CASE OF FRACTURE OF THE BASE OF THE SKULL; RECOVERY
PHYSICIAN TO THE WESTERN SKIN HOSPITAL, LONDON, ETC. THE diagnosis of alopecia areata is a matter of no difficulty in the majority of cases ; but it is not invariably easy to isolate it clinically and pathologically from certain other affections of the hairy parts. More than one distinct disease, in fact, may have alopecia areata as a prominent feature or symptom. A localised alopecia, too, may result from external pressure or friction, as on infants' heads from pressure of the pillow, on
... he pillow, on ladies' heads in the days of the "chignon," and on men's shins just above the boot, as was pointed out to me by Mr. Rickard Lloyd. The literature of the affection from the time of Willan and Bateman onwards is instructive from more than one point of view. As with many other diseases, we find that great authorities from time to time publish some observation, or supposed observation, and, proceeding from the particular to the universal, forthwith enunciate a general theory, under which, of course, all cases must be made to fall. Although certain cases, as shown by M. Brocq, are the result of a folliculitis or perifolliculitis, no prior pustulation is met with in the vast majority of them, as was formerly believed. Again, the general belief in the specific fungus " microsporon Audouini " as the cause of alopecia areata lasted for years, in consequence, no doubt, of the common tendency of our profession to accept without personal investigation or corroboration all that our great men may say. there are still persons who believe that all cases of alopecia areata are of parasitic origin, and others who hold that all cases are neuropathic ; but accurate observers in all parts of the world are more and more admitting that, while some are undoubtedly neurotic, many cases can only be explained on a parasitic hypothesis. Since Mr. Hutchinson and Dr. Radcliffe Crocker published their novel view that the majority of the cases of alopecia are etiologically related to common ringworm of the scalp I have as far as possible investigated the histories of 137 cases of alopecia areata, and have examined microscopically a considerable number. In no case which did not show other evidence of the affection being really tinea tonsurans could a trichophyton be found, and for some time it appeared to me that in comparatively few instances could a history of previous ringworm be obtained. The evidence as to this latter point seems, however, to be increasing, and the statistics now presented undoubtedly lend some support to Mr. Hutchinson's and Dr. Crocker's theory. It is apparent, indeed, that in no less than forty-four instances, or 33 per cent. of the cases, there had either been a previous history of ringworm in the patient or other members of the family, or persons more or less in contact with the patient had been at some time or other affected with that disease. [Dr. Abraham gave short notes of thirty-seven of these cases. ] There are certainly cases, on the other hand, in which no connexion with ringworm can be traced, and I can relate one, at least, in which I know and can vouch for all the facts. The question of the possible contagiousness of alopecia areata is also illustrated by my figures. In twenty-seven of the 137 cases there is a clear history of other members of the family or intimate friends having been affected with alopecia ; but some of them are of very doubtful value in proving contagion, for the individuals have been affected at very different periods of time-years sometimes interveningor after they had been long living apart. Instances are referred to of the occasional occurrence of epidemics of alopecia areata, as noted by Bateman, the French writers, by Hillier, and others. Quite recently a somewhat analogous series of cases which occurred in an orphanage came under my notice, which, in accordance with our preconceived notions, may be taken either to show that at times alopecia areata is a very contagious disease or that that affection and common ringworm of the scalp are practically due to the same cause. Four boys were brought to me at the Western Skin Hospital with bare patches on the scalp. The patches were quite smooth and white, with a few short hairs with atrophic roots around the margin and some loose atrophic hairs outside ; no fungus could be found. The history was as follows. A boy fourteen years of age (the patient was shown at the 1 Abstract of a paper read before the West London Medico-Chirurgical Society on Nov. 3rd, 1893. meeting) had ringworm four years ago and was said to have been cured. Bald patches commenced to appear about a yearsince. He shortly afterwards entered the orphanage and waspassed as having no contagious disease. Since his admission eighteen of the boys of a total of twenty-two in theestablishment had developed similar bald patches, and in most of them the hair had grown again under the influence of stimulating applications. During the spring of this year two other boys in the house showed signs of eommon ringworm ; and within the last few weeks another boy (this patient was also shown) had undoubted tinea tonsurans. Three weeks ago the matron informed me that. she, too, " had caught the disease "; and I found on her head three small round patches of commencing alopecia, without broken or clavate hairs, but with many loose hairs around with atrophied roots. In this case, too, no trichophytoncould be demonstrated. She remembered that on one occasion she was interrupted before washing her hands after attending to the boys' heads, and she thinks that she then, touched her head. There was slight itching before the hair began to fall. For a long time I have observed that certain persons suffering from alopecia areata had been the subjects of extensive seborrhoea, and I agree with M. Brocq in thinking that some cases may be the sequel to that affection. The case of a woman with multiple patches was a, marked instance ; I found that several other members of her family had extensive seborrhoea. Comparatively few (only thirteen) of the 137 cases gave a history of neuralgia or previous neuroses, and in those who complained of severe headaches I have just as frequently found the short clavate. hairs as in the others. I am aware that this is not in accordance with the views generally expressed. One of my cases illustrates this point. This patient is the mother of nine children, and none of them have ever had ringworm or alopecia ; nor does she know of anything of the kind among friends. One of her patches is very depressed and scarlike, and shows club-shaped hairs at the borders ; a smaller patch shows evident folliculitis. She had been out of health for some years, and suffered much from severe headaches; there was also extensive seborrhcea. With reference to treatment, parasiticidal ointments and the cautious occasional application of Burt's fluid are, I believe, serviceable in a majority of the cases. I have by these means seen alopecias cured which had lasted for years; and were apparently hopeless. I frequently use a carbolic. and salicylic acid ointment, and sometimes intermit with lotions like the "lotion excitante " of the St. Louis Hospital. I always treat the seborrhma if present. When I want to impregnate an area of scalp with a germicidal fluid I am. now trying an apparatus made for me some months ago by Messrs. Maw, Son, and-Thompson, which is constructed on the principle employed in creasoting logs of wood or railway sleepers. A partial vacuum is first produced over the diseased part, which has been previously epilated, shaved and washed with soft-soap, alcohol, and ether ; the germicide is then let in under the influence of the atmospheric pressure. It is curious to observe how the spots implicated come into view by a manifest localised hyperasmia of the subjacent cutis, a, fact of some pathological significance. I have only been able to use this method in a few cases, and I can say but ver:3 little at present as to results.