's itch. 
 
 Symptoms: — Eczema of the beard, which has been 
 often erroneously called '^barber's itch," has nearly 
 the same symptoms as eczema of the scalp. It may 
 be of the erythematous, vesicular, papular, pustular or 
 squamous variety, though by far the great majority of 
 cases are of the last two forms. The erythematous, pap- 
 ular, and vesicular varieties have precisely the same 
 clinical picture as the corresponding affections of the 
 scalp. Most all of the cases are pustular in character 
 and we shall speak only of that form. 
 
 Pustular eczema of the beard may be either acute or 
 chronic; may affect only one limited area, or the whole 
 beard; may be either symmetrical or asymmetrical; 
 and it may be confined to the bearded portion of the 
 face or pass over to the unbearded portions and to the 
 neck. Not infrequently the eyebrows and eyelashes 
 will be affected at the same time and in the same way. 
 When the disease is acute the affected part or parts 
 are swollen, tender and red, and feel stretched and 
 burning. Upon the red skin there will be an eruption 
 of small pin-head sized pustules which have no specinl 
 relation to the hairs, though many of them do occur
 
 330 DISEASES OF THE HAIR AND SCALP. 
 
 about the months of the hair-folUcles. These pustules 
 break of themselves in a very short time and discharge 
 their purulent contents, which glues the hairs together. 
 If the disease is very acute and violent the beard will 
 look as if some mucilaginous fluid had been poured over 
 it. Soon the exudation will dry into greenish or yel- 
 lowish-green thick crusts, in which the hairs ^vill be 
 entangled and matted together. When. the crusts are 
 removed a moist exuding surface will be exposed. 
 The hair will be unaffected excepting that it is stuck 
 together; and attempts at epilation will be painful. 
 
 In subacute and chronic cases the hair will be some- 
 what tliin, leaving the under-lying skin exposed. This 
 will be red and scahng in some places, covered with 
 greenish crusts in other places, and studded here and 
 there with small pustules, either about the mouths of 
 the hair-foUicles or independently of them. It will be 
 seen that the skin between the hairs is diseased as well 
 as about the hairs. To these subacute and chronic 
 cases sycosis is apt to join itself, or the eczema may 
 pass over into a sycosis. 
 
 Squamous eczema of the beard is the final stage of 
 the other varieties, through which they pass on their 
 way towards recovery. In it the skin is reddened and 
 thickened and covered with scales. Very often the 
 progress of the disease is stayed at this point and re- 
 covery does not set in. On the contrary, relapses are 
 liable to occur even after the squamous stage has lasted 
 for some time. 
 
 Itching accompanies all varieties of eczema of the 
 beard, and is, excepting the deformity, the most an- 
 noying feature of the disease. 
 
 Etiology. — This form of eczema is comparatively 
 rare. In 1800 consecutive skin cases occurring in Dr. 
 Geo. Henry Fox's service at the New York Skin and 
 Cancer Hospital, it was seen only sixteen times. Of
 
 ECZEMA CAPinS ET BARB.E. 331 
 
 course it occurs only in men. It is predisposed to by 
 the same constitutional disturbances as we noted un- 
 der eczema of the scalp. Its exciting causes are also in 
 large part the same as noted in the previous section of 
 this chapter. Exposure to dust and wind and weather; 
 the irritations from tobacco smoke, or the secretions 
 from nasal catarrh; the application of poultices for the 
 relief of neuralgia; scratching of the beard either 
 from habit or on account of the itching due to seborr- 
 hoea, and shaving, may be noted as special exciting 
 causes. 
 
 Diagnosis. — Eczema of the beard is to be diagnosed 
 from sycosis, trichophytosis barbae, acne, a pustular or 
 tubercular syphilide, and an epithehoma. 
 
 Eczema is a more superficial process than sycosis', 
 its pustules have no close relation to the hairs, it is 
 very itchy, its crusts are thick and seated upon a moist 
 and oozing surface, the hair is unaffected, and it is 
 often associated with the same disease on other parts 
 of the face or general integument. Sycosis is a deep 
 perifollicular inflammation, its lesions are seated about 
 the hair- follicles, the skin between the hairs being 
 unaffected except in old and severe cases, its crusts 
 are not so thick as those of eczema and do not mat the 
 hairs together, and it occurs only upon places supplied 
 with hair. It burns rather than itches, and the hairs 
 are readily pulled out. 
 
 Trichophytosis barbcB has a history of spreading 
 from one or two points, and often can be traced to a 
 source of contagion. It is generally- confined to the 
 chin and throat, and its lesions are tubercles and nod 
 ules. The hair is early aftected, is broken off and is 
 readily pulled out, or falls out of itself. The crusts 
 are small or wanting. It often extends beyond the 
 beard as a typical ringworm, or ringworms may be 
 found on other parts of the body. These symptoms
 
 '^3^ DISEASES OF THE HAIR AND SCALP. 
 
 are so characteristic that the two diseases should not 
 be confounded. 
 
 Acne occurs as isolated and discrete pustules or small 
 cutaneous abscesses on all parts of the face, and come- 
 dones are generally to be found. The skin between the 
 pustules is unaffected; there is no exudation, and no 
 itching. 
 
 In s2/p/r«7/.s there will be other lesions elsewhere on 
 the body, and a history of an initial lesion ov of some 
 other manifestation of the disease. The lesions are 
 discrete, and if there are crusts, well-marked specific 
 ulcers will be found beneath them when they are re- 
 moved. 
 
 It would hardly seem possible to confound an eczema 
 with an epithelioma, but it has been done. An epith- 
 ehoma occurs as a single lesion, rounded or irregular 
 in outline, of varying size from that of a one cent 
 piece to that of the palm, and forms a weU-marked ulcer 
 with raised hard waxy borders over which run delicate 
 branching blood-vessels. The ulceration may be only 
 superficial and covered with a delicate crust, but it is al- 
 ways sharply defined and bleeds easily. An eczema has 
 no weU-defined shape or border, and no raised edge. 
 An epithelioma is painful, the i^ain being lancinating 
 at times, while an eczema is itchy. 
 
 Prognosis. — The obstinacy of the disease, and it is 
 often exceedingly rebellious to treatment, is due to 
 the irritation of the skin by the stiff hairs of the beard. 
 Though the disease is obstinate it is perfectly curable; 
 but it is liable to relapses, and it is good policy to let 
 oiu" patient know- tliis before beginning treatment. 
 
 Treatment. — The treatment of eczema of the beard 
 is conducted on the principles we have learned in 
 studying the same disease of the scalp, but modified 
 in some particulars to suit the changed conditions. 
 When we can prevail upon the patient to cut his beard
 
 fiCZEMA CAPITIS ET BARB^. 333 
 
 close, we have taken a long step towards curing the 
 disease. Many patients prefer to allow the beard to 
 grow, as it serves to disguise the disfigurement to a 
 certain extent: but we can apply our dressings much 
 better if we get rid of the hair. Shaving may be prac- 
 tised and is recommended in many text-books : but it 
 is very painful in the acute stage of the disease and 
 unnecessary if the hair is clipped close. In the squa- 
 mous stage it should be advised because of its stimula- 
 ting effect. The first step in treatment is to remove 
 from the patient any irritant that has been acting upon 
 his skin. If the case is a bad one we should have the 
 patient stay at home until the violence of the disease 
 is abated. Even then a cure can be secured more 
 speedily if the patient will consent to stay in the house 
 during its whole course. 
 
 In acute eczema of the beard, after the hair is cut 
 close, a soothing application should be used. To this 
 end we may employ a carbolized oil, simple oil, black 
 wash, lime-water and oil, zinc oxide ointment, simple 
 ointment, or Lassar's paste, the latter composed as 
 follows: 
 
 Starch, 
 
 Zinc oxide, . . . aa3ij = 8. 
 
 Vasehne ad, . . . . 3J =32. 
 M. 
 
 answers admirably. Diachylon ointment is also excel- 
 lent. In this, as well as the more chronic form, tunie- 
 nol oil will often render good service if the patient does 
 not object to the black color. Whatever dressing is 
 selected, it should be used freely, the ointments being 
 spread thickly upon cloths, and bound down to the 
 part with a roller bandage. In Vienna even the acute 
 cases are treated by scrubbing the skin with green soap
 
 33^ DISEASES OF THE HAIR ANT) SCALP. 
 
 or its tincture, and following this with the diachylon 
 ointment. 
 
 As soon as the acuteness of the disease has some- 
 what subsided we should proceed to more active meas- 
 ures. All crusts must be gotten lid of by soaking with 
 oil and subsequent washing with soap and water. All 
 haii-s protruding from pustules should be plucked from 
 their folhcles. Now the tar preparations spoken of in 
 the section on eczema capitis may be used, or mild 
 sulphm- ointment. Lassar's paste with the addition 
 of about fifteen grains of sahc^^hc acid to the ounce is 
 soothing and efficient at this time. When the squam- 
 ous stage is reached the beard should be shaved off 
 every day or so, and then the stimulating remedies ap- 
 plied. As the disease becomes reduced to a slight red- 
 ness and the patient is going about liis usual avoca- 
 tions, the skin should be protected by a shght film of 
 vaseline or ointment, or with a dusting powder. In 
 fact throughout the treatment, if the patient is obhged 
 to go out he must protect the skin in this way, and 
 employ the more radical di'essings at night. 
 
 ECZEMA PALPEBRARUM. 
 
 This foiTU of eczema, which is also called Eczema 
 marginis ciliaris pcdpehraruin,BJidi Blepharitis ciliaris, 
 is seen by the opthahnologist more often than by the 
 dermatologist. Eczema of the eyehds usually accom- 
 panies the same disease on other parts of the head, 
 though it may occur on them alone. It is always pus- 
 tular in character at first, and afterwards squamous. 
 The edges of the hds are swollen and rounded, and 
 more or less thickly strewn with pustules that quite 
 commonly are situated al)out the cilia and take on a 
 sycosiform character. The lids after sleep are stuck 
 together so as to be opened with difficulty. The pus^ 
 tules rupture, and then the edges of the lids become cov
 
 ECZEMA PALPEBRARUM. 335 
 
 ered with yellowish or greenish crusts. When the 
 crusts are removed excoriations are left, and some- 
 times even small ulcers. The skin itches, and the rub- 
 bing by the patient for its rehef aggravates the disease. 
 When the process passes over into the squamous form 
 the edges of the hds are merely red and scaly. If the 
 inflammation about the cilia has beeu intense and ul- 
 cers have formed, cicatrisation will follow and loss of 
 the eyelashes. Both Hds are usually affected, and the 
 disease is commonly symmetrical. 
 
 With the blepharitis there will be more or less con- 
 junctivitis, with its characteristic symptoms. The 
 eyebrow, also, is often eczematous. Sometimes the 
 disease will remain confined to the corners of the eye, 
 especially the outer canthus, for a long time. 
 
 Etiology.— This disease is seen most commonly in 
 strumous subjects, and is a frequent complication of 
 phlyctenular ophthalmia and other strumous eye trou- 
 bles in children. When occurring with eczema else- 
 where it is an expression of the eczematous condition. 
 When occurring alone it is most frequently caused 
 either by some trouble with the eye itself, or by appli- 
 cations made to the eye for the relief of such troubles. 
 Sometimes it is difficult to determine whether a con- 
 junctivitis has caused the eczema, or an eczema has 
 provoked a conjunctivitis. 
 
 Treatment.— The eyes should be bathed with warm 
 water to remove the crusts, and then anointed to 
 prevent their sticking together. This should be done 
 especially before the patient goes to sleep. What oint- 
 ment is to be used will depend upon the condition. In 
 mild cases simple ointment will suffice. Generally 
 some form of mercurial ointment will do better, such 
 as that of the red or yellow oxide diluted eight or ten 
 times with vaseline or simple ointment. A. R. Robin- 
 son recommends an ointment composed of one grain
 
 330 DISEASES OF THE HAIR AND SCALP. 
 
 of the biniodide of mercury in one ounce of vaseline. 
 Deligxy has found the best apphcation to be : Plumbi 
 acetat. 0.25, Adeps. 25. La wsox regards ointments as 
 too irritating, and advises the following wash : 
 
 IJ Boracis vel zinc oxid, . 3ij, say 1.5 
 
 Glycerin, . . . 3iv ^' 3. 
 
 Aqua? sambuci, . . 3 ij *^ 12. 
 
 Aqua^ destil. ad . . rviij'^lOO. 
 
 M. 
 
 Another good remedy I owe to Prof. D. Webster, 
 
 and is as follows: 
 
 I^ Ac. sahcylici, . . . gr. x, say .8 
 
 Ungt. hydrarg. oxid. rubri, 3 i ^' 5. 
 
 Ungt. aqua? rosa?, . . 3 vi ^' 30. 
 
 M. 
 
 Whether we use ointments or lotions we must be 
 sure that any powders that enter into them are of the 
 finest, so that matters are not made worse by the irri- 
 tation of coai-se grains left l^y the apphcations. 
 
 When the process becomes sycosiform the ciha must 
 be plucked from the lids. If the disease prove very 
 obstinate we may evert the lids and binish over them 
 a solution of caustic potash, ten grains to the ounce, 
 alisorbing the superfluoits fluid with blotting paper and 
 then washing with water. This should be done every 
 day until there is an amelioration of the symptoms, 
 when one of the mercurial ointments may be used. In 
 aU cases constitutional treatment must be prescribed, 
 as well as special treatment f< /r the eyes, w^here these 
 are diseased. 
 
 eczema of other hairy parts. 
 
 Tlie hair on any part of the body may be attacked by 
 eczema and give rise to symptoms corresponding to those
 
 ECZEMA CAPITIS ET BARB^. S^t 
 
 just detailed. Thus we have eczema of the axilla and of 
 the pubes; a very annoying eczema of the hairs in the 
 nostrils; and a peculiar form of follicular eczema which 
 affects the hairs of tlie extremities or trunk. 
 
 The treatment of eczema of the axilla and pubes is 
 the same as for the same disease of the beard. 
 
 Eczema of the hairs of the nares is often obstinate. 
 We must endeavor to cure the nasal catarrh that is 
 usually present, and to apply ointments to the part on 
 pledgets of lint. Sometimes we may have to epilate 
 and apply a solution of nitrate of silver. Hardaway * 
 believes this condition is associated in many cases with 
 a broken-down state of health, and recommends active 
 internal treatment. For the local treatment he has 
 found Squire's glycerole of the subacetate of lead of 
 special service. This is made by mixing together ace- 
 tate of lead 5 parts, litharge 3^ parts, and glycerine 20 
 parts, by weight, heating to 350° F. and filtering 
 through a hot-water funnel. He opens the Httle ab- 
 scesses with a knife and when the disease is abated ap- 
 plies 
 
 Squire's glycerole plumb, subacetat, 3 ss say 2. 
 
 Glycerine, . . . . 3iss " 6. 
 
 Ungt. aq. rosae ad, . . . Ij " 32. 
 
 Cerse albae, qs. " qs. 
 
 M. 
 
 In very obstinate and relapsing cases he epilates 
 the offending hairs by electrolysis. Eczema seated 
 about the hair-follicles of the trunk and extremities 
 is, happily, rare, and is sycosic in its nature. I have 
 seen it only in a very few cases and then upon the legs 
 of strumous subjects. It occurs as disseminated and 
 discrete papules and pustules pierced by hairs, and is 
 very itchy, so that excoriations are frequently seen. It 
 
 * Jour. Cut. and Veu. Dis., 1880, iV. 360.
 
 338 DISEASES OF THE HAIR AND SCALP. 
 
 has always proved obstinate to treatment. A cure can 
 be effected only by attention to the general physical 
 state. Locally the disease is to be treated on the prin- 
 ciple of sycosiSo
 
 CHAPTER XXIL 
 
 PLICA POLONICA. 
 
 Synonyms: — Trichosis plica; Trichoma; Koltun (Po- 
 lish); Weichselzopf (Ger.); Plique polonaise (Fr.); 
 Polish ringworm (Eng.). 
 
 Symptoms: — The term Plica Polonica is used rather 
 to designate a condition than a disease, the condition 
 arising from various causes and producing the cUnical 
 picture of the long hair of the head or other parts 
 matted together into various shaped masses, in and on 
 which rest all sorts of extraneous matters deposited 
 from the floating dust of the atmosphere, and very 
 often vast hordes of pedicuh with their ova. At times 
 these masses of matted hair will be close to the skin or 
 scalp; at times removed to a considerable distance 
 from it. If close to the scalp we will find beneath 
 them a moist and oozing condition of the under-lying 
 part; if at a distance from the scalp, the latter may be 
 of normal appearance, or scaly. This is due to the 
 age of the plica, the freshly formed ones are near the 
 scalp, and when the disease of the scalp is recovered 
 from, the growing hairs will push the mass further and 
 further from the scalp until it either falls off of itself 
 or is cut off. Various names have been used to desig- 
 nate the different shapes these masses may take; thus 
 when the hair is short and there are many locks 
 matted separately it is called plica multiformis, or 
 caput Medusa; when but a single coil, and this long 
 and in the shape of a tail, it is called plica caudif ormis, 
 and such tails may be so long as to reach below the 
 knees. The odor of the head in plica polonica is pene-
 
 A Caudiform Plica Po lo>'ICA.
 
 PLICA POLONICA. 841 
 
 trating and disgusting; somewhat like that of rancid 
 fat. There are no special constitutional symptoms; 
 the patient may be cachectic, strumous, phthisical or 
 what not; or he may be perfectly sound and healthy. 
 The only subjective symptom is itching. 
 
 Such is the disease as viewed in the light of modern 
 medicine since the time when Hebra demonstrated its 
 dependence upon lack of care of the hair. Previous to 
 that it was described as a disease with four stages 
 namely: 1. Prodromal stage; 2. Stage of exudation; 
 3. Stage of efflorescence; 4. Stage of convalescence. 
 It was regarded as a safety-valve in severe illnesses, 
 and it w^as thought that if the patient could raise a 
 plica he would recover from his disease. It was on 
 that account held sacred from injury, and cases were 
 reported in which a man or woman died in conse- 
 quence of cutting off his or her phca. PHcas have 
 been described as having taken on a fleshy condition, 
 and reported as having bled from the stump wiien 
 cut off, or at least to have exuded a reddish fluid. 
 These were without doubt errors in observation. 
 
 ETioiiOGY. — The cause of this condition of the hair 
 is want of cleanliness combined with the presence of 
 lice, giving rise to pediculosis; or of any disease of the 
 scalp which is accompanied by moisture, principally ec- 
 zema. But this was not always thought to be the case, 
 and the literary war was long and stubborn before this 
 theory gained the victory over the old theories that 
 regarded the condition as a specific disease. It used 
 to be regarded as a dyscrasia occurring endemically in 
 certain countries, especially in certain provinces of Rus- 
 sia and Poland. It was thought to occur at the crisis 
 of many diseases, and was regarded as of favorable 
 prognosis. The common people had such great faith 
 in the salutary influence of a plica that they often pro- 
 duced one by the use of wax, pitch and the like.
 
 342 DISEASES OF THE HAIR AND SCALP. 
 
 Such an one was called a false plica. It was and 
 even now is endemic in certain parts of Poland, and 
 especially in the low-lying provinces, because the 
 people are wonderfully careless about personal cleanli- 
 ness, and are in the habit of wearing fur caps con- 
 stantly upon their heads, inducing sweating and favor- 
 ing an eczematous condition. It is seen both in men 
 and women, and while most common amongst the 
 lower ranks of society, it is met with also in the nobility 
 of Poland and Russia. We encounter the condition 
 now and again in this country, but of mild grade, and 
 as an unmistakable result of want of care of the scalp. 
 
 Treatment. — The condition is removed very readily 
 by soaking the hair T\ath oil, washing with soap and 
 water, and carefully combing; all combined with the 
 exercise of great patience and perseverance. If the 
 mass has gro^vn away from the scalp the easiest way 
 of treating it is by cutting it off. After the phca is 
 disposed of, we must apply ourselves to the cure of the 
 disease of the scalp that is at the bottom of the 
 trouble. The older writers endeavored to treat the 
 disease by internal medication. Rosenberg (76) gives 
 seventy remedies recommended at different times for 
 the cure of the disease. 
 
 Besides this true or phca polonica, there is a form of 
 felting of the hair which is apparently due to nervous 
 influences, probably of an hysterical nature. Cases of 
 this kind have been reported from time to time under 
 the name of neuropathic or nervous phca. Recently 
 Le Page (620) has reported a case of spontaneous and 
 rapid felting of the hair in a girl seventeen years of 
 age; and Pestonji (623) has related another occurring 
 in a woman twenty years old. Jarochevski (427 ap.) 
 reported another case in an hysterical young woman. 
 Microscopical examination showed the cuticle of the 
 hair to be entirely separated from the cortex, rough,
 
 PLICA POLONICA. 343 
 
 and its fibres split up. Its cortex showed irregular 
 disposition of pigment, and its medulla was broken 
 up. De Amicis (426 ap.) has also reported a case. In 
 all cases the hair had been wet before it began to twist 
 up, and in both there was headache and an entire ab- 
 sence of disease of the scalp.
 
 CHAPTEE XXIII. 
 
 DER^L\TITIS PAPILLARIS CAPILLITH. 
 
 Synonyms: — Dermatitis papillomatosa capillitii; 
 Frambcjesia; S}XOsis framboesia (Hebra); Sycosis 
 capillitii (^Rayer); Mycosis frambcesioides or acue 
 keloidique or Pian ruboide ( Alibert); Acne keloid. 
 
 Symptoms: — Tliis exceedingly rare disease of the 
 
 Dermatitis Papillaris Capillitii. 
 
 skin was first described as a separate entity by Kaposi 
 (<;20) in ISOO. The same group of symptoms had al- 
 ready been described by ALiBEPtT in ISl^, but regarded 
 by him as a manifestation of syphilis. From time to 
 time the disease had l>een ol)served and mentioned by 
 the older authorities, and to it the name of Framboesia
 
 DERMATITIS PAPILLARIS CAPILLITII. 34:5 
 
 had been applied on account of the resemblance of its 
 peculiar lesions to a raspberry, that being the mean- 
 ing of the word " frambcesia. " Both in Hebra and 
 Kaposi's Lehrbuch der Hautkrankheiten 1S72, 
 and Kaposi's Patliologie unci Thet^apie der Hcmt- 
 kraiikheiten,^' 18S0, the disease is placed in the chap- 
 ter or section on sycosis. Kaposi, in the article re- 
 ferred to and in his book, described the disease as fol- 
 lows: " The primary manifestations consist of an 
 eruption of large and small papules which are very 
 hard, of uniform consistence, and contain no pus. 
 These lesions are elevated many hnes above the skin, 
 and form variously sized, deeply furrowed, uneven, 
 lobulated tumors. They generally are covered with a 
 thick epidermis, bleed only when cut or deeply 
 wounded, are rarely moist, and then but in a few 
 places; and the few vesicles or pustules that may be 
 present are superficial and purely accidental. Th? 
 papules are discrete at first, but soon run together to 
 form the tumors, which at last flatten down into cica- 
 tricial tissue. The hair is deeply seated in the furrows 
 between the lobules of the tumors; is formed into ht- 
 tle bundles or wisps; and resists attempts at epilation, 
 often breaking instead of coming out. Sometimes, on 
 the other hand, it seems to be retained only mechani- 
 cally in the furrows, and comes out easily when j)ulled 
 upon. It often appears atrophied, and sometimes is 
 entirely wanting in large areas, but never is connected 
 with a pustule. The disease begins in most cases upon 
 the occiput low down at the edge of the hair, and from 
 there spreads upwards; sometimes involving the whole 
 posterior part of the head. When so extensive, the 
 lesions form a papillomatous vegetation which exudes 
 a foul-smelling secretion, bleeds easily and is covered 
 with crusts; sometimes abscesses form." 
 Hans Hebra, Jr. (620) in 1874 reported a case of '^syco-
 
 346 DISEASES OF THE HAIR AXD SCALP. 
 
 sis framboesioides " Avhich occurred upon the side of the 
 head in the form of raised and sclerosed patches sown 
 vdih millet-seed sized papules and somewhat larger pus- 
 tules, out of which protruded httle bundles of hair. In 
 ISSl Sangster (63U) reported a case of papillary tumor 
 of the scalp which was about the shape and size of a 
 pigeon's egg; situated low down on the occiput; about 
 half an inch in height; studded with hempseed seized 
 papules; brown colored at the circumference, violaceous 
 toward the centre; slightly ulcerated here and there, 
 with thin crusts. It had begTui at birth, and was in- 
 creasing gradually in size. The hah- was plentiful at 
 the margin, but sparse and devoid of pigment towards 
 the centre, and grew up between the papiUae without 
 piercing them. There was a second tumor over the 
 left ear. Kaposi pronounced this to be a case of der- 
 matitis jxtplUaris capiUitii. Hyde (628) has reported 
 two cases, in each of which puncture caused a dis- 
 charge of mucoid fluid followed by an exudation of 
 thin venous blood and serum. He describes the first 
 stage as an eruption of pin-head sized papules, vesicles, 
 or vesico-pustules. Baker (625) and Williams (632) 
 have reported cases under the name of "Acne Ke- 
 loid. " Hervouet (627) reported a case of papiUii- 
 form hypertrophy of the scalp, which corresponds in 
 many particulars to the disease as described by Kaposi. 
 Veritee (631) has also reported a case mider the name 
 of Acne Keloidique. Another case is by Eve.* 
 
 Through the kindness of Dr. Geo. H. Fox, of New 
 York city, I am able to add the followmg case which 
 I had the opportunity of studying with him: J. E., 
 set. 30. Large, well-developed and healthy man. One 
 year ago (1884) there appeared on his neck an einiption 
 of hard nodules, which have been steadily increasing 
 in munber and size. The eruption is situated upon 
 the occiput amongst the han, and upon the contiguous 
 
 * Path. Trans., 1884, xxxv., 397.
 
 DERMATITIS PAPILLARIS CAPILLITII. 34:7 
 
 portions of the neck. It consists of numerous small, 
 reddish, hemispherical tumors, each one of which is per- 
 forated by hairs. A few of these tumors showed a 
 tendency to suppurate about the mouths of the folli- 
 cles. Some of the tumors tend to become aggregated, 
 and to form mulberry -like masses of dull red color. 
 The smaller nodules are very firm, and hard and shotty 
 to the touch. They do not bleed readily when punc- 
 tured. They are not tender nor sore, and he is troubled 
 only by the deformity caused by their presence. 
 
 From a study of these cases we learn that the dis> 
 ease begins as an eruption of papules of small size, 
 which are usually few in number, and situated upon 
 the back of the neck at the margin of the hair. These 
 papules are of the color of the skin, or slightly more 
 reddish, and sometimes have an inflammatoiy halo. 
 They are exceedingly hard and firm, and do not con- 
 tain pus. If pricked they give vent to a little bloody 
 serous fluid. Slowly they increase in number, and 
 form larger raspberry-like elevations which have un- 
 even, lobulated surfaces. New lesions appear from 
 time to time upon the neck following the line of the 
 hairs, or the disease encroaches upon the hairy scalp, 
 and in the course of months or years it may reach 
 even up to the vertex. When these lobulated masses 
 attain a certain size they often become softened a lit- 
 tle, and when cut may be found to contain pus. At 
 times they secrete a foul-smelling fluid, and become 
 crusted. When the papules run together the inflam- 
 matory halo disappears. Gradually the growths be- 
 come sclerosed and assume a keloidal appearance. 
 When the hairy scalp is attacked, pustules may forju 
 out of w^hich little bundles of hair protrude; but the 
 hair is not loosened. The keloidal masses are genei'ally 
 bald; but some have a few bundles or tufts of hair in 
 them, which usually is firmly seated and resistant to
 
 348 DISEASES OF THE HAIR AND SCALP. 
 
 attempts at epilation. Sometimes these tufts are ap- 
 parently only mechanically held in the fm-rows of the 
 growths and are readily pulled out. Sometimes the 
 hair when pulled appears healthy; sometimes atro- 
 phied; sometimes it breaks upon shght traction. 
 
 The disease may give rise to some tenderness or may 
 be absolutely painful. Sometimes there are no sub- 
 jective symptoms, and the patient will complain only 
 of the deformity and the inconvenience. The course 
 of the malady is exceedingly slow, but steadily pro- 
 gressive. 
 
 Etiology.— The etiology of the disease is very ob- 
 scure. From its location at the back of the neck, at 
 about the place where the band of the shirt or other 
 clothing rubs, it has been suggested that the rubbing 
 of the shirt-collar may be an etiological factor. It oc- 
 cm^s both in women and men, and may begin at any 
 age. 
 
 Pathology. — The disease process is described by 
 Kaposi as a chronic inflammation of the chorion prin- 
 cipally, attended by a great increase in the number of 
 the blood-vessels and in the size of the papillae. This 
 is followed by the formation of new connective tissue, 
 w^hich by pressure destroys the sweat and sebaceous 
 glands, and finally compromises the existence of the 
 hair-follicles, and the hair itself. 
 
 Diagnosis.— The peculiar location of this disease 
 upon the back of the neck at the margin of the haii% 
 the arrangement of the hair in little tufts in the keloidal 
 masses, and the great hardness of the lobulated or 
 papillomatous tumors, distmguish this malady from 
 all others. In sycosis w^e have no hard tumors, 
 and the hairs are surrounded by pustules; in our pre- 
 sent disease the pustules that may be present either 
 have no relation to the hairs, or else suiTOund a number 
 of them. Warts or pcq^iUomcfs of. the scalp lack the
 
 DERMATITIS PAPILLARIS CAPILLITII. BttO 
 
 hardness of dermatitis papillaris capillitii, do not oc- 
 cupy the same region, do not tend to increase in size, 
 and do not take on a keloidal condition. The large 
 uneven tumors of mykosis fungo'ide resemble the 
 growths of dermatitis papillaris capillitii, but they 
 are not quite so soft; they are more generally distribu- 
 ted over the whole body, come and go in a capricious 
 manner, often break down and ulcerate, and do not 
 slowly change into keloidal tumors or streaks. 
 
 Prognosis. — So far as reported the growths are be- 
 nign and are compatible with a good state of health. 
 But they do not yield readily to treatment, and left to 
 themselves are progressive, and show no tendency to 
 spontaneous recovery. 
 
 Treatment. — The best treatment is the most radi- 
 cal, that is to scrape out the small growths with the 
 sharp spoon, to cut off the longer small ones with the 
 scissors, and to excise the large ones. In any case, 
 care must be used to get down to the true skin and to 
 remove the whole growth. After removal by any 
 means the base should be cauterised, and for this pur- 
 pose we may use the nitrate of silver stick, which both 
 cauterises and stops the sometimes not insignificant 
 bleeding following the operation. In some cases tlie 
 stronger caustics may be employed with benefit with- 
 out operation. Hebra, Jr., (16) speaks highly of the 
 galvano-cautery in this disease, and has found that it 
 was as effectual in removing the growi;hs, and more 
 active in preventing their return, than any other oper- 
 ative procedure.
 
 CHAPTER XXIY. 
 
 N^VUS PILOSUS. 
 
 Hair-moles or birth-marks are usually congenital, 
 and even in cases in which they have developed within 
 a few years after birth, the hair grows upon a con- 
 genitally hyperpigmented surface, a pigmentary 
 
 mole. They are of all sizes from that of a split pea 
 up to that of a huge patch big enough to involve the 
 surface of the body from a line betAveen the angles of 
 the scapulae to half way down the thigh. They may
 
 N^VITS PlLOSUS. 351 
 
 be unilateral or bilateral, and sometime? symmetrical. 
 There may be only one of them, or there may be scores 
 of them; and they may be located on any region of 
 the body. It is when they are located on the face or 
 arms that they come most often under our observa- 
 tion. 
 
 Wherever they are located, and whatever their size 
 may be, they possess the same characteristics, namely: 
 upon a thickened and pigmented patch of skin, usually 
 of dark brown or black color, there is a more or less lux- 
 uriant growth of dark stiff hair, and the whole patch is 
 slightly raised above the level of the skin, and, if 
 large, its surface is more or less uneven. The color 
 of the patch varies with the complexion of the individ- 
 ual, being light brown in blondes, and dark brown or 
 black in brunettes. The hair is nearly always darker 
 upon these moles than it is on the head of the same 
 person, excepting when the latter is black. Tlie 
 amount of hair present varies exceedingly; sometimes 
 it is very luxuriant and grows close like the fur of an 
 animal; sometimes there are only a few stiff hairs in 
 the mole. The thick growth is seen more often on the 
 lai'ge moles; while the sparse growth is more common 
 on the small moles, as on the face. These hairs are 
 coarser than those on the head; even when a hairy 
 n^vus occurs upon the scalp, the hairs covering it will 
 be coarser than those about it Exceptionally the hairs 
 are fine. Pigmentary moles may or may not coexist 
 with these hairy moles; molluscum fibrosum has been 
 met Avith in several cases. 
 
 Most of the cases reported as ^'circumscribed hyper- 
 trichosis " are examples of hairy na^vi. Some of these 
 have been given in our chapter on Hypertroi)hia Pilo- 
 rum ; sometimes these moles undergo a change into 
 epithehoma. 
 •The etiology of. npevus pilosus is obscure; our only
 
 352 DISEASES OF THE HAIR AND SCALP. 
 
 supposition is that they are due to some nervous influ- 
 ence. At times they occur along the course of nerves, 
 and cases of extensive hairy moles of the back and 
 thighs are not inf requenth^ associated Txith spina bifida. 
 They are sometimes hereditary, and I have seen them 
 on the face in a number of cases of facial hirsuties. 
 The popular idea that they are due to maternal impres- 
 sions received during pregnancy is supported by not a 
 fe^v instances in ancient and modern times. 
 
 Bull (635) in 18S2 reported the case of a child with an 
 extensive hair-mole whose mother was frightened by 
 a dog in the third month of pregnancy; and Sommer 
 (6-iO), in 1885, described another case with the history 
 of the mother having been frightened by a bear. Ho^v 
 far maternal impressions really influenced these and 
 other similar cases is not for me to determine. 
 
 HistoIogicaJJij these growths consist of a slight hy- 
 pertrophy of the papillary layer of the skin, with a de- 
 posit of brown and black pigment granules in the rete 
 mucosum. Morris (2.1:.) The hairs are hypertrophied; 
 the large hair-follicles are close together and j^ossess 
 small accessory hair- follicles in which are developed 
 hairs; and there is a more rapid fall and new growth 
 in them than in the skin of normal hairy parts. 
 (MiCHELSON (^0), in Ziemssen.) Chiari (428 ap.) found 
 in one extensive case a heaping-up of cells in the 
 corium. They had spindle-shaped nuclei and but little 
 protoplasm. The papillae were broadened by the cells. 
 The rete appeared thinned, and the corneous layer 
 thickened. The hairs were thickened, contained little 
 medulla, and stood in more or less marked clumps. 
 
 The diagnosis of haiiy moles from cii'cumscribed 
 hirsuties is determined by the presence of pigmenta- 
 tion and thickening of the skin in the former, and 
 their absence in the latter. 
 
 Treatment. — The best treatment of hairy moles is
 
 N^VUS PILOSUS. 353 
 
 electrolysis, practised as taught in our chapter on Hy- 
 pertrophia Pilorum. This is an exceedingly brilliant 
 operation in the small nsevi of the face, not only des- 
 troying the hair but also removing the discoloration. 
 In large naevi it will certainly destroy the hair, and if 
 any discoloration remains, it may be readily gotten rid 
 of by the careful application of nitric or acetic acid, 
 or the like. Of com'se it is possible to remove the growths 
 by the knife or by powerful caustics, but electrolysis is 
 a less painful method, and if done with sufficient care it 
 will leave scarcely any scar.
 
 CHAPTEE XXV. 
 
 SYPHILIS— LUPUS — VITILIGO. 
 
 These Ihree diseases affect the scalp, either as part 
 of a general eruption, or as limited to that region, 
 alone. When occurring upon the scalp, their etiology 
 and pathology are the same as when upon other regions. 
 Their symptoms differ slightly from those seen on non- 
 hauy parts, and in tliis chapter will he noted only such 
 variations. 
 
 Syphilis. 
 
 The erythematous, papular, pustular, tubercular and 
 gummatous forms of syphilis are met with on the scalp; 
 while the squamous, bullous, vesicular, and pigmentary 
 forms are not met with there. When syphihs attacks 
 hairy paiis it tends to assume the pustular form, the 
 pustules forming about the hair-follicles; and this holds 
 true during the whole of the active stage of the dis- 
 ease, or what has been named the secondary period, 
 whether the eruption upon the trunk and extremities 
 be erythematous, papular, or pustular. Thus Basse- 
 REAU (1), found, in 153 cases of erythematous syphilis, 
 the scalp affected with a 
 
 Pustular eruption, . . .106 times 
 
 Pityriasis, . . . . 13 '* 
 
 Papular eruption, . • . 4 ^^ 
 
 Macular " . . . . 2 ^^ 
 Noemption, ... . 28 '' 
 
 Erythematous syphilis of the scalp does occur, 
 however, with macules alone, which here as elsewhere
 
 SYPHILIS — LUPUS— VITILIGO. 355 
 
 are round or oval, rosy or red spots, out of which the 
 red color may be driven by pressure. They cause the 
 patient no annoyance, and he would be ignorant of 
 their presence were it not that at this time there is of- 
 ten some seborrhoea, and the accumulation of sebaceous 
 matter about the mouths of the hair-follicles forms 
 little crusts upon which the comb catches in combing 
 the hair. Pustules located about the hair-follicles are 
 associated very often with the macules, and the httle 
 scales they form in drying aid in producing that symp- 
 tom of "catching of the comb" which is one of the 
 diagnostic marks of syphilis. The macular syphilide 
 of the scalp is rare, and is met with most often along 
 the margin of the hair upon the forehead and occiput. 
 If it is accompanied by a good deal of seborrhoea we 
 may have a marked fall of the hair and alopecia. 
 
 The Papular syphilids is seen upon the scalp more 
 commonly than the macular syphilide. It is often ac- 
 companied by pustular syphilides, and by seborrhoea, 
 and is sometimes itchy. Its most frequent site is 
 along the margin of the hair, and the papules may be 
 either small or large. The small papular syphilide is 
 round and slightly elevated above the surface; red in 
 color at first, afterwards becoming coj^pery or raw 
 ham colored; in close relation to the hairs; and some- 
 times a little scaly. It becomes absorbed after some 
 weeks' duration, and as it disapjiears the hair falls out. 
 The alopecia is only partial and transient, and the hair 
 soon gi'ows again. The large papular syphilide is of 
 greater diameter and more elevated than the preced- 
 ing variety. Like it, it is scaly, and when it becomes 
 absorbed the hair falls. This syphilide sometimes 
 ulcerates and heals with a cicatrix. Sometimes the 
 papules become greatly hypertrophied, and run together 
 to form raspberry-formed masses to which the name 
 of " framboesoid, " vegetative, or verrucous syphilide
 
 o56 DISEASES OF THE HAIR AND SCALP. 
 
 has been applied. Each mass is formed of a number of 
 hypertrophied papules and resembles the papillomatous 
 formation of a wart. It is round, of varying size, and 
 gives vent to a foul-smelling secretion; its surface is 
 sometimes moist and sometimes crusted, and when the 
 crust is removed a shallow ulcer is uncovered. These 
 masses may be present in great numbers so as to involve 
 a large part of the scalp. They at last become absorbed 
 or break down, and always leave permanent baldness. 
 The Pustular syphilide is very common upon 
 the scalp, and probably occurs in every case of syph- 
 ilis with cutaneous manifestations. It is seen very 
 early in the disease \vith the erythematous eruption; oc- 
 curs also with the papular eruption; it may be part of 
 a general pustular eruption, or may occur as a local- 
 ized and relapsing syphilide. The pustules are either 
 scattered, or grouped in circles or segments of circles, 
 and usually occur about the hair- follicles. They may 
 be smaU and superficial, or large, deep and ulcerating; 
 and are surmounted by a greenish or blackish crust 
 varying in size, thickness and color. The small super- 
 ficial and pustular syphilide of the scalp, the acne-form 
 sypliiUde, is seen usually within the first six 
 months of the disease, but it may relapse and appear 
 later. It is a papulo-pustular lesion, the papule appear- 
 ing first and the pustule slowly forming on top of ii. 
 The pustule is conical or shghtly rounded in form, and 
 of pin -head size, or slightly larger. The pustule soon 
 opens and discharges its contents, which dries into the 
 characteristic gi^eenish crust of syphihs. This syphiHde 
 is often very slow in its course, especially when it oc- 
 curs as a part of a general specific pustular eruption, and 
 on healing leaves a small cicatrix. The hair falls out 
 of the folhcles in relation with the pustules, but new 
 hair grows again, excepting in cases in which the dis- 
 ease has been more severe than usual, so that the deep
 
 SYPHILIS— LUPUS— VITILIGO. 357 
 
 parts of the hair-follicles have been destroyed. The 
 pustular syphihde may be in the form of lesions which 
 are pustules from the beginning and tend to run to- 
 gether and form patches. This is known as the im- 
 petigo-form sypliilide. The patches are covered with 
 greenish or blackish thick crusts; are evidently made 
 up by the coalescence of several pustules; and when 
 the crusts are removed an ulcerating surface is ex- 
 posed. The ulceration may be superficial or deep, and 
 in debilitated subjects it may become serpiginous. This 
 form of pustular sypliilide occurs later than the acne- 
 form syphihde, usually after the first six months; it 
 may be met with in the second or third year of the 
 disease. Sometimes it is apparently the form in which 
 the acne form of syphilide relapses. Its course is slow; 
 it always heals by cicatrization; and is always followed 
 by permanent baldness. 
 
 The third and last form assumed by the pustular 
 syphilide on the scalp is called the ecthyma-form 
 sypliilide. This syphilide may occur during the second 
 half of the first year, or be one of the late or tertiary 
 manifestations of the disease. Occurring early in the 
 disease the pustules may be very numerous, and tend 
 to group; occurring late in the disease there are but 
 few of them, and these are grouped in circles or seg- 
 ments of circles. The pustules are larger than the 
 other pustular syphilides, rapidly become ulcers; and 
 are covered soon with a thick greenish or brownish 
 crust. These lesions are usually superficial in the 
 early period of the disease; deep and often serpiginous 
 when occurring as a late lesion. The ulcers heal by 
 cicatrisation and leave a bald spot. 
 
 The Tubercular syphilide is one of the late forms 
 of syphilis, and occurs sometimes upon the scalp, either 
 alone or in connection with the same lesion elsewhere 
 upon the body. They begin as deep red spots, which
 
 358 DISEASES OF THE HAIR AND SCALP. 
 
 increase in size and become elevated. They are from 
 a half to one inch in diameter; tend to group in circles 
 or segments of circles; are sometimes surmounted with 
 a scale; sometimes ulcerate and become serpiginous; 
 and sometimes become verrucous, and assume that 
 framboesoid character described uiider the papular 
 syphilide. T\niether ulcerating or not they leave a 
 cicatricial spot behind them, and this is absolutely 
 bald. This lesion is prone to relapse, so that at times 
 a large part of the scalp becomes bald. 
 
 The Gummatous syphilids is not very common on 
 the scalp. There may be only one gumma, or there 
 may be a number of them. Small ulcerations fre- 
 quently take place about the hair-folhcles, so that the 
 whole gummatous mass is covered with ulcers. The 
 gumma is either absorbed or breaks down and ulcer- 
 ates, and then the bones of the skull may be more or 
 less damaged. It occurs most frequently upon the 
 frontal and parietal region, and causes permanent 
 baldness. Though these syphilides have been described 
 here as affecting the scalp, they occui' quite commonly 
 on all the other hairy regions and then present similar 
 symptoms. Erysipelas may compHcate syphihs of the 
 scalp. 
 
 The DIAGNOSIS of the early syphihdes is unattended, 
 as a rule, with difficulty, other unmistakable symptoms 
 of constitutional syphilis being present upon the general 
 integument. It is probable that unless they cause 
 baldness they are frequently overlooked. When ques- 
 tioning a patient, with some doubtful skin lesion, as to 
 his having had syphilis, the two most important facts to 
 ascertain in regard to the scalp are the occurrence of 
 baldness in patches coming on suddenly; and the 
 catching of the comb upon the little scales on the 
 scalp. Sometimes the later lesions offer considerable 
 difficulty in diagnosis, and we are called upon to deter-
 
 SYPHILIS— LUPUS— VITILIGO. 3i).9 
 
 mine whether a pustular eruption is an eczema, simple 
 impetigo, or non-specific ecthyma, or a syphilide; or 
 we may have to decide whether a given lesion is lupus 
 or an ulcerating tubercular syphilide. The gumma 
 resembles a kerion; and a papular syphilide may be 
 mistaken for psoriasis. 
 
 From eczema or simple impetigo a pustnlar syphilide 
 is differentiated by the history of the initial lesion and 
 preceding specific eruptions; by the greater slowness 
 of the development of the pustules, and their not 
 breaking down readily; by the absence of itching and 
 burning; by the greenish or blackish crusts; by the 
 little cicatrices left by the pustules; and by the baldness 
 it causes. 
 
 From non-specifiG ecthyma, the specific form may 
 be known by the history of other specific lesions; by 
 the grouping of its pustules and their slower course, by 
 the ulcers they form, which are often serpiginous, 
 always have abrupt edges, and are deep, with their 
 floors covered with a thick puriform fluid; by the 
 crusts being thicker and more heaped up; and by the 
 smooth, white, bald cicatrices they leave. 
 
 From lupus, the ulcerating tubercular- syphilide 
 differs in occurring upon the scalp alone at times, 
 while lupus vulgaris never occurs there without being 
 found elsewhere upon the face or extremities; in 
 syphilis there is an entire absence of the characteristic 
 brownish nodules or papules of lupus. Syphilitic 
 ulcers are rounded, often serpiginous, always punched 
 out and deep, are covered with thick, heaped-up green- 
 ish or blackish crusts, and heal by a smooth, white, 
 non-deforming cicatrix. Lupus ulcers are more ir- 
 regular in shape, their crusts are thinner, and they 
 heal, if at all, with more or less puckered and unsightly 
 ^cicatrices. SyphiHs is a disease of adult or advanced
 
 360 DISEASES OF THE HAIR AND SCALP. 
 
 age, while lupus is a disease that begins most often in 
 childhood. 
 
 The history and c^ourse of kerion is entii^ely different 
 from that of a gummatous syphihde, as it occurs in 
 childhood, is usually a single lesion, forms rapidly, is 
 painful and tender, and most often stands in some re- 
 lation to trichoph^^tosis capitis. A gumma has a 
 marked tendency to break down and ulcerate, whereas 
 kerion has no such disposition. 
 
 Psoriasis may readily be distinguished from a papu- 
 lar syphihde in groups by the fact that it never occurs 
 on the scalp alone. It is, moreover, very decidedly 
 scaly when upon the scalp, while the syphihde is not 
 scaly though it may be crusted. Psoriasis causes 
 neither cicatrices nor baldness; syphihs gives rise to 
 hoth. 
 
 It is possible that an epithelial cancer may be mis- 
 taken for an ulcerating syphihde; but its hard, waxy 
 and raised edge, with dehcate blood-vessels running 
 over it; its much slower course; the shooting pains 
 that accompany it; the great proneness to bleeding 
 that it evinces; and the fact that it is uninfluenced by 
 antisyphihtic remedies, sufficiently estabhsh its diag- 
 nosis. 
 
 The TREATMENT of the syphilides of hairy parts is 
 the same as that of the same lesions located elsewhere. 
 InternaUy mercury is indicated for the early lesions; 
 mercury with or without the iodide of potassium for 
 the intermediary or late lesions; the iodide of potas- 
 sium in increasing doses and pushed rapidly until the 
 nose runs and the eyes water, in the ulcerating lesions. 
 These drugs, combined with tonics as needed, and the 
 enforcement of the laws of hygiene, will enable us to 
 effect a cure of the disease in most cases even ^Aathout 
 local treatment. Local treatment is demanded to 
 combat certain symptoms and to hasten the disappear-
 
 SYPHILIS— LUPUS— VITILIGO- 361 
 
 ance of the lesions. The early syphilides usually do 
 not require treatment. If the scalp is covered with 
 scabs and crusts they should be removed with soap 
 and water, and an ointment of the white precipitate of 
 mercury with or witliout vaseline, or of the nitrate of 
 mercury in the strength of one or two drachms to the 
 ounce of vaseUne, may be applied. If there are super- 
 ficial ulcerations, the same ointments may be used; 
 and if the ulcers are deep, iodoform in powder will 
 form a good dressing. The treatment of alopecia re- 
 sulting from syphihs has been given already in our 
 chapter on Alopecia. 
 
 Lupus Vulgaris. 
 
 This never occurs primarily upon the scalp. When 
 seen in this region it is usually an extension from the 
 forehead, and presents but a single patch. It then, 
 according to Hans von Hebra (16), takes the form of a 
 flat, httle elevated, even infiltration of the skin which 
 slowly proceeds to ulcerate. The hairs may grow 
 with scarcely impaired vigor for some time after the 
 disease has invaded the scalp. The disease is steadily 
 progressive, heals with cicatricial tissue in one place 
 I while spreading in another, and in the course of years 
 may involve the whole scalp, converting it into a mass 
 of puckered cicatrix, which of course is without hair. 
 
 The DIAGNOSIS and treatment of the disease as it 
 affects the hairy parts is the same as when it attacks 
 other parts, and for this the reader is referred to the 
 text-books of dermatology. 
 
 Lupus Erythematosus. 
 
 This disease which originates in the hair-follicles 
 and the sebaceous and sweat-glands of the skin is not 
 infrequently met with on the scalp and hairy parts of 
 the body. The scalp may be invaded from a patch
 
 S6^ DISEASES OF THE HAIR AND SCALP. 
 
 upon the face, or occur coincidentally with the disease 
 on the nose, cheeks or other parts. It may occur 
 upon the scalp alone. It hegins in one or a number of 
 round red spots situated about the hair-f oUicles. These 
 increase in size, and, new spots appearing, they at last 
 coalesce to form a patch, which is irregular in shape 
 and of various sizes up to one large enough to involve 
 the greater part of the scalp. A fuUy formed patch 
 is of red or violaceous color, covered with closely ad- 
 herent, thin, parchment-like scales, which are attached 
 to the follicles of the scalp; sharp in outhne, always 
 dry, and having its centre formed of dehcate cicatri- 
 cial tissue. EventuaUy cicatrization will take place in 
 the whole patch, and the part will become absolutely 
 and permanently bald. The disease is slow and 
 chronic in its course, and at times is attended with 
 burning or itching. 
 
 The DIAGNOSIS of the disease is easy. It is most apt 
 to be confounded with ringworm and psoriasis. Bing- 
 worm differs from it in having a history of contagion, 
 III its rounded shape, in its abundant scales and crusts, 
 in its broken off and diseased hairs, and in its sponta- 
 neous recovery without leaving a cicatrix or baldness. 
 Psoriasis is distinguished by having characteristic 
 patches upon other parts of the body, by its more 
 abundant scahng, by its not affecting the hair, by its 
 history of recovery and relapses, and by its lea^mig no 
 cicatrix. 
 
 The TREATMENT of lupus erythematosus of the scalp 
 is the same as that of the same disease on other parts. 
 I would here only lay special stress upon the great 
 value of the local appHcation of pure carboHc acid, a 
 plan of treatment proposed by Dr. Geo. H. Fox, of 
 New York, and one that is attended with wonderful 
 results in many cases. The acid is to be carefuUy ap- 
 phed by means of a little cotton on a bit of wood, and 
 the application repeated every week, or more often^
 
 SYPHILIS— LUPUS — VITILIGO. 363 
 
 the frequency depending upon the fall of the crusts 
 left by the previous burning. Cutler's fluid of equal 
 parts of carbolic acid, tincture of iodine, and chloral 
 hydrate, painted on every four or five days, is also 
 good. Phosphorus in the dose of ^ to i^ of a grain 
 in pill form may be administered by the mouth at the 
 same time, care being had ta intermit its use at inter- 
 vals. 
 
 Vitiligo. 
 
 Leucoderma, acquired albinism, or vitihgo often 
 befalls the hair, and causes white patches or tufts of 
 hair to appear among the darker hair of the part. 
 The skin of the scalp beneath the tuft is perfectly 
 healthy, aild the only change either it or the hair suf- 
 fers is the loss of color on account of a loss of pigment. 
 There may be only a single patch of white hair, or there 
 may be so many that the whole hair of the head is 
 nearly white. The hair may be affected on any part 
 of the body. The disease is unattended with symp- 
 toms, and is chronic. Electricity in the form of gal- 
 vanism or in the static form offers the only chance for 
 improving the condition, but that chance is very small. 
 Besides the diseases already described many other of 
 the cutaneous diseases may occur upon hairy parts, but 
 the situation in no wise affects the symptoms of such 
 diseases, and therefore their consideration has not been 
 included in this book.
 
 BIBLIOGRAPHY 
 
 Note. — References in the text (1, 2, 3, etc.), are to be found in 
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 3. Behrend, G. — Lehrbuch der Hautkrankheiten, 2d Ed., Ber- 
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 4. Bulkley, L. D. — Manual of the Diseases of the Skin, 2d Ed., 
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 I
 
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 604. Chincholle — De la Nature Parasitaire du Pityriasis Capitis 
 ■et de FAlopecie Consecutive, Paris, 1874. 
 
 605. Duhring, L. A.— Seborrhoea of the Scalp and Face, Med. 
 Times, Phila. 1879-80, x. 34. 
 
 606. Ferrari— Etiology of Pityriasis, Atti Acad. Gioencla di Sc. 
 Natur. i Catania, vol. xviii.; Abst. Montshft. f. prakt. Derm. 1886, 
 ^\ 84. 
 
 607. Fournier— Pityriasis Capitis, Jour, de Med. et de Chir. 
 1886, Ivii. 63. 
 
 608. Heitzmann, C. — On the Treatment of Seborrhoea, Trans. 
 Int. Med. Cong. Phila. 1876, pg. 723. 
 
 609. Jackson, Geo. T.— Dandruff; What it is and How to Cure 
 it, Med. Rec. New York, 1884, xxv. 428. 
 
 610. Manino Lorenzo— The Microsporon dispar of Yidal in Se- 
 borrhoea, Giorn. Ital. d. Mai. Yen. Mcli. & April, 1886; Abst. 
 Yrtljschr. f. Derm. & Syph. 1886, xiii. 457. 
 
 611. Morison, R. B. — A New Instrument for the Treatment of 
 Seborrha3a and Eczema Capitis, Maryland Med. Jour. 1888, x. 
 446. 
 
 612. Oudemanns & Pekelharing — Saccharomyces Capillitii, ein 
 Spaltpilz der Behaarten Kopfhaut, Tiydsch'rift voor Genees- 
 kunde; also, Archv. Neerl. d. Sc. Exactes, 1886, xx. 404; Abst. 
 Montshft. f. prakt. Derm. 1886, v. 823. 
 
 613. Payne, J. F. — Microsporon Furfur in Pitvriasis of Scalp, 
 Brit. Med. Jour 1886, ii. 922. 
 
 614. Pellizzari, C. — Microphytes of the Normal Human Skin 
 and of Alopecia Areata, Bollettino del Soc. Tra. i. Cultori del Sc. 
 Med. i. Siena; Abst. Yrtljschr. f. Derm. u. Syph. 1884, xi. 523. 
 
 Plica Poloxica. 
 
 615. Beigel, H. — Specimen of Plica Polonica, Tr. Path. Soc. 
 Lond. 1866, xvii. 418. 
 
 616. Beigel, H.— The Second Case of PUca Polonica observed in 
 England, Med. Times & Gaz. 1867, i. 509.
 
 390 BIBLIOGRAPHY. 
 
 617. Dietl — Ziir Streitfrage des Weichselzopfes, Wien. Med. 
 Wochnshrft. 18()3, xxx. 737. 
 
 018. Hamburger — Ueber die Irrlehre von der Plica Polonica, 
 Zeit. V. Klin. Med. 1861. 
 
 619. Lessing, F.— Plica Polonica, Med. Times, Phila. 1882-83, 
 xiii. 82. 
 
 620. Le Page, J. T.— On ^'europathic Plica, Brit. Med. Jour. 
 
 1884, i. 160. 
 
 621. Le Viseur — Fragments zur Nosographie des Weichselzopfs,^ 
 Deutsch. Klinik. 1859, xi. 373. 
 
 621a. Le Viseur— Zur Weichselzopffrage, Deutsche Klinik. 1861, 
 xiii. 349. 
 
 622. Mettenheimer, C. — Zur Entstehungsgeschichte der Weich- 
 selzopfsartigen Bildungen, Jahrb. Mr Kinderheil. 1875, ix. 149. 
 
 623. Pestonji, D. B. — On a Case of ZS^europathic Plica, Lancet, 
 
 1885, ii. 431. 
 
 624. Urbanowicz — De la Plique Polonaise, Archv. Gen. de Med. 
 1871. i. 215. 
 
 XoTE. — For literature prior to 1839, see Rosenberg, Der Weich- 
 selzopf. Miinchen, 1839, pg. 65. 
 
 Dermatitis Papillaris Capillitii. 
 
 625. Baker, M.— Acne Keloid, Trans. Path. Soc. Lond. 1882, 
 xxxiii. 367. 
 
 626. Hebra, H.. Jr. — Bericht von Hebra's Klinik. in Wien. fiir 
 1874, Vrtljshr. f. Derm. u. Syph. 1876, iii. 98. 
 
 627. Hervouet. H. — Xote sur un Cas d'Hypertrophie Papilli- 
 forme du cuir Chevelu, Annal. Derm, et Syph. 1883, iv, 421. 
 
 628. Hvde, J. N. — A Clinical Studv of Dermatitis Papillaris 
 Capillitii, Jour. Cutan. & Yen. Dis. 1882, i. 33 et seq. 
 
 629. Kaposi (Kohn) — Ueber Sogenannte Framboesie, Archiv. f. 
 Derm. u. Syph. 1869, i. 382. 
 
 630. Sangster, A.— A Papillary Tumor of the Scalp, Trans. In- 
 ter. Med. Cong. Lond. 1881, iii. 143. 
 
 631. Verita, A.— Acne Keloidique, Acad. Med. Sc. Mav 9th, 
 1882; Abst. Gaz. Med. 1882, iv. 245. 
 
 632. Williams, R.— Acne Keloid, Brit. Med. Jour. 1884, i. 668. 
 
 ]S"aetus Pilosus. 
 
 633. Anonvmous — Remarkable Case of Hairv Xaevus, Lancet, 
 1869, ii. 276. ' 
 
 634. Baker, W. M. — On the Removal, by Operation, of a Hairy 
 Mole occupying one-half the Forehead. Lancet, 1877, ii. 803. 
 
 635. BuU.'W. A. — Case of Diffused Superpigmented Mole of Ab- 
 domen, Brit. Med. Jour. 1882. i. 304. 
 
 636. Despres, A. — Heterotopic Pileuse Cutanee Congenitale; 
 !Xaevus Pilosus occupant presque tout le Corps, Gaz. Hebdom. 
 Par. 1874. xi. 244. 
 
 637. Hildebrandt, H. — Feber Abnorme Haarbildung beim 
 Menschen. Schrft. d. Physik. okon. Gslshft. 1878, vol. xix. 
 
 638. Lawson. Geo. — Epithelioma of Large Mole, Trans. Path. 
 Soc. Lond. 1873, xxiv. 256. 
 
 639. Murrav, Jno. — Extensive and Increasing Hair Mole in a 
 Child, Trans.' Path. Soc. Lond. 1873. xxiv. 257. 
 
 640. Sommer. W. — Ein Xeuer Fall von Hypertrichosis circum- 
 scripta, Virchow's Archiv. 1885, cii. 407.
 
 APPEJSTDIX. 
 
 Note. — This appendix is intended to fill out the bibliography and 
 journal literature of the diseases of the hair and scalp down to 1892 in- 
 clusive. 
 
 Treatises on the Skin and Syphilis. 
 
 1. Anderson, T. McC. — Parasitic Affections of the Skin, London, 
 1861. 
 
 2. Anderson, T. McC. — A Treatise on the Diseases of the Skin, Lon- 
 don and Philadelphia, 1887. 
 
 3. Brocq, L. — Traitement des Maladies de la Peau, 2d Ed., Paris, 
 1892. 
 
 4. Campbell, C. M. — Skin Diseases of Infancy and Eaily Life, Lon- 
 don, 1889. 
 
 5. Crocker, H. R.— Diseases of the Skin, London and Philadelphia, 
 1888; 2d Ed., 1893. 
 
 6. Duhring, L. A. — Epitome of Diseases of the Skin, Philadelphia, 
 1886. 
 
 7. Elchhoff, P. J.— Die Hautkrankheiten, Leipzig, 1890. 
 
 8. Erichsen, J. E.— Practical Treatise on the Diseases of the Scalp, 
 London, 1842. 
 
 9. Fox, W. T.— Skin Diseases of Parasitic Origin, London, 1863. 
 
 10. Fox, T. and T. C. — Epitome of Skin Diseases, London and Phila- 
 delphia, 1883. 
 
 11. Friese, C— Haut und Haare, Berlin, 1891. 
 
 12. Hardaway, W. A.— Manual of Skin Diseases, Philadelphia, 1891. 
 
 13. Hardy, A — Traite des Maladies de la Peau, Paris, 1886. 
 
 14. Hunt, T. — Pathology and Treatment of Certain Diseases of the 
 Skin, London, 1847. 
 
 15. Jackson, G. T.— Ready- reference Handbook of Diseases of the 
 Skin, Philadelphia, 1892. 
 
 16. Jamleson, W. A. — Diseases of the Skin, 3d Ed., Philadelphia and 
 Edinburgh, 11-92. 
 
 17. l\aposi, M. — Pathologic et Traitement des Maladies de la Peau, 
 ed. Besnier et Doyon, Paris, 1891. 
 
 18. Keyes, E. L. — Genito-Urinary Diseases with Syphilis, New York, 
 1888. 
 
 19. Kippax, J. R. — Handbook of Diseases of the Skin, Chicago, 1884. 
 
 20. Klencke, H. — Dietetische Kosmetik, Leipzig, 1888. 
 
 21. Kopp, C. — Die Trophoneurosen der Haut, Wien. 1886. 
 
 22. Leloir et Vidal. — Traite descriptif des Maladies de la Peau, Paris, 
 1889, et seq. 
 
 23. Liveing, R. — Handbook of Skin Diseases, London, 1887. 
 
 24. Morris, M.— Management of Skin and Hair, London,
 
 392 APPENDIX. 
 
 25. Neumann, C. E. O.— Die Haut, Hjiare, Nagel und Zahne des 
 Meuschen, Leipzig. 
 
 26. Olimanu-Dumesnil, A. H.— Handbook of Dermatology, St. Louis, 
 18^9. 
 
 27. Piffard, H. G. — Practical Treatise on Diseases of the Skin, New 
 York, 189L 
 
 28. Pvavogli, A.— The Hygiene of the Skin, Cincinnati, 1888. 
 
 29. Rohe, G. H.— Practical Manual of Diseases of the Skin, Philadel- 
 phia, 1892. 
 
 30. Schultz, H.— Haut, Haare und Nagel, Leipzig. 1885. 
 
 31. yhoemaker. J. V. — Practical Treatise on Diseases of the Skin, 
 2d Ed., New York. Ib92. 
 
 32. Startin, J. — Lectures on Parasitic Diseases of the Skin, London, 
 18!il. 
 
 33. Stelwagon, H. W.— Essentials of Diseases of the Skin, Philadel- 
 phia, 1890. 
 
 3i. Van Harlingen, A.— Handbook of Skin Diseases, 2d Ed., Phila- 
 delphia 1889. 
 
 Treatises on the Hair. 
 
 35. Audrain, I. — Contribution a TEtude de la Trichophytie tonsu- 
 rante, These de Paris, lb92. 
 3(5. Barteau, P. A.— De la Teigne tonsurante, These. Paris, 1856. 
 
 37. Bchr, Th. and E. — Das neue Haarerzeugungsverfahren, Leipzig. 
 
 38. Bernhardt, H — De Sycosi, Berlin, 1862. 
 
 39. Beschoruer, F. — Der Weichselzopf, Breslau, 1843. 
 
 40. Besnier. E.— Sur la Pelade, Paris, 18^8. 
 
 41. Blumenthal, B. — Ueber Sycosis vulgaris et parasitaria, Darm- 
 stadt, 1886. 
 
 42. Boeck, F.— Ueber die Area Celsi, Greifswald, 1867. 
 
 43. Bondi, E.— Pathologic des Weichselzopfs, Berlin, 1828. 
 
 44. Braschoss, J. — Merkwlirdige Fiille von Favuserkrankung, Bonn, 
 1887. 
 
 45. Braunstein. H. — Ueber Alopecia areata, Freiburg, 1873. 
 
 46. Buchiu, M.— De la Pelade : Nature, Traitement, Prophylaxie, 
 Paris, 1887. 
 
 47. Bulkley, L. D.— Acne and Alopecia, Detroit, 1892. 
 
 48. Burnett, J, C. — Ringworm: its Constitutional Nature and Cure, 
 Loudon, 1892. 
 
 49. Cantani, A. — Un Caso de Atrofia progressiva, Napoli, 1887. 
 
 50. Carrere, G. A. — iLl\i6e sur le Traitement de la Teigne toudante, 
 Paris, 1890. 
 
 51. Churlet, M.— Dissertation sur la Teigne, Strasbourg, 1811. 
 
 52. Claudat, F. N.— De la Teigne et de son Traitement, Paris, 1879. 
 
 53. Clemenceau. — La Pelade, Nantes, 1891. 
 
 54. eleven, K.— Die Haarkur. Berlin, 1891. 
 
 55. Feiertag, I. — Ueber die Bildung der Haare, Dorpat, 1875. 
 
 56. Geyl. — Beobachtungen und Ideen iiber Hypertrichose, Hamburg 
 und Leipzig, 1890. 
 
 57. Goossens, L C. H. — Over Area Celsi, Rotterdam, 1885. 
 
 58. Grenier, J. N. — Essai sur la Teigne, Strasbourg, 1810. 
 
 59. Gurney, Thos. — Specific Disease a Cause of Baldness, London, 
 1888. 
 
 60. Hamburger, E. — Ueber die Trrlehre von der Plica polonica, Ber- 
 lin, 1861. '
 
 APPENDIX. 393 
 
 61. Hayes, P. S. — Electricity and the Methods of its Employment ia 
 the Removal of Superfluous Hair, etc.. Chicago, 1889. 
 
 62. Hennocque, C— Du favusde la Peau et des Muqueuses, ThSse, 
 Paris, 1885. 
 
 63. Kaeseler, G.— Ueber Area Celsi seu Alopecia areata, Greifswald, 
 1886. 
 
 64. Kruska, E. — Ein Beitrag zu dem Kapitel : Abnorme Behaarung 
 beim Menschen, Jena, 1890. 
 
 65. Landau, C. — Ueber Sycosis parasitaria, Bonn, 1885. 
 
 66. Lanoix. — Beobachtungen liber die mit dem Abschneiden der 
 Haare verbundene Gefahr, 179-. 
 
 67. Lettre, M. D.— Ueber Plica oder Zopfkrankheit. Berlin, 1870. 
 
 68. Loriot, G.— Contribution a I'Etude de la Pelade, Paris, 1887. 
 
 69. Marcus, M. — Ueber Alopecia areata, Bonn, 1886. 
 
 70. Marianelli, A. — Achorion Schoenleinii, Pisa, 1893. 
 
 71. Muret-Deperet. — De la Folliculite conglomeree trichophytique, 
 ThSse de Paris, 1892. 
 
 72. Nachtigal. — Ueber Area Celsi, Wlirzburg, 1885. 
 
 73. Nollet, H. C. — liiudes sur la Nature de la Pelade, Bordeaux, 
 1888. 
 
 74. Reissner, E. — Beitriige zur Kenntniss der Haare des Menschen 
 und der Siiugethiere, Breslau, 1854. 
 
 75. Richard, J. — De la Teigne faveuse, Neucbatel, 1859. 
 
 76. Richter, W.— Ueber Area Celsi, Wlirzburg, 1884. 
 
 77. Romisch, W. — Ueber Favus und Favusbehandlung, Freiburg, 
 1891. 
 
 78. Rothenberg, J.— Der Weichselzopf, Wlirzburg, 1841. 
 
 79. Rowland, A. — The Human Hair, London, 1853. 
 
 80. Sommerfeld. T. — De Ziekten van het Huar, Amsterdam, 1891. 
 
 81. Thin, Geo. — Pathology and Treatment of Ringworm, London, 
 1887. 
 
 82. Wollermann, T,— Ueber Plica poionica, Berlin, 1868. 
 
 JOURNAL LITERATURE. 
 Anatomy and Physiology. 
 
 83. Duclert, L. — Determinisme de la frisure des productions pileuses, 
 Jour. d. TAiiat. et Phys., 1888, xxiv., 103. 
 
 84. Foley, J. L.— The hygiene of the hair, N. Y. Med. Jour., 1887, 
 xlv.,406. 
 
 85. Garcia, R. — Beitrage zur Kenntniss der Haarwechsels bci mensch- 
 lichen Embryonen und Neugeborenen, Abst. Montshft. f . prkt. Der- 
 mat., 1892, xiv., 242. 
 
 86. Giovannini, S. — Ueber die normale Entwicklung und iiber einige 
 Veranderungen der menschlichen Haare, Vrtljhr. f. Derm. u. Syph., 
 1887, xiv., 1049. 
 
 87. Giovannini, S. — De la regeneration des poils apr^s I'epilation, 
 Arch. Mikros. Anat., 1890, xxvi., 528. 
 
 88. Giovannini, S. — Delle alterazione dei follicoli nella depilazione, 
 etc., Giorn. ital. d. mal. ven,, etc., 1890, xxv., 378. 
 
 89. Giovannini, S. — Sur la keratination dii poil et les alterations des 
 follicules causees par I'epilation, Arch, de Biologic, 1890, x., 609. 
 
 90. Giovannini, S. — Ueber ein Zwillingshaar mit einer einfachcu 
 Wiirzelscheide, Arch. Derm. u. Syph., 1893, xxv., 187,
 
 394 APPENDIX. 
 
 91. Mertsching, A. — Beitrage zur Histologie des Haares und Haar 
 balges, Archiv. Mikros. Anat., 1887-8. xxxi., 32. 
 
 92. Recker, H. — Eiue Nachlese zu Erdls und Waldeyers Untersuch- 
 ungen liber die Haare, Jahrsbrcht. d. Westfalischen Prov.-Vereins, 
 Mimster, 1891, xix. 
 
 93. Schein. M. — Ueber das Waclisthum der Haiit und der Haare des 
 Menschen, Wien. kliu. Woch., 1892, v., 86; Arch. Derm. u. f yph., 
 1892, xxiv., 429. 
 
 94. Schweninger, E. — Ueber Transplantation und Implantation von 
 Haaren, (his works) 1886, i., 1. 
 
 95. Sewell, H. — The cleansing functions of hairs, Science, 1893, 
 xxi., 117. 
 
 96. Stieda, L.— Ueber den Haarwechsel, Biol. Centrlbl., 1887-8, vii., 
 353. et seq. 
 
 97. Veraglia ed Conti. — Contribute alio Studio delle ghiandolo 
 cutanee e dei foUicoli piliferi, Giorn. del. R. Acad, di Med. di Torino, 
 1885 (abst. Monatshft. f. prkt. Dermat., 1887, vi., 720). 
 
 Bonnet.— Morpholoe:. Jahrb., 1885-0, xi., 220; Sitzungsb. d. phys. med. 
 
 Gslschft. z. Wiirzb., l'<8!t. 129. 
 Hoffmann, L —Deutsche Zeitschr. f. Thiermed., 1885-6, xii., 51. 
 Maurer, F— Morphol Jahrbuch., 1891-*^, xvi.i., 7l7. 
 Topinard, P.— Rev. d'Anthrop , 1887, ii., 1 
 Voigt, C. A.— Denkschrif t d. K. Akad. d. Wissenschaft. Ed. xiii. 
 
 Canities. 
 
 98. Breda, A. — (Ringed Hair) Rivista Veneta di Scienze mediche; 
 abst. Montshft. f, prkt. Dermat., 1888, vii., 291. 
 
 99. Falkenheim, H. — Zur Lehre von den Anomalien der Haarfarbung, 
 Vrtljhr. f. Dermat. u. Syph., 1888, xv., 33. 
 
 100. Lesser, E. — Ueber Ringelhaare, Tagebl, d. Versamml. deutsche 
 Katurforsch., etc., 18d5, Iviii., 160; also Ann. Derm. et. Syph., 1886, 
 vii., 36. 
 
 101. Lesser, E. — Ein Fall von Ringelhaaren, Vrtljhr. f. Derm. u. 
 Syph., 1886, xiii., 51. 
 
 102. Morgan, J. H.— Hereditary tuft of white hair on the forehead, 
 Brit. Med. Jour., 1890, ii , 85. 
 
 103. Robinson, T. — Lalduess and grayness, Wood's Med. and Surg. 
 Monog., 1891, ix., 725. 
 
 Obolonski, N.— Sborn. rabat Charkoflf., 1886-7, ii., 74. 
 
 Ottolenshi.— Arch di priehiat. Torino, 1.S89, x., 194. 
 
 SchuUe, J. C— Vrhndl. d. Berl. Gesellshft. f. Anthrop., 1886, p. 559. 
 
 Discoloration of the Hair. 
 
 104. Prentiss, D. W. — Change of color in the hair from the internal 
 use of pilocarpin, Trans. X. Int. Med. Cong., 1891, iv., 24. 
 
 Alopecia. 
 
 105. Anonymous. — Therapie der Alopecia pityrodes, Montshft. f. 
 prkt. Dermat., 1888, vii., 295. 
 
 106. Arnozan, H. — Folliculites depilantes des parties glabres, Ann. 
 Derm, et Syph., 1892, iii., 491. 
 
 H»7. Besnier, E. — Alopecie cicatricielle innominee, Ann. Derm, et 
 Syph., 1888, X., 104,
 
 APPENDIX. 395 
 
 lOS. Blaschko —Alopecia mit Trichorrhexis, Montshft. f. prkt. Derm., 
 1891, xiii., 105. 
 
 109. Brocq, L. — Des folliculites et perifolliculites decalvantes, Bui. 
 etMem. Soc. Med. et Mem. Hop. de Par., 18S8, v., 399. 
 
 110. Brocq. L. — Treatment of alopecia syphilitica, Jour. Cut. and 
 Gen.-Urin. Dis., 1889, vii., 346. 
 
 111. Brocq, L. — Des rapports qui existent entre les aloperies de la 
 keratose pilaire et les alopecies dites seborrhtique, Ann. Derm, et 
 Syph., 1893, iii., 773. 
 
 113. Carrier, A. E.— Bald heads, Trans. Mich. Med. Soc, 1891, xv., 
 106. 
 
 113. Curtis, R. J.— Brains or hair, Med. Rec, 1886, xxx., 526. 
 
 114. Darier. — Sur I'examen microscopique descheveux dans Talopecie 
 syphilitique, Ann. Derm, et Syph., 1889, x., 198. 
 
 115. De Molines, P. — Sur uu cas d'alopecie congenitale, Ann. Derm. 
 etSyph., 1890, i., 54. 
 
 116. Elliot, Geo. T. — Alopecia praematura : its most frequent cause, 
 seborrhoeal eczema, N. Y. Med. Jour , 189;{, Ivii., 130. 
 
 117. Ferros. — Beitrag zum Studium der Alopecie, Montshft. f. prkt. 
 Dermat., 1893, xiv., 528. 
 
 118. Fournier, A — De alopecies, Med. Modern., 1889-90, i , 957. 
 
 119. Fournier, A. — L'alopecie syphilitique, Union med., 1890, l.,793; 
 Gaz. med. de Par., 1888, v. 49. 
 
 130. Giovannini — (Anatomical Changes in Alopecia areata and Alo- 
 pecia syphilitica) abst, Montshft. f. prkt. Dermat., 1888, vii , 28. 
 
 131. Giovannini. — (Alopecia syphilitica) Arch. Derm. u. Syph, 1893, 
 xxiv., 1033. 
 
 133. Gouinlock, "W. C. — Hats as a cause of baldness. Pop. Sc. Month., 
 1887, xxxi.,97. 
 
 133. Graetzer, E. — Die Lassar'sche Haarkur in der Privatpra.xis, 
 Therap. Montshft., 1889, iii., 453. 
 
 134. Holder, A. B. — Diseases among Indians, Med. Rec, 1893, xlii., 
 357. 
 
 135. Hyde, J. K— Congenital alopecia, Internat. Clinics, 1891. i , 321. 
 126. lUingworth.— Tinea decalvans, Brit. Med. Jour., 1S91, ii . 457. 
 
 137. Jackson, G. T. — A practical treatise on baldness. Wood's Med. 
 and Surg. Monographs, 1889, iv., GOl. 
 
 138. Jackson, G. T.— Baldness : what can we do for it ? Med. Rec, 
 1887, xxxi., 509. 
 
 129. Jardit, P. — Observation d'alopecie du cuirchevelu et de labarbe, 
 etc.. Ann. Derm, et Syph., 1891, ii., 461. 
 
 130. Lassar, O.— Ueber Haarkuren. Therap. Montshft., 1888, ii., 543. 
 
 131. Mapother. — Alopecia symptomatica, Brit. Med. Jour , July 5th, 
 1891. 
 
 133. Mayerhausen, G.— Die franklinische Kopfdouche als mittels 
 gegen das Ausfallen der Haare, Int. kiln. Rundschau, 1890, iv. , 1841. 
 
 133. O'Neil, W.— Rejuvenescence of hair of head and beard, 18S9, ii., 
 113. 
 
 134. Paschkis, H.— Traitement de l'alopecie d'origine seborrheique, 
 Nouv. Montpelr. med., October 8th, 1893, J. d. ]\lal. cut. et Syph., 
 1893, iv., 667. 
 
 135. Paschkis. H.— Die Therapie des Haarausfalles, Centrlbl. f. d. 
 ges. Therap., 1893, x., 321. 
 
 136. Quinquaud. — Folliculite epilante decalvante, Ann. Derm, et 
 syph., 1889, x., 99.
 
 596 APPE>T)IX. 
 
 137. Robinson, T. — Baldness and grayness, Wood's Med, and Surg. 
 Monographs, 1891, ix , 725. 
 
 13S. Schultz, F. J. -Atrichia adnata, Vrhndl. der Rigaer Gesellsch. 
 deutsch. Aerzte. 1891 ; ref. Montshft. f. prkt. Derm , 1893, xvi., 242. 
 
 139. Semeleder, F. — Congenital baldness, Med. Rec, 1888, xxxiii., 
 441. 
 
 140. Tyson, W. J. — Some remarks on premature baldness, Lancet, 
 1891, ii., 173. 
 
 141. Unna, P. G. — (Successful inoculation of alopecia pitvrodes) 
 Montshft. f. prkt. Derm., 1892, xiv., 413. 
 
 142. Ward, E. B.— Baldness: what shall we do with it ? Med. Age, 
 1887, v., 391. 
 
 143. Wheeler. G. H.— About bald heads, New York Evening Post, 
 Auffust 6th, 18-7. 
 
 144. White. A.— Alopecia adnata. Med. Age. 1887, v., 318. 
 
 145. Wickham, L. — An undescribed form of alopecia, Brit. Jour, 
 Dermat., 1888-9, i., 227. 
 
 Alopecia Areata. 
 
 146. Arnozan, X. — Pseudopelade avec plaques achromateuses et 
 plaques hyperchromateuses, Bui. Soc. Fran9. d. Dermat., 1891, ii., 352. 
 
 147. Askanazy, S. — Casuitisches zur Frage der Alopecia neurotica, 
 Arch. Derm. u. Syph., 1890, xxii.. 523. 
 
 148. Barthelemy. — Pelade geueralisee au cuir chevelu et ^ la face, 
 traitee par le procede du Dr.^Moty, Bui. Soc. Fran9, d, Dermat., 1891, 
 ii., 421,443. 
 
 149. Barthelemy. — Pelade traitee par les injections intradermiques de 
 sublime. Ann. Derm, et Syph., 1892, iii., 1165. 
 
 150. Behrend, G. — Ueber die klinischen Grenzen der Alopecia are- 
 ata, Berl. klin. Woch., 1887, xxiv., 108. 
 
 151. Behrend. G. — Ueber Alopecia areata und iiber die Veranderun- 
 geu der Haare bei derselbeu. Arch. path. Anat.. 1887, cix,, 493, 
 
 152. Belirend, G. — Zur Frage von der Alopecia areata, Berl. klin. 
 Woch., 1888, XXV., 148. 
 
 153. Buhrend, G. — Ueber Nervenliision und Haarausfall mit Bezug 
 auf der Alopecia areata. Arch. path. Anat., ]8'*'9, cxvi., 173, 
 
 154. Besnier, E— Instruction provisoire sur les mesures a prendre a 
 regard des sujets atteints de pelade, Trib. med., 1^89, xx., 410. 
 
 155. Blaschko, A.— Vor-stelluno: eines Falles von Alopecia areata, 
 Berl. klin. Woch., 1891, xxviii., 1152. 
 
 156. Blaschko, A. — Alopecia areata und Trichorrhexis, Berl. klin. 
 Woch., 1892, xxix., 71 , Trans. Ann, Derm, et Syph., 1892, iii., 211.^ 
 
 157. Brocq, L. — Doit on considerer la pelade comme une affection 
 contagicuse, Gaz. hebdom., 1887, xxiv.. 307. 
 
 158. Brousse. — Un cas de pelade totale du cuir chevelu, Bui. Soc. 
 Fran9. de Dermat., 1891, ii., 195. 
 
 159. Bulkley, L. D.— Clinical studv on alopecia areata and its 
 treatment, Trans. Med. Soc. N. Y., 1889, 184 ; Med. Rec, 1889, xxxv., 
 231. 
 
 160. Bulklev, L. D, — A therapeutic note on alopecia areata, Jour. 
 Cut. and Gen.'-Urin. Dis., 1892, x., 47. 
 
 161. Busquet, G. P. — Du traitement antiseptic^ue des teignes et en 
 particulier de la pelade, Ann. Derm, et Syph., 1892, iii., 269. 
 
 162. Chatelain, E. — Du traitement de la pelade par le collodion iode, 
 J. d. Mai. cutan. et syph., 1890-1, ii., 221.
 
 Appendix. 397 
 
 163. Chatelain, E. — Nouvelles observations sur le traitement de la 
 pelade par le collodion iode, J. Mai. cutan. et syph., 1891, iii., (505. 
 
 164. Crocker, H, R. — Alopecia areata : its pathology and treatmeot, 
 Lancet, 1891, i., 478. 
 
 165. Crocq, J. — Ueber Wechselseitige Beziehungen von Alopecia 
 areata, Psychosen, und Spermatorrhoea, Presse med. Beige, 1892, 
 No. xiv. 
 
 166. Cutler, C. W. — The use of iodine, carbolic acid, and chloral in 
 dermatology. Jour. Cut. and Gen.-Urin. Dis., 1892, x., 380. 
 
 167. De Tullio. — (Progressive areaform atrophy of hair follicles) 
 Rif. Med., 18S7 ; Montshft. f. prkt. Dermat., 1887, vi., 769. 
 
 168. Eichhoff, P. J.— Zur Frage der Kontagiositiit der Alopecia are- 
 ata, Montshft. f. prkt. Dermat., 1888, vii., 1025. 
 
 169. Ferros. — Contribution au traitement de la pelade, Annal. Soc. 
 d'Hydrol. med. Par., 1892, xxxvii., 249 ; Ann. Derm, et Syph., 1892, 
 iii.. 546. 
 
 170. Feulard, H. — La favus et la pelade en France, Ann. Derm, et 
 Syph., 1892, iii, 1118. 
 
 171. Feulard, H.— Pelade decalvante et vitiligo, Ann. Derm, et 
 Syph., 1892, iii., 842. 
 
 172. Fournier, H. — La recrudescence de la pelade. Jour, de Med. 
 Par., 1888, xv., 35. 
 
 173 Froelich, L.— Pelade et lesions oculaires, Rev, med. de la Suisse 
 Romande, 1890, x., 745. 
 
 174. Froelich, L. — Ueber Augenerkrankung bei Alopecia areata, 
 Berl. klin. Woch., 1891, xxviii., 343. 
 
 175. Giovannini, S. — (Anatomical changes in alopecia areata, etc.) 
 abst. Montshft. f. prkt. Derin., 1888, vii., 28. 
 
 176. Giovannini, S. — Recherches sur I'histologie palhologique de 
 la pelade, Ann. Derm, et Syph., 1891, ii., 921. 
 
 177. Giovannini, S. — Ueber die histologischcn Venlnderungen der 
 syphilitischen Alopecie und ihr Verhilltniss zu den Verilnderuugen der 
 Alopecia areata, Montshft. f. prkt. Dermat., 1893, xvi., 157. 
 
 178. Griudon, J. — Etiology of alopecia areata, Wkly. Med. Rev., 
 1889, XX., 381. 
 
 179. Hallopeau, H. — Sur une nouvelle variete d'angionevrose don- 
 nant lieu a la plaques d'alopecie pseudo-peladique, Bui. Soc. Fran9. de 
 Dermat.. 1891, ii., 157. 
 
 180. Hallopeau, H. — De la nature de la pelade et des antiseptiques 
 propres a son traitement, Union med., 1889, xlviii., 337. 
 
 181. Havenith, Dubois. — La policlinique, Brux., 1892, No. 10. 
 
 182. Hoffmann R. — Ein Fall von Alopecia areata nficli Trauma, 
 Allg. Med. Centrl.-Ztg., 1889, Iviii., 1361; Maryland Med. Jour., 1889- 
 90, xxii., 344. 
 
 183. Hutchinson, J. — Alopecia areata usually a sequel of ringworm, 
 Arch. Surg., 1889-90. i., 162. 
 
 184. Hutchinson, J. — The permanency of cures in alopecia areata, 
 Arch. Surg., 1889-90, i., 163. 
 
 185. Hutchinson, J. — Universal alopecia in middle age with history 
 of severe ringworm in childhood, Arch. Surg., 1889-90, i., 370. 
 
 186. Hutchinson, J. — On alopecia areata and its relation to ring- 
 worm, Arch. Surg., 1893, iv , 289. 
 
 187. Joseph. M. — Zur Aetiologie der Alopecia areata, Centrlbl. f. d. 
 med. Wissenschft., 1886, xxiv., 178. 
 
 188. Joseph, M. — Experimentelle Untersuchungen iiberdie Aetiologie 
 der Alopecia areata, Wien. med. Woch., 1886, xxxvi., 1642.
 
 398 APPENDIX. 
 
 189. Joseph, M. — Zur Aetiologie und Symptomatik der Alopecia 
 areata, Berl. klin. Woch., 1888, xxv., 82, etc. 
 
 190. Joseph, M — Erwiderung auf Herrn Dr. G. Behrend's Aufsatz, 
 etc., Arch. path. Anat.. 1889, cxvi., 333. 
 
 191. Kaposi, M. — Alopecia areata oder Area Celsi, Internat, klin. 
 Rundschau, 1889. iii., 536. 
 
 192. Kinney, Thos. H. — Alopecia from nervous shock, Yirg. Med. 
 Month., 1880^81, vii., 937. 
 
 193. Lavallee, A. Morel. — Sur un mode de traitement rapide de la 
 pelade, etc.. Union med.. 1892, liii., 889 ; Ann. Derm, et Syph., 1892, 
 iii.. 713; Bull. Soc. Fr. Derm., 1892, iii., 318. 
 
 194. Leloir, H. — De la pelade et des peladoi'des, Bull. Acad. Med. 
 Par., 1888, xix., 936; Gaz. Hop., 1888, Ixi., 700. 
 
 195. Leo. — Ein Fall von Alopecia areata, Monlshft. f. prkt. Derm., 
 1887, vi., 1119. 
 
 196. Lewinski. — Ein eigenartiger Fall von Verlust des Kopfhaares, 
 Montshft. f. prkt. Dermat^, 1887, vi., 141. 
 
 197. Merklen, P. — Etiologie et prophylaxie de la pelade, Ann. Derm. 
 etSyph., 1888, ix., 813. 
 
 198. Mibelli. V.— Sulla patogenesi dell' Alopecia areata, Giorn. ital. 
 d. Mai. ven., 188S, xxix., 416. 
 
 199. Mibelli, V". — (Alopecia areata) Boll. n. r. Accad. d. fis. di 
 Sienna, 1887, v., 63 (abst. Montshft. f. prkt. Dermat., 1887, vi., 629). 
 
 200. ;^[orrow, P. A. — The treatment of alopecia areata, Jour Cut, 
 and Gen.-Urin. Dis., 1891, ix., 381. 
 
 201. Motv.— Xouveau traitement de la pelade, Ann. Derm, et Syph., 
 
 1891, ii.. 406, 864. 
 
 202. Nachtigal. — Ueber das Yerhalten der electrocutaneous Sensibilitat 
 bei Area Celsi. Mitth a. d. med. Klin. z. Wurzb., 1886, ii., 405. 
 
 203. xsimier, H. — De la folliculite microbienne tonsurante du cuir 
 chevelu, Gaz. hebdom., 1890, xxvii., 234. 
 
 204. Ohmann-Dumesnil, A. H. — A case of alopecia areata due to 
 traumatism, Tr. Med. Assoc. Missouri, 1889, p. 144; St. Louis Clin. 
 Phys. and Surg., 1890, iii., 104. 
 
 205. Ohmann-Dumesnil, A. H.— Some successful methods of treat- 
 ing alopecia and alopecia areata. N. O. Med. and Sura:. Jour., 1892, 
 XX., 1; Med. News, 1892, Ixi., 146; Monatshft. f. prkt. '^Dermat., 1892, 
 XV., 49. 
 
 206. Ollivier, A.— La pelade et lecole, Bul. Acad. Med. Par., 1887, 
 xviii.. 725; Rev. de Hygiene, 1887, ix., 195. 
 
 207. Overall, G. W. — Alopecia the result of lesions of trophic 
 nerve centres, Alienist and Xeurol., 1886, vii., 254. 
 
 208. Petrini. — Note sur uu cas de calvitie et de pelade generalisee, 
 Bul. Soc. Fr. Derm, et Svph., 1892, iii., 250; Ann. Derm, et Syph., 
 
 1892, iii., 554. 
 
 209. Pontoppidan, E. — Ein Fall von Alopecia areata nach Operation 
 am Halsen, Montshft. f. prkt. Dermat., 1889, viii., 51. 
 
 210. Putnam, C. P.— An epidemic of baldness in spots (alopecia 
 areata ?) in an asylum for srirls. Arch. Pediat., 1892, ix., 595. 
 
 211. Queely, E. St. G.— Alopecia areata, Lancet, 1887, ii., 1266. 
 
 212. Quinquaud. — De la pelade, Semaine med., 1890, x., 301. 
 
 213. Raymond, P. — Considerations sur le traitement de la pelade, 
 Bul. Soc. Fr. Derm, et Syph., 1892, iii., 386; Ann. Derm, et Syph., 
 1892, iii., 794. 
 
 214. Raymond, P. — Les nouveaux traitements des peladiques, Gaz. d. 
 Hop., 1892, Ixv., 893.
 
 APPENDIX. 899 
 
 215. Robinson, A. R. — The pathology and treatment of alopecia 
 areata, Trans. IX. Inter. Med. Cong., 18»7, iv., 241; Moutshft. f. prkt. 
 Dermat., 1888, vii., 476. 
 
 216. Samuel, S. — Ueber Dr. M. Joseph's " Atrophischen Haaraus- 
 fall," Arch. path. Anat. und Phys,, 1888, cxiv., 378. 
 
 217. Schachmann. — Contribution au traitement de la pelade, Ann. 
 Derm, et Syph., 1887, viii., 178. 
 
 218. Schutz, J. — Beitrage zur Aetiologie und Symptomatologie der 
 Alopecia areata, Montshft. f. prkt. Dermat., 1887, vi., 97. 
 
 219. Schutz. J. — Ein Fall von Alopecia neurotica, Montshft. f. prkt. 
 Dermat., 1887, vi., 296. 
 
 220. Schutz, J. — Sechs Flille von Alopecia neurotica, Miinch, med. 
 Woch., 1889, xxxvi., 124. 
 
 221. Stelwagon, H. W. — Alopecia areata, Internal. Med. Magazine, 
 1892, i., 726. 
 
 222. Sympson, E. N. — Case of alopecia of entire scalp. Arch. 
 Pediat., 1892, ix., 840. 
 
 223. Thibierge, G. — Sur la question de la contagion de la pelade, 
 Ann. Derm, et Syph., 1887, viii., 503. 
 
 224. Tison, M. E, — Traitement de la pelade par le collodion iode, Bui. 
 soc. Med. Prat. Par., 1893, p. 255; J. d. Mai. cut. et Syph., 1892. iv., 
 239. 
 
 235. Vaillard, L., et Vincent, H. — Sur une pseudo-pelade denature 
 microbienne, Ann. de I'lnstitut Pasteur, 1890, iv., 446. 
 
 236. Variot. — Observations et reflexions sur la pse.do-alopecie, etc., 
 Bui. et Mem. Soc. med. d. Hop., Paris, 1891, viii., 253; Gaz. med., 1891, 
 viii., 313. 
 
 227. Vidal, E.— Pelade generalisee, Ann. Derm, et Syph., 1889, x., 
 575. 
 
 228. Wermann. — (Cases) Korrespndzbl. d. ilrztl. Kreis. u. Bezirks- 
 Vereine Sachsens, 1891, viii., 1; Mouatshft. f. prkt. Dermat., 1893, xiv., 
 29"^. 
 
 229. Wickham, L. — On a case of pseudo-pelade of Brocq, Brit. Jour. 
 Dermat., 1890, ii., 251. 
 
 Archambault, P.— Jour med. d. Bordeaux, 1889-90, xix., 424. 
 
 Basu, B. J— Indian Med. Rec, 1892, iii., 8. 
 
 Bourguet, L.— Gaz. hebdom. d. Sc. med. d. Montpellier, 1887, ix , 145. 
 
 Brocq, L.— Rev. fj6n. de elin. et de th6rap., 18»9, iii , 399. 
 
 Brooke, E. M. W.— Proc. Alumnse Assoc. Worn. Med. Col. Penn., 1890, xv., 
 
 I0.i. 
 Butte, L — Annal. d. la Po iclin. Paris, 1892. ii., 361. 
 Cantani, A.— (iior. intern, d. Sc. med., Napoli, 1887, ix., 305. 
 Colin, L —Arch d. Med. et Pharm. mil., 1888, xii., 81. 
 Colquhon, D.—Tr. Intern. Med Cong., Melbourne, 1889, ii., 972. 
 Coustan.— Rev. d Hygir^ne, 188T, vi., 555. 
 
 Dubreuilh, W.— Mem. et Bui. Soc. Med. et Chir. Bordeaux, 1889, page 288. 
 Dubreuilh, W.— Jour. d. Med. d. Bordeaux. 18H8-89, xviii.. 522. 
 Giovannini.— Gior. d. r. Accad. med. d. Torino, 1892, xl., 65. 
 Kazanli. A. I.— Vrach St. Petersburg, 188s, ix., 703. 
 Krotkoff, M.— Med. Obozr., 1889, xxxii., 391. 
 Mansuroff, N.— Klin. Sboi'n p. dermat. i sif , 1889, page 15. 
 Ploquin, A —Annal. de la Policlin. Paris, 1890-91, i., 2i7. 
 Pontoppidan, E.— Hosp. Tid. Kopenh., 1889. vii., 221. 
 Robinson, T.— Illust. Med. News, 188;«, v , 171. 
 Schindelka, H— Oestr. Ztschr. f. wissen. Veterin, 1887, i., 247. 
 V. Sehlen.— Sitzungsbr. d. Gslschft. f . Morph. u. Phys. in Munchen, 1885, i., 
 
 117. 
 Seleneff, I. T.— Med. Obozr.. 1890, xxxiv., 773. 
 Tommasoli, P. L.— Boll. d. Soc tra i cult. d. sc. med. in Sienna, 1886, iv., 
 
 379 
 Vaillard et Vmcent.— Arch. Med. et Pharm. mil, 1891, xviii., 369. 
 Wermann. -Koz. Bl. d. artzl. Kreis. in Sachsen, 1891, Ii., 38.
 
 400 APPEXDIX. 
 
 Atrophia Pilorum Propria. 
 Triclwrrhexis Nodosa. — Fragilitas.— Ringed Hair. 
 
 230. Abramovitch, A. — (Contribution to the study of trichorrhexis 
 nodosa) Russk. Med., 1888, vi., 457; abst. Arch. f. Derm. u. Syph., 
 1889, xxi., 106. 
 
 231. Archambault, P. — Note sur un cas de cheveux moniliformes, 
 Ann. Derm, et Syph., 1890. i., 392. 
 
 232. Abraham, P. S.— Moniliform hair, Brit. Med. Jour., 1891, ii., 
 1148. 
 
 233. Abraham, P. S.— A case of monilethrix, Brit. Jour. Dermat., 
 1892, iv., 21. 
 
 234. Beatty and Scott.— Moniliform hairs (monilethrix), Brit. Jour. 
 Dermat.. 1892, iv., 171; Monatshft. f. prkt. Dermat., 1892. xv.. 207. 
 
 235. Behrend, G. — Ueber Trichomycosis nodosa (Juhel-Renoy), 
 Piedra (Osorio), Berl. klin. Woch., 1890, xxvii., 464. 
 
 236. Blaschko. — Alopecia mit Trichorrhexis, Monatshft. f. prkt. 
 Dermat., 1891, xiii., 105. 
 
 237. GiovaDnini, P. — Ueber normale Entwicklung und liber einige 
 Veranderunsen der menschiichen Haare, Vrtlihr. f. Derm. u. Syph., 
 
 1887, xiv., 1149. 
 
 238. Hallopeau, H. — Sur un aplasie moniliforme des cheveux, Bui. 
 Soc. Frany. deDerm. etSyph., 1890, i., 78, 117; Bui. Med , 1891), iv., 501. 
 
 239. Hudelo. — Aplasie moniliforme familiale des cheveux, Ann. 
 Derm, et Syph., 1892, iii., 1144. 
 
 240. Jamieson, A. — Case of nodose hairs, Med. Press and Circ, 
 
 1888, xlvi., 35 
 
 241. Lesser. — Aplasia pilorum intermittens, Monatshft. f. prkt. 
 Dermat., 1887. vi., 1099; Archiv f. Dermat. u. Svph., Ib92, Erganz- 
 ungsheft i.; Verhandl. d. Deutsch. Dermat. Gslschft., 1892. p 248. 
 
 242. McMurrav, W. — Notes on some abnormal conditions of the 
 hair, Australasian Med. Gaz., 1891-92, xi., 279. 
 
 243. Montiromerv, D. W. — Trichorexis nodosa, Pacif. M. and S. 
 Jour., 1887, XXX., 640. 
 
 244. Newton. R. C. — Nosoditas crinium or trichorrhexis nodosa, Med. 
 Rec, 1889, xxxv., 375. 
 
 245. Parker, R.— A novel hair disease : (?) acne mentagra, Brit. Med. 
 Jour., 1888, ii., 13:^5. 
 
 246. Pavne, J. F. — Hair showing remarkable nodose condition, or 
 "beaded hairs " Trans. Path. Soc. Lond., 1886, xxxvii., 540. 
 
 247. Ravenel, M. P. — Trichorrhexis nodosa, Med. News, 1892, Ixi., 
 489. 
 
 218. Raymond, B. — Recherches sur la trichorrexis nodosa, Bull. Soc. 
 FranQ. de Derm, et Syph., 1891, ii , 339; Ann. Derm, et Syph., 1891, 
 ii., 568. 
 
 249. Sabouraud. R. — Dix-sept cas de cheveux mouiliformes (moni'e- 
 thrix) dans une meme famille. Bui. Soc. Fran9. de Derm., 1892-93, 362; 
 
 249a. Sabouraud, R.— Sur les cheveux moniliformes, Ann. Derm, et 
 Syph., 1892, iii., 781. 
 
 250. Steven, J. L. — Cases of trichorexis nodosa with hereditary 
 history, Glasgow ^led. Jour., 1889, xxxi., 459. 
 
 251. Tenneson. — Keratose pilaire et aplasie moniliforme des cheveux, 
 Ann. Derm, et Syph., 1892, iii., 1146. 
 
 Breda. A.— Rev. veneta di Si. med., 18S7, vii., 4.57. 
 Sasaki.— (Trichor. nod ) Sei-I-Kwai M. Jour., 1890, ix., 249.
 
 APPENDIX. 4:01 
 
 Hypertrophia Pilorum. 
 
 252. Aulas. — Notesurune casd'hypertrichosede la main. Loire Med.. 
 1888, vii., 113. 
 
 253. Bloom, I. N. — Permanent removal of superfluous hair, Amer. 
 Pract. and News, 1887, iv., 9. 
 
 254. Brocq, L. — De la destruction des poils par I'electrolyse, Ann. 
 Derm, et Syph., 1887, viii.. 460. 
 
 255. Brocq, L. — De la destruction des poils par I'electrolyse, Bui. et 
 Mem. Soc. Med. Hop. Paris, 1888, v., 147 and 387. 
 
 256. Brocq, L. — Nouveaux details sur la destruction des poils par 
 i'electrolyse, La Semaine med., 1891. xi., 127. 
 
 257. Cliiari, H. — Ueber Hypertrichosis des Menschen, Prag. med. 
 Wochenschr., 1890, xv., 495. 
 
 25S. Clasen, E. — Elektrolytische Operationen in derarztlichen Praxis, 
 Deutsch. med. Zeitg., 1892, No. 63. 
 
 259. Dodd, A. H — A case of lumbar hypertrichosis, Lancet, 1887, 
 ii., 1063. 
 
 260. Dubreuilh. — De I'epilation par I'electrolyse, Jour. d. Med. d. 
 Bordeaux. 1890-91, xx..5()6. 
 
 261. Dubreuilh. — l^pilation electrolytique, Bui. Soc. Fr. Dermat. et 
 Syph., 1892, iii., 191; Ann. Derm, et Syph., 1892, iii., 495. 
 
 263. Faulkner. — A peculiar growth of hair on the face, N. Y. Med. 
 Jour., 1890, Iii., 155. 
 
 263. Gottheil, W. S.— Hypertrichosis, Trans. IX. Int. Med. Cong., 
 1887. iv., 180. 
 
 264. Grube, C. H. — Hypertrichosis, or unnatural growth of the hair, 
 Med. World, 1887, v. 424. 
 
 265. Hardaway, W. A — A supplemental account of the case of a 
 bearded woman, etc., Med. News, 188s, Iii.. 490. 
 
 266. Hillerz. C.— Electrolysis in removal of superfluous hair, Peoria 
 Med Month., 1886-87, vii., 426. 
 
 267. Jamieson, A. — 1 he treatment of hypertrichosis. Pract , 1889, 
 xliii., 1. 
 
 268. Joseph, M. — Ein Fall von Schwimmhosen symmetrischen thier- 
 fellahnlichen pilifer pigmentosa, Deutsch. med. Woch.. 1888, xv.. 482. 
 
 269. Joseph, M. — Ueber Hypertrichosis auf pigmentirter Haul, Berl. 
 klin. Woch.. 1892, xxix., 163. 
 
 270. Juhel-Renoy, E.— Epilation, Diet. Encyl. d. Sc. med., 1887, 
 XXXV., 111. 
 
 271. Lawrence, H. — Removal of superfluous hair by electrolysis, 
 Austral. Med. Jour., 1891, xiii., 504. 
 
 272. Leviseur, F. J. — The removal of superfluous hair by electrolysis, 
 Med. Rec, 1893, xli., 209. 
 
 273. Leviseur, F. J.— Elektrolyse in der Behandlung von Hautkrank- 
 heiten, Montshft. f. prkt. Dermat., 1890, x., 307. 
 
 274. McMurray, W. — Notes on some abnormal conditions of the 
 hair. Australas. Med. Gaz., 1891-92, xi., 279. 
 
 275. Miehelson, P.— Ueber die galvano chirurgischen Depilations- 
 Methoden, Vrtljhr. Derm. u. Syph.. 1887, xiv.. 237. 
 
 276. Ohmann-Dumesnil, A. H.— Circumscribed hypertrichosis (ac- 
 quired) in the lumbar region, Weekly Med. Rev. (St. Louis), lb87, 
 XV., 317. 
 
 277. Ohmann-Dumesnil, A. II —Circumscribed hypertricliosis (ac- 
 quired) in the lumbar region, Jour. Cut. and Gen.-Urin. Dis., 1888, 
 vi.. 97.
 
 dt02 APPENDIX. 
 
 278. Ohmann-Dumesnil, A. H. — Hypertrichosis due to general dis- 
 ease of the nervous system, Alienist and Neurologist, 1887, viii., 483. 
 
 279. Ohmann-Dumesmil, A. H. — Hypertrichosis, Progress, Louisville, 
 1887-88, ii., 403. 
 
 280. Oliver, F. W. — Electricity in the removal of superfluous hair, 
 Med. Reg., 1889, v., 273. 
 
 281. Ornstein. — Fall eines geschwanzten Menschen, Berl. Geslschft. f. 
 Anthropolog., March, 1885. 
 
 282. Ornstein. — Ueber Sakrale Trichosen, Berl. Geslschft. f. Anthro- 
 polog., December, 1876; December, 1877. 
 
 283. Overton, J. W. — Permanent removal of superfluous hair by 
 electrolysis, Alabama M. and S. Age, 1888-89, i., 75. 
 
 284. Prince, M. — Electrolysis: proper and improper methods of using 
 it in the removal of superfluous hair, Amer. Jour. Med. Sci., 1889, 
 xcvii., 479. 
 
 285. Regensburger, A. E. — Treatment of hypertrichosis by electro- 
 lysis, Occident Med. Times. June, 1892. 
 
 286. Rohe, G. H. — Studies in hirsuties, Trans. Int. Med. Cong., 
 Washington, 1887, iv., 180. 
 
 287. Rohe, G. H. — Hypertrichosis, Maryland Med. Jour., 1887, xvii., 
 463. 
 
 288. Sack, A. — Ueber radicalepilation auf electrolytischem Wege, 
 Berl. klin. Woch., 1892, xxix., 10:7. 
 
 289. Sommer, W. — Ein neuer Fall von Hypertrichosis circumscripta, 
 Arch. path. Anat., 1885, cii., 407. 
 
 290. Stierlin. — Spina bifida lumbalis mit Hypertrichosis, Korre- 
 spondzbl. f. Schweiz. Arzte, 1^92, xxii., 408, 482. 
 
 291. Thin, G.— Hypertrichosis, Trans. IX. Int. Med. Cong., 1887, iv., 
 180. 
 
 292. Vanderburg, C. R. — Treatment of hypertrichosis by electrolysis, 
 Columbus Med. Jour., 1887, vi., 245. 
 
 293. Woody, S. E. — Permanent removal of hair by electrolysis, 
 Amer. Pract. and News, 1886, ii., 65. 
 
 Anonymous.— Indian Med. Jour., 1886, v., 310. 
 
 Anonymous— Jour. Anthrop. Soc. Bombay, 1386-87, i., 14. 
 
 Bartels, M.— Ztschrft. f. Ethnol., 1876 18T'J, 1881, 18S3, 1884. 
 
 Bonnet, R.— Anat. Hefte Wiesb., 1891-9-.2, i., 233. 
 
 Cristiani, A.— Arch, di Psichiat.. 1892, xiii., 70. 
 
 Ecker, L. -Globus, l^rs. xiii.; Arch. f. Anthrop., 1879, xi.; 1880, xii. 
 
 Ekama, C— Album der Natur, 1S8S. 
 
 Fauvelle.— Bull. Soc. d"Anthrop., 1886, ix., 439. 
 
 Geyl — Biolo^. Centrlbl., l88S-8.>. viii.. >3i 
 
 Giovannini, S.— Gior. d. r. Accad. med. di Torino, 1890. xxxviii., 338. 
 
 Mansuroff, N.— Klin. Sborn p. dermat. i sif., 1889. page 10. 
 
 Meyer, A. B — Vrhndlungr. d. Brl. Gslshft. f . Anthrop., 1886, page 516, 
 
 Miklucho-Maclay.— Zeitshrfr. f Ethnol.. 1876 and 1881. 
 
 Neisser.— Jahrb. d. Schles. Gslshft. f. vatrl. Kult.. 1885, Ixii., 66. 
 
 Ornstein. B.-Zeitschrft. f. Ethnol., 1875, 1876, 1877, 1679, 1880, and 1S84; 
 
 Archiv f. Anthropol., 18P6. 
 Parreydt, J.— Deutsche Montshft. f. Zahnheil, 1886. iv., 2. 
 Ranke.— Vrhndlng. d. Munch. Anthrop. Gslshft., 188S, i., 4. 
 Tepljascbin, A —Med. Obozr., l*^sS, xxix . 39. 
 Virchow, R.— Zeitschrft. f. Ethnologie, 1875, vii.; 1884, xvi. 
 Zojo, G.— Boll. Scient. Pavia, 1886, xiii., 33. 
 
 Sycosis. 
 
 294. Bockhardt, M. — Ueber die Aetiologie und Therapie der Impeti- 
 go und der Sycosis, Monatshft. f. prk. Dermat., 1887, vi., 450. 
 
 295. Brooke, H. G. — The contagious nature of sycosis, Brit. JouTt 
 Dermat., 1888-9, i., 467. .
 
 APPENDIX. 403 
 
 296. Davidson, A. R. — Sycosis non-parasitica, Buf. Med. and Surg. 
 Jour., 1886-7, xxvii., 215. 
 
 297. Dubreuilh, W. — Deux cas de sycosis non parasitaire, Annal. de 
 1. Polyclin. Bord., 1889, i., 113. 
 
 298. Fabry, J. — Zur Aetiologie der Sycosis simplex, Deutsch. med. 
 "Woch., 1891, xvii., 976. 
 
 299. Hardaway, W. A.— Inflammation of the hair follicles within the 
 nares, Jour. Cutan, and Ven. Dis., 1886, iv., 360. 
 
 300. Hutchinson, J. — Case of severe sycosis of pubes, Archv. Surg., 
 1889-90, i., 264. 
 
 301. Hutchinson, J.— Sycosis ; acne of scalp with lichenous and pus- 
 tular acne of trunk, Archv. Surg., 1889-90, i., 371. 
 
 302. Jackson, G. T. — Sycosis : a clinical study, Jour. Cutan. and 
 Gen.-Urin. Dis., 1889, vii., 13. 
 
 303. Knott, J.— Tinea sycosis. Lancet, 1890, i., 294. 
 
 304. Kromayer, E. — Beitrag zur Therapie der Sycosis, Therap. Mo- 
 natshft., 1892, vi., 181. 
 
 305. IVIichelson, P. — Ueber Trichofolliculitis bacterica, Deutsch. med. 
 Woch., 1889, XV., 586. 
 
 306. Ohmann-Dumesnil. — Treatment of sycosis, St. Louis M. and S. 
 Jour., 1890, Iviii., 137. 
 
 307. Rona, S.— -(Parasitic sycosis in Hungary) Pest. med. chir. Presse, 
 1887 ; (abst.) Jour. Cutan. and Gen.-Urin. Dis., 1887, v., 351. 
 
 308. Rosenthal, O. — Beitrag zur Aetiologie und zur Behandlung der 
 Sycosis vulgaris, Deutsch. med. Woch., 1889, xv., 459. 
 
 309. Shoemaker, J. V. — Pathology and treatment of sycosis, Jour. 
 Am. Med. Assoc, 1890, xv., 177. 
 
 310. Salomon, L. F.— Sycosis, New Orleans M. and S. Jour., 1887-8, 
 XV., 12. 
 
 311. Tommasoli, B. — Ueber bacillogene Sykosis, Monatshft. f. prkt. 
 Dermat., 1889, viii., 483. 
 
 312. Unna, P. G. — Hyphogenic, coccogenic und bacillogcnic Sycosis, 
 St. Louis M. and S. Jour., 1889, Ivii., 81. 
 
 313. Unna, P. G. - Ueber Ulerythema sykosiforme, Monatshft. f . prkt. 
 Derrnt., 1889, ix., 134. 
 
 314. Williams, W. — A localized epidemic of acne sycosis traceable to 
 a barber's shop. Lancet, 1890, i., 346. 
 
 315. Zeisler, J. — Epilation ; its range of usefulness as a dermato- 
 therapeutic measure. Jour. Cut and Gen.-Urin. Dis., 1891, ix., 444; 
 Trans. Amer. Derm. Assoc, 1891. 
 
 Martin, H.— Arztl. Veroinsbl. f . Peutschl., 1890, xvii., 488. 
 
 Nystrooi, A.— Hy^ei.. Stocktiolm, l!S90. 
 
 Rona, S.— Orvosi hetil., 1887, xxxi , 385. 
 
 Rona, S.— Pest. med. chir. Presse. 1887, xxiii., 353. 
 
 Rosenberg, M.— Arztl. Mitth. a Baden, 1891, xiv., 109. 
 
 TRicnoPHYTOSis Capitis. 
 
 316. Allyn, H, B — Treatment of ringworm of the scalp, Med. and 
 Surg. Reprtr., 1887, Ivii., 106. 
 
 317. Audrain, J.— Contribution a I'etude de la trichophytie tonsu- 
 rante, Ann. Derm, et Syph., 1892, iii., 1051. 
 
 318. Brocq, L. — Traitement local de la trichophytie du cuir chevelu 
 (teigne tondante), Ann Derm, et Syph., 1890, i , 147. 
 
 319. Busquet, G. P. — Du traitement antiseptique des teignes, etc., 
 Ann. Derm, et Syph., 1892, iii., 269. 
 
 330. Butte, L. — De I'emploi du collodion iode dans le traitement des
 
 tt04: APPENDIX. 
 
 teignes pour remplacer I'epilation, Jour, d. Mai. cutan. et syph., 1892, 
 iv., 459. 
 
 321. Cantrell, J. A. — Some experiments with electrolysis in cases of 
 tinea tonsurans, Polyclinic, Phil., 1888-9, vi., 141. 
 
 321a. Charon et Gevaert, Jour, de Med. de Brux.. 1887, page 673. 
 
 322. Dockrell, M. — Hydronapthol as specific in the treatment of tinea 
 tonsurans, Lancet, 1889," ii., 110, 
 
 323. Dubreuilh, W. — De quelques formes rares de la trichophytie du 
 cuir chevelu. Jour. Mai. cut. et syph., 1891, iii.. 438. 
 
 324. Dubrisay. — L'ecole des tei'gneux a IHopital St. Louis, Rev. de 
 B.yg. Par., 1887, ix., 296. 
 
 325. Duhring, L. A. — Experiences in the treatment of chronic ring- 
 •worm in an institution, Am. J. Med. Sc, 1892, ciii., 109. 
 
 326. Eddowes, A. — The treatment of ringworm of the scalp, Brit, 
 3Ied. Jour., 1893, i., 785. 
 
 327. Eloy, C. — Un traitement nouveau de la teigne tondante, Gaz. 
 hebdom. de 3Ied., 1889, xxvi., 475. 
 
 328. Fournier, H, — Les hopitaux et les ecoles de t«igneux, J. Mai. 
 derm, et syph., 1891, iii., 643. 
 
 329. Furthmann, W,, und Neebe, C. II.— Vier Trichophytonarten, 
 Monatshft. f. prkt. Dermat., 1891, xiii., 477. 
 
 330. Harrison, A. J. — Further researches on the treatment of tinea 
 tonsurans, Brit. M. Jour., 1889, i., 465. 
 
 331. Hutchison. J — Tincture Siegesbeckia orientalis in ringworm, 
 Brit. M. Jour., 1887, i., 1384. 
 
 332. Hutchinson, J. — Notes on cure of ringworm. Arch. Surg., 1889 
 -90, i., 276. 
 
 333. Hutchinson, J. — Herpes tonsurans which travelled from scalp to 
 hand. Arch. Surg., 1889-90, i., 367. 
 
 334. Juhel-Renoy. E. — Teignes : nature et traitement, Arch. gen. de 
 Med., 1887, ii., 84. 
 
 335. Kerley, C. G. — A report of thirty-one cases of ringworm of the 
 scalp treated successfully with bichloride, kerosene, and iodine, N. Y. 
 Med. Jour., 1891, liy., 396. 
 
 336. Leyiseur, F. J. — Irritation and the treatment of ringworm of the 
 scalp, Med. Rec, 18-9, xxxv., 594. 
 
 387. Leyiseur. F. J. — The prophylaxis of ringworm of the scalp, 
 Post-Grad., 1889-90, v., 36 ; N. Y. .Med. Jour., 18S9, 1., 43. 
 
 338. Marianclli. A.— Sulla cura della tigna tonsurante del capillizio, 
 Giorn. ital. d. Mai. yen., 1890, xxv., 359. 
 
 339. Mazza, G — Di una forma rara di tricophitiasis. Giorn. ital. d. 
 Mai. ven., 1889, xxiv.. 168. 
 
 310. Megnin, P. — Difference specifique entre le champignon de la 
 teigne des poules et celui de favus, Compt. rend. Soc. biol.,1890, ii., 151. 
 
 341. Morris, M. — Ringworm in the elementary schools. Lancet. 1891, 
 ii., 348. 
 
 342. Newman, W. — Short notes on ringworm transmission from 
 cows, Brit. Med. Jour.. 1889, ii., 1276. 
 
 343. Noyes, A. W. F —The artificial cultiyation of trichophyton fun- 
 gus (ringworm) of the skin and hair, Australian Med. Jour., Ib91, xiii., 
 473. 
 
 344. Obemdorfer, J.— Die differential Diagnose und Therapie der 
 Tinea trichophytina, N. Y. med. Presse, 1S86-7, iii., 143 
 
 345. Ohmann-Dumesnil, A. II. — Case of ringworm of the scalp 
 complicated by pustular eczema, Cincin. Med. News, 1890, xix.. 376; 
 Brit. J. Dermat., 1888-9, i., 264.
 
 APPENDIX. 405 
 
 346. Pelizzari. — Trichophyton tonsurans, abst. Monatshft. f prkt. 
 Dermat., 1887, vi., 1049. 
 
 347. Purdon, H. S. — Note on the treatment of tinea tonsurans. Dub. 
 J. M. Sc, 1889, Ixxxviii , 299. 
 
 348. Qaincke,H. — Ueber Herpes tonsurans, Monatshft. f. prkt Derm., 
 1887, vi, 987. 
 
 349. Quinquaud. — Les teignes ■ la teigne faveuse, la trichophytie, la 
 pelade, Gaz. hop., 1890, Ixiii.. 990. 
 
 350. Quinquaud. — Prophylaxie et traitement de la trichophytie. 
 Union med., 1890, 1., 49. 
 
 351. Quinquaud et Butte. — Note sur les resultats obtenus dans le 
 traitement de la trichophytie, Bui. Soc. Fran9. d. Dermat 1891. ii , 152. 
 
 352. Reynolds, H. J. — X new method of treating the vegetable parasi- 
 tic diseases of the skin, Trans. Inter. Med. Cong., 18':i7, iv.. 189. 
 
 353. Roberts, H. L. — Observations on the artificial cultivation of the 
 ringworm fungus, Brit. J. Dermat , 1888-9. i., 359. 
 
 354. Sabouraud, R. — Contribution t Tutude de la trichophytie hu- 
 maine, Ann. Derm, et Syph., 1892, iii., 1061 et seq. 
 
 355. Sabouraud, R. — Nouvelles recherches sur lamycologie du tricho- 
 phyton ; des especes de trichophyton a gros.ses spores, Bui de la Soc. 
 Fran9. de Dermat. et Syph , 1893. iv., 59. 
 
 356. Smith, A. — Ringworm of the head and its treatment. Lancet, 
 1886. i., 418. 
 
 357. Tenneson et Berdal. — Trichophytie disseminee des regions 
 glabres et du cuir chevelu a ITige adulte, Bui Soc. Fran 9. Derm, et 
 Syph., 1882, iii., 314 ; Ann. Derm, et Syph.. 1892. iii . 709. 
 
 358. Thin, G. — Pathology and treatment of ringworm, Practitioner, 
 18S7, xxxviii., 241. 
 
 359. Thin, G. — Experimental researches concerning trichophytina 
 tonsurans, Brit. M. Jour., 1889, i., 397. 
 
 360. Thin, G. — Pathology and treatment of ringworm. Wood's M. 
 and S. Monog., 1889, iv., 721. 
 
 361. Trichophytosis.— Cong. Internat. de Derm, et Syph., 1890, p. 191. 
 
 Arnaud, F.— Marseilles mM., 1688, xxv., 534. 
 
 Bertarelli, A.— Boll, di Poliambul. di Milan, 1890, iii., 1. 
 
 Bertrand, L. E.— Arch. d. m6d. Nav., 1891, Iv., 471. 
 
 Butte, L.— Assistance, Par., 1891, i , 204. 
 
 Cramoisy.— Compt. rend. Cong, inter, d. homoeop., 1889, p. 199. 
 
 D6claux, E.— Compt. rend. Soc. de Biol., Paris. 
 
 Laennec, T.-Gaz. m^d. d. Nantes, l891-'2, x., 53. 
 
 Mazza, G.— Boll. d. r. Accad. med. d. Genoa. 1891, vi.. 1. 
 
 M6gnin, P.— Bull. soc. centr. d. M»'d. vet . 1890, viii., 183. 
 
 Monteverdi, L— Bol. d. Comit. med. Cremona, 188"), v., 209. 
 
 Peroni, G.— Giorn. d. r. Accad. med. d. Torino, 1891, xxxix., 33. 
 
 Simon, R. M.-Illust. Med. News. 1890. vi., 100. 
 
 Simon, R. M.— Rev. med. de TEst, 1890. xxii., 493. 
 
 Taussig.— Bol. d. r. Accad. med. d. Roma, 1890, xvii., 54. 
 
 Trabut.— Alger, med., 1888, xvi., 220. 
 
 TRicnopnYTOSis Barb^. 
 
 362. Besnier, E. — Traitement du sycosis (parasitaire). Jour. d. Med. 
 etChir., 1887, Iviii., 248. 
 
 363. Besnier, E.— Trichophytie erythemateuse circinee, etc., Ann. 
 Derm, et Syph.. 18^9, x., 111. 
 
 364. Feye.— Epidemic de trichophytie, Arch. med. Beiges, 1886, 
 XXX., 17. 
 
 365. Gottheil, W. S.— Barber's itch, Med. News, 1892, Ixi., 342. 
 
 366. Hallopeau.— Trichophytie de la barbe, Ann. Derm, et Syph., 
 1889, X., 327,
 
 406 APPENDIX. 
 
 367. Hutchinson, J. — Case of ringworm of the beard, Arch. Surg., 
 18«9, i., 55. 
 
 Favus. 
 
 368. Boer, O. — Zur Biologie des Favus, Yrtljhr. f. Derm. u. Syph., 
 1887, xiv., 429. 
 
 369. Busquet, G. P, — Du traitement antiseptique des teignes et en 
 particulier de la pelade, Ann. Derm, et Syph , 1892, ill., 269. 
 
 370. Busquet, G. P. — De rorigine muridienne du favus, Ann. Derm. 
 etSyph.. 1892, iii., 916. 
 
 371. Elseubers:, A. — Ueber den Favuspilz, Arch. Derm. u. Syph., 
 1889, xxi., 179, and 1890, xxii , 71 ; Gaz lek. Warsz., 1889, ix., 170, 
 and 1890, x,, 208. 
 
 372. Esteves, J. — Tratamiento del favus por la resorcina, Annal. d. 1. 
 Assistancia publica, Buenos Ayres, 1891 ; abst. Ann. Derm, et Syph., 
 1891, ii., 798. 
 
 373. Evans, S. G. — Favus and its treatment ; results in 129 cases, 
 Med. Rec, 1892, xli.. 490. 
 
 374. Fabry, J. — Klinisches und Aetiologisches ueber Favus, Arch. 
 Derm. u. Syph., 1889, xxi., 461. 
 
 375. Feulard. H. — La favus et la pelade en France, Ann. Derm, et 
 Syph., 1892, iii., 1118. 
 
 376. Frank L F —Favus, Monatshft. f. prkt. Dermat., 1891, xii., 
 254. 
 
 377. Hutchinson, J. — A very severe case of favus. Arch. Surg., 1890, 
 i., 9. 
 
 378. Jadassohn, J. — Demonstration von Favusculturen, Vrhndl. d. 
 deutsch. dermat. Gslschft.. 1889, i., 77. 
 
 379. Jadas.sohn. J. — Bemerkung zu der Arbeit Elsenberg's " Ueber 
 den Favuspilz bei Favus herpeticus," Arch, Derm. u. Syph., 1890, 
 xxii., 451. 
 
 380. Jamieson, W. A. — Favus occurring under somewhat peculiar 
 circumstances as to origin. Brit. Jour. Dermat., 1893, v., 140. 
 
 381. Kaposi, M. — Zur Patliologie und Therapie des Favus, Intrnt. 
 klin. Rundschau, 1891, v.. 503. 
 
 382. Krai, F.— Ueber den Favuserreger, Wien, med. Woch., 1890, xl., 
 1441 ; Trans. X. Int. Med. Cong., 1891, iv., 13. 
 
 383. Krai, F. — Untersuchungen iiber Favus, Beitrage z. Derm. u. 
 Syph., 1891, i. 79 
 
 384. Mibelli, V. — Di alcuni casi di tigna favosa curata con Toleato di 
 rame senza depilazione, Bol. d. cult. d. Sc. med., 1888. 
 
 385. Mibelli, V. — Di alcuni casi di tigna favosa curata con I'oleato di 
 rame senza depilazione, Giorn. ital. Mai. ven., 1888, xxiii., 329. 
 
 386. Mibelli, V.— Sul fungo del favo, Riforma medica, 1891, p. 817, 
 and 1892; Ann. Derm, et Syph., 1892, iii., 228. 
 
 387. Morris, M. — An extensive case of favus, Brit. Jour. Dermat., 
 1891, iii , 101. 
 
 388. Munnich, A. J. — Beitrag zur Kenntniss des Favuspilzes, Arch. f. 
 Hygiene, 1888, viii., 246. 
 
 389. Neumann, S. — Identite du favus des poules et du favus de 
 I'homme, Compt. rend. Soc. biol. Par.. 1886, iii , 173. 
 
 390. Peroni, G. — Di un nuovo metodo pratico per curare la tigna fa- 
 vosa, Gior. d. r. Accad. d. Med. Torino, 11591 ; abst. Ann. Derm, et 
 Syph., 1891, ii., 797. 
 
 391. Pick, F, J. — Experimenteller Beitrag zur Kenntniss des Favuser- 
 regers, Wien. klin. Woch., 1890, iii., (542.
 
 APPENDIX. 407 
 
 392. Pick, F. J.— Untersuchungen uber Favus, Zeitschr, f. Heilk., 
 
 1891, xii., 153 ; also Arch. Derm. u. Syph. Ergnzhft., 1891; also Beitrag 
 z. Dermat. u. Sypb., 1891, i., 57. 
 
 393. Plaut, H. L.— Beitriige zur Favusfrage, Cntrlbl. f. Bakteriol. u. 
 Parasitk., 1892, xi., 357. 
 
 394. Quincke, H. — Ueber Favuspilze, Arch v. expermnt. Palh. u. 
 Pharm., 1886-7, xxii., 62 ; also Vrhndl. d. Cong. f. Int. Med., 1886, v., 
 467 ; also Mntshft. f. prkt. Dermat., 1887, vi., 981. 
 
 395. Quincke, H. — Doppelinfektion niit Favus vulgaris und Favus 
 herpeticus. Mntshft. f, prkt. Dermat., 1889, viii., 49. 
 
 396. Quinquaud. — Les teignes : la teigne faveuse, la trichophytie, la 
 pelade, Gaz. hop., 1880, Ixiii., 990. 
 
 397. Reynolds, H. J.— Favus, Med. Age, 1889, vii., 270. 
 
 398. Itossi, A. — La tigna favosa della facia, La Kiforma medica, 1891, 
 p. 87. 
 
 399. Schuster. — Ueber Favusbehandlung, Mntshft. f. prkt. Dermat., 
 1889, ix., 1. 
 
 400. Schwengers. — Ueber Einwirkung von Medikamentenauf Kultu- 
 ren von Favus und Trichophyton, Mntshft. f. prkt. Dermat., 1890, xi., 
 155. 
 
 401. Unna, P. G. — Drei Favusarten, Montshft. f. prkt. Dermat., 
 
 1892, xiv., 1 ; Brit. Jour. Derm., 1892, iv., 139. 
 
 402. Unna, P. G. — Die bisher bekanuten neun Favusarten, Montshft. 
 f. prkt. Dermat., 1893, xvi., 17. 
 
 Ambrosi, A.— Raccoglitore med. Forli., 1888, vi., 282. 
 
 Andronico, C— Bol. d. Sc. med. d. Bologna. 1886, xvii., 377. 
 
 Dahl, J.— Norsk. Mag f Laegevidensk., 1888, iii.. 392. 
 
 Desville, L.-Jour. d. Sc med. d. Lille, 1892. ii., 49. 
 
 Desmet, E.— La Clinique, Brux., 1889, iii., 341. 
 
 Hiorth, W.— Norsk. Mag. f . Laegeviden.sk., 1888, iii., 105. 
 
 Kovalevski, I.— Archv. vet. i auk. St. Peters., 1887, xvii., 47. 
 
 Krasin, A A.— Vrach., 18iK), xi., 5i07. 
 
 Mibelli, V — Riforma med., 1891, vii.. 817. 
 
 Eossi, A.— Riforma med., 1891, vii., 87. 
 
 V. Walsen, A. J.— Nederl. mil. geneesk. Arch., 1889, xiii., 333. 
 
 Pediculosis. 
 
 403. Besnier. — Destruction des pediculi pubis. Jour, de Med. et de 
 Chirurg., 1887, Iviii., 248. 
 
 404. Cantrell, J. A.— Pediculosis capillitii, Ann. Gynec. and Pediat., 
 1889-90, iii., 485. 
 
 405. Frazer, W. — Pediculi : their treatment by parasiticides, Med. 
 Press and Circ, 1885, ii., 550 
 
 406. Goldenberg, H.— Ueber Pediculosis, Berl. klin. Woch., 1887, 
 xxiv., 866. 
 
 407. Greenough, F. B.— Clinical notes on pediculosis, Boston M. and 
 S. Jour., 1887, cxvii., 469. 
 
 408. Grellety.— Traitement de la phthiriase, Jour, de Mai. cut. et 
 syph., 1890-91, ii., 20. 
 
 409. Reiser, I.— Pediculi pubis auf der behaarten Kopfhaut, Arch. 
 Derm. u. Syph., 1892, xxiv., 589. 
 
 410. Jamieson, W. A.— On some of the rarer effects of pediculosis, 
 Brit. J. Derm., 1888-9, i., 321. 
 
 411. Mathews, P. W. P.— Notes on phthiriasis, Canad. M. and S. 
 Jour., 1886-7, xv., 45. 
 
 412. Payne, J. F.— Maculae ccerulca) and other symptoms produced
 
 1:08 APPENDIX. 
 
 Dy pediculosis pubis, Brit. J. Derm., 1890, ii., 209; also Mntshft. f. prkt 
 Derm., 1890, xi., 388. 
 
 413. De Schweinitz and Randall. — Phtlieiriasis palpebrarum, Univ. 
 SL Mag., 1891-2, iv., 137. 
 
 41-4. Trouessart. — Sur une phthiriase du cuir chevelu causee par la 
 phtliirius inguinalis, Compt. rend. Acad. Sc, Par., 1891, cxiii., 1067. 
 
 Grellety.— Actuality mM., 1890, ii.. 161. 
 Pjatnitski.— Med. Obozr. Mosk., 1886, xxvi., 288. 
 
 Parasitic Diseases. 
 
 415. Behrend, G. — Ueber Trichomycosis nodosa, Berl. klin. Woch., 
 1890, xxvii., 464. 
 
 416. Juhel-Renoy, E.— Recherclies histo-biologiques et histologiques 
 5ur la trichomycosis nodulaire, Ann. Derm, et Syph., 1890, i., 765. 
 
 417. Juhel-Henoy, E. — Note pour servir de I'histoire de la piedra, 
 Compt. rend. Soc. biolog. Paris, 1888, v., 827. 
 
 418. Patieson, R, G. — Trichomycosis nodosa, a bacillary disease of 
 the hair, Brit. M. Jour., 1889, i., 1166 ; also Tr. Roy. Acad. Med. Ir., 
 1889, vii., 85. 
 
 419. Patteson, R. G. — Trichomycosis nodosa, a note on its character, 
 etc., Dub. J. M. Sc, 1889, Ixxxviii., 207 ; Brit. J. Derm., 1890, ii., 101. 
 
 Oudemans and Pekelharing.— Arch. neerL d. Sc. exact., 1886, xx., 401 
 
 Daxdruff. 
 
 420. Gamberini. — Pitiriasi del capo, Giorn. ital. d. Mai. ven., 1891 ; 
 Archv. f. Derm. u. Syph., 1893, xxv., 307. 
 
 420a. JacksoD, G. T.— Seborrha?a, Gaillard's Med. Monthl., 1890. 
 
 421. Mannino, L. — II microsporon dispar di Yidal nella seborrea, 
 Giorn. ital, d. Mai. ven., 1886, xxi,, 84. 
 
 422. Unua, P. G. — Was wissen wir von der Seborrhcea, 3Intshft. f. 
 prkt. Derm., 1897, vi., 698. 
 
 423. Van Harlingen, A. — The pathology of seborrhcea, Arch. Derm., 
 1878, iv., 97. 
 
 Keratosis Pilaris. 
 
 424. Brocq, L. — Notes pour servir u I'histoire de la keratose pilaire, 
 Ann. Derm, et Syph., 1890, i., 25. 
 
 425. Hutchinson, J. — Cacotrophia folliculorum, Annal. Surg., 1892-3, 
 iv., 45. 
 
 Plica Polonica. 
 
 426. De Amicis. — Du trichoma vrai, Ann. Derm, et Syph., 1892, iii., 
 1182. 
 
 427. Jarochevski, S. — Un cas de tricoma (plique polonaise) aigu, 
 abst. Jour. Mai. cutan., 1892, iv., 533 
 
 N^VUS PiLOSUS. 
 
 428. Chiari, H. — Ueber Hypertrichosis beim Menschen, Prag. med. 
 AVochsch., 1890, xv., 495. 
 
 Ornstein.— Vrhndlng. der Gesellschft. f. Anthrop., Ethnol., etc., 1884.
 
 IKDEX. 
 
 PAGE 
 
 Abscess 242 
 
 Acbor 314 
 
 barbatus 329 
 
 Achorion Schonleinii 260 
 
 Acne. 190,332 
 
 decalvante 198 
 
 indurata .251 
 
 keloidique 344 
 
 mentagra.., 182 
 
 pilaire cicatricielle depi- 
 
 lante 198 
 
 sycosis. 182 
 
 Adenotrichie 182 
 
 Alopecia 80,221,269 
 
 Alopecia adnata 81 
 
 symptoms 81 
 
 etiology 81 
 
 pathology 81 
 
 prognosis 82 
 
 treatment 82 
 
 Alopecia areata 115, 220 
 
 symptoms 116 
 
 etiology 118 
 
 pathology 124 
 
 diagnosis 120 
 
 prognosis 131 
 
 treatment. . 138 
 
 Alopecia circumscripta 115 
 
 follicularis 96 
 
 f urf uracea 92 
 
 occidentalis 115 
 
 pityrodes. . „ 92 
 
 Alopecia prematura idiopathica, 85 
 
 symptoms , 85 
 
 etiology 85 
 
 pathology 88 
 
 prognosis 89 
 
 treatment.. , 90 
 
 Alopecia prematura symptoma- 
 tica 91, 129 
 
 symptoms 91 
 
 etiology 96 
 
 pathology 99 
 
 prognosis 100 
 
 PAGE 
 
 Alopecia premature symptoma- 
 tica— diagnosis 101 
 
 treatment 101 
 
 Alopecia senilis 83, 129 
 
 symptoms tZ 
 
 etiology 83 
 
 pathology 84 
 
 prognosis 84 
 
 treatment 84 
 
 Alopecia syphilitica 94, 130 
 
 Alopecie cicatricielle innomi- 
 
 nee 198, 199 
 
 Aplasia pilorum intermittens. .153 
 
 Aplasia pilorum propria 153 
 
 symptoms 154 
 
 etiology 154 
 
 pathology 155 
 
 treatment 156 
 
 Area Celsi 115 
 
 occidentalis diffluens 115 
 
 occidentalis serpens 115 
 
 occidentalis tyria 115 
 
 Arrectores pilorum 31 
 
 Athrix depilis 80 
 
 Atrichia 80 
 
 Atrophia pilorum propria 140 
 
 Bacterium decalvans 126 
 
 Baldness 80 
 
 circumscribed 115 
 
 congenital 81 
 
 premature 85 
 
 senile 84 
 
 Barber's itch 182, 245, 329 
 
 Bartfinne -. 182 
 
 parasitische 245 
 
 Bartflechte 182 
 
 Bearded women 164 
 
 Bed-hair 39 
 
 Beigel's disease 290 
 
 Bibliography 365 
 
 appendix 391 
 
 Black hair 78 
 
 Blepharitis ciliaris 334
 
 410 
 
 INDEX. 
 
 PAGE 
 
 Blood-vessels 30 
 
 Blue hair 78 
 
 Brown hair 78 
 
 Brushes, selection of 54 
 
 Brushing = 54 
 
 Cacotrophia folliculorum 103 
 
 Calotte , 271 
 
 Calvezza 80 
 
 Calvities 80 
 
 Canities 63 
 
 symptoms . 63 
 
 etiology 68 
 
 pathology 68 
 
 treatment 71 
 
 Canities, acquired 63 
 
 congenital 63 
 
 sudden ... , 66 
 
 Cheveux monilif ormes ........ 153 
 
 Clastothrix 144 
 
 Coccogenous sycosis 182 
 
 Color altered by chemicals 79 
 
 change after death 78 
 
 Combing 55 
 
 Combs, selection of 55 
 
 Cortex, the 23 
 
 Crustalactea 314 
 
 Cuticle, the 24 
 
 Cutis anserina 311 
 
 Dandruff, symptoms 299 
 
 e'tiology 301 
 
 pathology 302 
 
 diagnosis 303 
 
 treatment 304 
 
 Dartre furfuracee arrondie. . . .205 
 pustuleuse mentagra. . .182 
 
 Dasyma 158 
 
 Defluvium capillorum 95 
 
 Depilatio 80 
 
 Depilatories 176 
 
 Dermatitis 322 
 
 Dermatitis papillaris capilli- 
 
 tii 198,344 
 
 symptoms 344 
 
 etiology 348 
 
 pathology 348 
 
 diagnosis 348 
 
 prognosis 349 
 
 treatment. 349 
 
 Dermatitis papillomatosa capil- 
 
 litii 344 
 
 Dermatomykosis barbae nodosa, 245 
 
 favosa 256 
 
 palmellina....295 
 
 PAGK 
 
 Dermatomykosis tonsurans 205 
 
 trichophytina,205 
 
 Distichiasis 181 
 
 Duhring's parasitic disease 296 
 
 Dyes for hair 72 
 
 Ecthyma 359 
 
 Eczema. 189, 219,267, 303, 312, 359 
 
 Eczema barb* 250, 329 
 
 symptoms 329 
 
 etiology 330 
 
 diagnosis 331 
 
 prognosis 332 
 
 treatment 332 
 
 Eczema capitis 314 
 
 symptoms 314 
 
 etiology 317 
 
 diagnosis 320 
 
 treatment 323 
 
 prognosis. 329 
 
 Eczema narium 337 
 
 Eczema palpebrarum 334 
 
 symptoms 334 
 
 etiology 335 
 
 treatment 335 
 
 Eczema seborrhoicum . . . 299, 301 
 
 Electrolysis 170 
 
 Embryonal hair change 34 
 
 End atrophy 156 
 
 Epithelioma 251,332,360 
 
 Erbsrrind 256 
 
 Erysipelas 321 
 
 Erythema ichorosum 314 
 
 Favus .129, 218, 256, 323 
 
 symptoms 256 
 
 etiology 260 
 
 pathology 261 
 
 diagnosis ...266 
 
 prognosis 270 
 
 treatment 270 
 
 Fikosis 182 
 
 Flechte, scherende 205 
 
 Fluxus pilorum 80 
 
 Foetal hair 32 
 
 Folliculite epilante 198, 199 
 
 Folliculitis barbae 182 
 
 Folliculitis decal vans 1 97 
 
 symptoms 197 
 
 etiology 200 
 
 pathology 200 
 
 diagnosis 200 
 
 treatment 200 
 
 prognosis 200
 
 INDEX. 
 
 411 
 
 PAGE 
 
 Folliculitis pilorum 182 
 
 Fragilitas crinium symptoma- 
 tica 140 
 
 etiology ....141 
 
 treatment 141 
 
 Fragilitas crinium idiopathica.141 
 
 patliology 142 
 
 etiology 143 
 
 treatment 143 
 
 Framboesia 344 
 
 Fuchsraude 80 
 
 Gangrsena alopecia 80 
 
 Gourme 314 
 
 Granuloma tricliophyticum . . .238 
 
 Gray ness 63 
 
 Green hair 76 
 
 Hair, anatomy of 21 
 
 appearances of 41 
 
 bed 39 
 
 centres 36 
 
 change at puberty 35 
 
 chemical constitution ... 48 
 
 color of 43 
 
 curly o 47 
 
 cutting 57 
 
 development of 82 
 
 diameter of /. . 46 
 
 discoloration of I. 74 
 
 dressing .56 
 
 dyes 72 
 
 elasticity of 48 
 
 electricity of 48 
 
 embryonal change in. . . . 34 
 
 follicle 26 
 
 general description of . . . 21 
 
 growth of 35, 45, 46 
 
 hygiene of 51 
 
 length of 45, 46 
 
 muscles of. 50 
 
 number of 46 
 
 papilla 29 
 
 physiology of 33 
 
 pigment 24 
 
 racial dillerences 47 
 
 regeneration of 40 
 
 root 24 
 
 shedding of 38 
 
 superfluous 158 
 
 technique 43 
 
 transplantation of 46 
 
 uses of 49 
 
 Hair-cone, primitive 33 
 
 PAGE 
 
 Hairiness 158 
 
 Hats 57 
 
 Henle's layer 28 
 
 Heroes circinatus 205 
 
 circine parasitaire . . . .205 
 pustulosus mentagra. .182 
 
 sqiiamosus 205 
 
 tonsurans 205 
 
 tonsurans barbaj 245 
 
 tonsurante 205 
 
 Hirsuties 158 
 
 Huxley's layer 28 
 
 Hyperkeratosis pilaris .310 
 
 Hypertrichosis 158 
 
 symptoms 158 
 
 etiology 166 
 
 treatment 169 
 
 Hypertrichosis acquisita par- 
 tialis 163 
 
 congenita par- 
 tialis 162 
 
 congenita uni- 
 versalis 158 
 
 pilorum 158 
 
 transitory. ... 165 
 
 Ichthyosis 312 
 
 Impetigo 322 
 
 figurata 314 
 
 lactantia 314 
 
 muciflua 314 
 
 mucosa 314 
 
 sycosiforme 329 
 
 Kahlheit... 80 
 
 kreisflcckige 115 
 
 Keratosis pilaris 310 
 
 symptoms .310 
 
 etiology 311 
 
 pathology 311 
 
 diagnosis 311 
 
 treatment 312 
 
 prognosis 313 
 
 Kerion 239, 256, 360 
 
 symptoms , 239 
 
 etiology 241 
 
 pathology 241 
 
 diagnosis 242 
 
 prognosis. . .243 
 
 treatment 243 
 
 Kerion Celsi 239 
 
 Koltun 339 
 
 Kopskurv 256
 
 412 
 
 INDEX, 
 
 PAGE 
 
 LaDugo hair 25 
 
 Lapsus pilorum 81 
 
 Lausesucbt 270 
 
 Lepothrix.. 293 
 
 Lichen menti 182 
 
 pilaris 310 
 
 planus 312 
 
 scrofulosorum 312 
 
 Lipsotrichia .. 80 
 
 Loss of hair — condition of sub- 
 jects of 108 
 
 occupation of 
 
 subjects of... .108 
 age at beginning, 108 
 part of scalp af- 
 fected 109 
 
 complicating dis- 
 eases 169 
 
 diseases of scalp 
 
 and hair 109 
 
 heredity of 110 
 
 Lousiness 275 
 
 Lupoid sycosis 198 
 
 Lupus erythematosus, 209, 268, 
 304, 321, 361 
 
 Lupus vulgaris 190, 359, 361 
 
 Lymphatics 30 
 
 Maculse cerulean 284 
 
 Maladie pediculaire . .275 
 
 Mails pediculi 275 
 
 Medulla, the 22 
 
 Melitagra 3l4 
 
 Mentagra 18.^ 245 
 
 Microsporon Audouini 125 
 
 Milk crust 314 
 
 Mouilethrix 153 
 
 Moniliform hairs 1 53 
 
 Morbus pedicularis 275 
 
 Muscles of the hair.. 31 
 
 Mycosis f ramboesiodes 344 
 
 fungoide 349 
 
 Nsevus pilosus 350 
 
 symptoms 350 
 
 etiology 350 
 
 pathology 352 
 
 diagnosis., 352 
 
 treatment 352 
 
 Nerves 30 
 
 Nodositas crinium 144 
 
 Noduli laqueati ...... 156 
 
 Oligotrichia 80 
 
 PAGE 
 
 Ophiasis 80, 115 
 
 Paschkiss's soap 53 
 
 Paxton's disease 293 
 
 Pedicularia 275 
 
 Pediculosis capillitii 275 
 
 Pediculosis capitis 275, 320 
 
 symptoms 275 
 
 etiology 276 
 
 pathology 277 
 
 diagnosis 279 
 
 prognosis 279 
 
 treatment 279 
 
 Pediculosis palpebrarum 289 
 
 Pediculosis pubis 283 
 
 symptoms 283 
 
 etiology 285 
 
 pathology... 285 
 
 diagnosis 287 
 
 prognosis 288 
 
 treatment 288 
 
 Pelada 80 
 
 Pelade .115 
 
 acromatosa 115 
 
 decalvante 115 
 
 ofiasica 115 
 
 Phagmesis 156 
 
 Phaiacrotes 80 
 
 Phthiriasis 275 
 
 Phy toalopecia 115 
 
 tonsurans 205 
 
 Plan ruboide 344 
 
 Piedra 291 
 
 symptoms 291 
 
 etiology 292 
 
 pathology 292 
 
 diagnosis 292 
 
 Pigment 43, 44 
 
 Pityriasis 320 
 
 capitis 300 
 
 pilaris 310 
 
 Plica polonica 339 
 
 symptoms 339 
 
 etiology 341 
 
 treatment 342 
 
 Plique polonaise 339 
 
 Polls accidentels 158 
 
 Poliotes 63 
 
 Poliothrix 63 
 
 Polish ringworm. 339 
 
 Polytrichia 158 
 
 Pomades 59 
 
 Porrigine tonsurante 205 
 
 Porrigo 314
 
 INDEX. 
 
 413 
 
 PAGE 
 
 Porrigo decalvans 115 
 
 favosa 256 
 
 f urf urans 205 
 
 lavalis 256 
 
 lupinosa 256 
 
 phyta 250 
 
 scutalata 256 
 
 tonsoria 205 
 
 Psilosis 80 
 
 Psoriasis... .218, 268, 303, 322, 360 
 Pubic hair 35 
 
 Rhizophyto-alopecia 205 
 
 Ringed hair 67 
 
 JRingskurv 205 
 
 [Ringworm 206, 304, 321 
 
 of the beard 245 
 
 crusted 256 
 
 honeycomb 256 
 
 of scalp 205 
 
 Root-sheath 27 
 
 Scall, vesicular 314 
 
 Scalled head 250, 314 
 
 Scissura pilorum 140 
 
 Sebaceous glands, anatomy of, 31 
 glands, physiology 
 
 of 49 
 
 Seborrhcca 268 
 
 capitis 217 
 
 sicca 322 
 
 sicca capitis .299 
 
 Shampoo 52 
 
 Shaving 58 
 
 Sicosi parasitaria 245 
 
 Spilosis poliosis 63 
 
 Squarus tondens 205 
 
 Superfluous hair ] 58 
 
 Sweat concretions 295 
 
 Sycosis 183, 250, 331, 348 
 
 symptoms 182 
 
 etiolog}^ 185 
 
 pathology 186 
 
 diagnosis 188 
 
 treatment 190 
 
 prognosis 197 
 
 Sycosis barbae 182 
 
 capillitii 344 
 
 chronique 198 
 
 contagiosa 182 
 
 framboesia 344 
 
 menti 182,245 
 
 non-parasitica 182 
 
 parasitica 245 
 
 PAGE 
 
 Syphilis 190, 251, 311, 323, 
 
 332, 354 
 
 symptoms 354 
 
 diagnosis 358 
 
 treatment 360 
 
 Taches ombrees 284 
 
 Teigne annulaire 2U5 
 
 du pauvre 256 
 
 faveuse 206 
 
 herpetique furfuracee..205 
 
 mentagra 245 
 
 pelade 115 
 
 tondante 205 
 
 tonsurantc 205 
 
 Thin's para.siiic disease 296 
 
 Tinea araiantacea 314 
 
 asbestina 314 
 
 barba} 245 
 
 decalvans 115 
 
 favosa 256 
 
 ficosa .256 
 
 furfuracea 314 
 
 granulata 314 
 
 kerion 239 
 
 lupinosa 256 
 
 maligna 256 
 
 nodosa 293 
 
 sycosis 245 
 
 tondens 205 
 
 tonsurans 205 
 
 vera 256 
 
 Trichauxis 158 
 
 Trichiasis 180 
 
 Trichoclasia 144 
 
 Trichoma 339 
 
 Trichomyces tonsvirans 205 
 
 Trichomykosis 205 
 
 barbae 245 
 
 capillitii...;.. 239 
 
 favosa 25<» 
 
 Trichonosis cana 03 
 
 discolor 6) 
 
 furfuracea 205 • 
 
 poliosis 63 
 
 Trichophytie 205 
 
 sycosique 245 
 
 tonsurantc. ... .205 
 
 Trichophyton tonsurans 212 
 
 Trichophytosis barbae, 189,245,331 
 
 symptoms 245 
 
 etiology 248 
 
 pathology. ...249 
 diagnosis 249
 
 414 
 
 INDEX. 
 
 PAGE 
 
 Trichophytosis barbae— treat- 
 ment 251 
 
 prognosis . 255 
 
 Trichophytosis capitis 129, 205' 
 
 symptoms. ...205 
 
 etiology 210 
 
 pathology 212 
 
 diagnosis 217 
 
 treatment 222 
 
 prognosis 238 
 
 Trichorrhexis nodosa 71, 144 
 
 symptoms 145 
 
 edology 146 
 
 pathology 149 
 
 treatment 153 
 
 Trichorrhoea 80 
 
 Trichosis athrix 80 
 
 decolor 74 
 
 farfuracea 205 
 
 hirsuties 158 
 
 Trichosis pityriasica 2Uo 
 
 plica .339 
 
 tonsurans 205 
 
 Trichosyphilis 144 
 
 Trichoxerosis 140 
 
 Tricolorosi 74 
 
 Twin hairs 29 
 
 Ulerythema sycosiforme 198 
 
 Verrucse 348 
 
 Vespajo del caplllizio 239 
 
 Vitiligo capitis ..115, 130, i;63 
 
 Vitreous membrane. 27 
 
 Vulpis morbus 80 
 
 Weichselzopf 339 
 
 Wigs 56 
 
 Yellow hair 78 
 
 ^-
 
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