Common Baldness: Its Cause and Treatment -Delos Parker, 1907

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COMMON BALDNESS: ITS CAUSE AND TREATMENT.

By Delos L. Parker, M. D.,

Adjunct Professor of Materia Medica Detroit College

of Medicine, Detroit, Michigan.

Baldness is not a disease of itself. It is merely the symptom of a disease, or disturbing influence that is exerting an effect, general or local, upon the body. The term baldness, however, is often employed to express the affection or condition that underlies it, just as the expression chills and fever is sometimes used to express the disease malaria, of which the chills and fever are symptoms. In this sense the word baldness is used in this paper.

There are three different types of baldness. These, in the order of their importance, are as follows: Common baldness (alopecia vulgaris), alopecia areata (area Celsi), and alopecia secundaria. Each of these forms of baldness is possessed of characteristics so peculiarly its own that the making of a differential diagnosis in a case is a matter devoid of difficulty.

Common baldness (alopecia vulgaris) is peculiarly an affection of adult life, the earlier and later stages of this period being those in which it prevails to the greatest extent. This type of baldness also exhibits a marked tendency to affect males rather than females, particularly before the advent of age, and a constant tendency to destroy the hair of the top of the head. Occasionally the hair may be lost from the upper parts of the sides and back of the head, but this is exceptional and occurs only after the affection has existed for many years and has destroyed all the hair of the top of the head. It is doubtful if common baldness ever causes all of the hair of the head to disappear. Besides these characteristics, common baldness causes a form of hair-shedding that is never recovered from spontaneously, although such hair-shedding may become arrested at any stage of its development. Common baldness accounts for more than 90 per cent of all cases of baldness.

Alopecia areata (area Celsi), on the other hand, affects both children and adults, but rarely occurs in persons past middle life. It affects the sexes equally, and oftener than not

disappears spontaneously. The hair-shedding it induces is usually confined to one or more round or oval patches, which as a rule arelocated on the sides or back of the head. In exceptional cases these patches enlarge and coalesce, with the result that irregular tracts of scalp, or the whole head, may be left temporarily or permanently denuded of hair.

Finally, alopecia secundaria is loss of hair occurring as a symptom or sequel of another disease. Among the diseases capable of causing this form of baldness are erysipelas, syphilis, scarlet fever and typhoid fever. This form of baldness is rarely permanent. It usually disappears either of itself, or under the influence of the treatment applied to the basic disease. This fact renders it the least important of the different forms of baldness. Common baldness is the only form of baldness considered in this paper.

Alopecia areata and alopecia secundaria combined furnish less than 10 per cent of the baldness in existence.

Cause.—The direct or exciting cause of common baldness is a soluble poison circulating in the blood. This poison, discovered, isolated and named by me in 1901, is termed trichotoxin (hair poison).

Trichotoxin is a crystalline body. The crystals are needle-shaped and arranged for the most part either in bundles, or in overlapping layers like the grains of a growing barley head. Trichotoxin is freely soluble in water and ether, but insoluble in absolute alcohol. Watery solutions are neutral in reaction and do not deviate polarized light. Trichotoxin may be extracted from its aqueous solution with the aid of ether, or collected by evaporation. It may also be precipitated from like solutions by most of the soluble preparations of barium, and also by strontium nitrate. It is permanent in the air.

Trichotoxin is a product of a change that invariably takes place in expired air whenever such air is kept chambered in the presence of warmth and moisture. The term expired air, as used here, refers to air that has been taken into the lungs and become charged with the waste products that are normally excreted by the lungs. In this sense air exhaled from the lungs, the breath, and air left in the lungs, the so-called residual air, is what is meant to be expressed by the term expired air.

Expired air is an extremely complex substance. Among its constituents are oxygen, nitrogen, carbon dioxide, argon, watery vapor, and organic matter. There probably is also present an oxidizing ferment.

Expired air inclosed in a clean flask along with a small amount of water and the whole kept at body temperature is practically in the same condition and surroundings as air chambered in the lungs, or, what is the same thing, as residual air in a portion of the lungs not used for breathing purposes. Expired air in a flask in these circumstances undergoes change and develops trichotoxin, which becomes dissolved in the water. By evaporating this water to dryness on a water bath a residue appearing to the unaided aye like a thin coating of frost on a window pane is secured. This residue contains trichotoxin and another body to which the name of stearotoxin has been given. The stearotoxin can be removed by washing the residue with absolute alcohol, in which it is freely soluble. When a fixed quantity of expired air is kept chambered in the presence of warmth and moisture about six hours must pass before trichotoxin begins to be formed, and about four or five days must elapse before the process of conversion is completed. The amount of trichotoxin a fixed quantity of expired air is capable of developing is small—one liter yielding Gm. O.0003, or, what is the same thing, one gallon yielding grain 1-53.

The nature of the change that expired air undergoes when trichotoxin is formed has not been definitely determined. It has been found that it is not bacterial in character. There are reasons for thinking that the ferment above mentioned holds a causal relation to it. When expired air has been subjected to a temperature of 80 degrees C. it cannot be made to yield trichotoxin.

Trichotoxin circulating in the blood produces its characteristic effects by exerting a selective poisonous action on the hair-papillae. Specificaly the hair papillae are made to undergo atrophy. This property is possessed by this substance by reason of some peculiarity not understood, and is comparable, so far as its nature is concerned, to the property of contracting unstriped muscular tissue possessed by ergot, or the property of dilating the blood vessels possessed by the nitrites.

The statement that the hair-shedding of common baldness is associated with atrophy of the hair papillae is based on the researches of Quain, Sabouraud and others.

Trichotoxin circulating in the blood is carried to all parts of the body and as a result is brought into contact with the hair-papillae in all regions of the body where they exist. This being the case, the question naturally arises, why should a poisonous substance coming in contact with all the hair-papillae of the body limit its destructive effects to the hair-papillae of the top of the head, as must be the case if it is to be held responsible for the existence of common baldness? The answer is this: The hair-papillae of the top of the head lie in close relationship with the hard, glistening and practically bloodless occipitofrontal aponeurosis, from which they derive little or no nourishment, while the hair-papillae of other parts of the body lie in close relationship with soft, blood-saturated muscular tissue from which they derive much nourishment. As a result of this anatomical peculiarity the hair-papillae of the top of the head are of lower vitality than those of other parts of the body and consequently are less resistant to the action of disturbing influences.

The occipito-frontal aponeurosis, it may not be wholly superfluous to say, is a flat tendonous structure something more than a handbreadth in width, which begins anteriorly just below the hair line (its junction with the muscle being outlined by the uppermost of the wrinkles that appear on the brow when the eyebrows are elevated) and passes backward over the top of the head to end in a point or prolongation at the occipital protuberance. Common baldness tends to cause all the hair to fall from every part of the portion of the scalp lying over this tendon. When this has occurred the affection may be spoken of as complete.

Trichotoxin gains access to the blood by being absorbed from the place of its origin, namely, the air cavities of a portion of the lungs that have not been utilized for some time previously for breathing purposes. To explain how this occurs it is necessary in the first place to call attention to certain points connected with the anatomy of the thorax and lungs, the circulation of the blood in the lungs, and the mechanism of respiration.

The thorax is a bony cage, the vertical walls of which are formed chiefly by the ribs. The ribs of the thorax articulate with the dorsal vertebrae posteriorly and with the sternum through the costal cartilages anteriorly. From the vertebral column the ribs slope downward. They also are securely joined together by muscles and other tissues. The floor of the thorax is formed by the upward-arching diaphragm.

The lungs themselves contain many millions of air spaces. These consist of bronchial tubes, large and small, and the air-cells. The air-cells are gathered about the dilated extremities of the bronchial tubes. A cluster of such cells is called a lobule. The bronchial tubes and the lobules always contain air. The walls of the bronchial tubes are thick, comparatively speaking and only slightly elastic, while the walls of the air-cells are thin and highly elastic. As a result of this difference in the elastic properties of their walls, the lobules are practically the only air spaces of the lungs that have the volume of their contained air increased or. diminished when air enters or leaves the lungs through the respiratory act. Practically the only place where exchanges of material between the blood and the air of the lungs occurs is through the walls of the air-cells forming the different lobules. ,

Circulation Of The Blood In The Lungs. —When venous blood from the right side of the heart reaches the lungs it is contained in distinct masses of vessels made up of a network of capillaries, each of which surrounds intimately the air-cells of a single lobule, but does not extend beyond such lobule. In other words, when a portion of blood has passed through a group of capillaries in the lungs, or, what is the same thing, has been brought in contact with the walls of the air-cells of a single lobule, it enters the veins and is carried back to the left side of the heart, whence it is forced into the systemic circulation.

On account of this, blood that has been in contact with a single lobule of the lungs and yet contains impurities, whether waste products that have not been excreted, or material that has been absorbed from the lobule during such contact, must enter the general circulation and carry its impurities to the "different parts of the body.

Respiration.—Inspiration is produced by muscular force so applied as to elevate the anterior ends of the down-sloping ribs, or to depress the diaphragm, or to bring about both these results at the same time, processes, alone or combined, that enlarge the chest and cause air to pass through the trachea into the lobules of the lungs just as the separating of the walls of a bellows causes air to pass through its nozzle into the interior. Expiration, on the other hand, is produced not by muscular effort but by the contracting of the tissues of the lungs themselves. These tissues are elastic and when put on the stretch by the expanding chest develop enough force to bring the chest back to a contracted condition as soon as opposing muscular stress has been removed. In certain positions of the body gravity also aids

expiration. In forced expiration muscular exertion, of course, is called into requisition. Inspiration is the active element of respiration and expiration the passive.

Besides being divided into its component parts, respiration can be classified into types, which are determined by the manner in which inspiration is performed. These types are represented by the terms superior costal, inferior costal and diaphragmatic or abdominal. When the respiration is of the superior costal type, that is, when the upper ribs rise during inspiration, the anterior ends of all the ribs of the thorax rise, since these ribs are all connected together. This enlarges the chest throughout its whole length, regardless of whether the diaphragm has descended or not, and causes air to enter the lobules of all parts of the lungs.

When the respiration is of the inferior costal type, however, a different condition prevails. In such case there is no movement of the upper ribs when inspiration is made, and in consequence the lobules of the portion of lungs lying beneath these motionless ribs do not have the volume of air they contain increased.

And when the respiration is of the abdominal type, a form of breathing in which there is practically no movement of the ribs, the portion of the lungs that gains no increase in the air in its lobules becomes still more extended.

The correctness of the statements just made becomes evident if one will stop to consider that air in the lungs is contained in numerous cavities, and that none of these cavities can enlarge, so as to admit more air than is already present, unless the overlying chest wall provides room for such enlargement by expanding.

Again, by way of further illustration, it may be assumed that the lobules of the lungs are small cyclinders placed at the ends of the bronchial tubes by which they are connected through the air passages with the air outside the body. Also that each of these cylinders contains a piston, which is connected by a rod with the overlying chest wall. With these conditions present the air in any of the cylinders is increased when the overlying chest wall is expanded, is decreased when such part of the chest wall is contracted, and remains stationary in amount when the overlying chest wall is at rest.

The amount of air that is present in the lobules of the lungs is comparatively large. In respiration the tidal air is but one-sixth of what the lungs contain at the end of an ordinary inspiration. This means that when a portion of the lungs is not used for breathing purposes such portion still contains five-sixths as much air as is present at the end of an ordinary inspiration.

In normal breathing the whole chest is enlarged and contracted alternately. This causes a certain amount of atmospheric air to enter and become mixed with the air already present in all the lobules of all parts of the lungs during inspiration, and a certain amount of the contents of the lobules to be expelled with each expiration. This, besides getting a supply of oxygen to the blood, and removing waste products from the blood, has another very important result. It keeps the air in the lobules from undergoing change and developing new products just as the inflow and outflow of a small amount of water is often seen to keep a pool of water from becoming foul.

Departures from the normal in breathing, however, are extremely common. There is a double cause for this. In the first place, human beings are provided with lung capacity greatly in excess of what is actually needed to support life under ordinary conditions, and, in the second place, less exertion is required to utilize a part of the lungs for breathing purposes than is required to utilize all of the lungs. Thus there is a natural tendency for normal breathing to become abnormal in character. When breathing becomes abnormal in character, so far as persons with normal lungs are concerned, it assumes one of three types. It becomes inferior costal, or a combination of inferior costal and abdominal, or entirely abdominal. In other words, it becomes a type that does not include superior costal breathing. In view of what has been written above, absence of superior costal, or upper chest breathing, can therefore be taken to express either an abdominal method of breathing in which the lobules of the portion of lungs lying beneath the upper ribs are not utilized for breathing purposes, or a form of breathing in which only the lobules in the vicinity of the diaphragm are used for breathing purposes.

Absence of upper chest breathing, therefore, leaves residual air undisturbed or stagnant in the lobules of a greater or less portion of the lungs, or what is the same thing, leaves expired air chambered in the presence of warmth and moisture. In these circumstances, as said above, expired air invariably undergoes change and develops at least two new substances, one of which is trichotoxin. And, further, trichotoxin thus developed is in a position to be readily absorbed by the blood, by which it is carried to all parts of the body.

Thus common baldness is made to depend

for its existence on a double cause, one the remote or fundamental cause, represented by the absence of upper chest breathing, a condition that allows a poisonous substance capable of destroying hair growth to develop in the lungs; the other, the direct or exciting cause, represented by this poisonous substance circulating in the blood.

The investigation of the subject of common baldness that is accountable for this paper was begun in 1887. The theory that absence of upper chest breathing holds a causal relation to the affection was evolved in 1891. Evidence that this theory is correct has been derived from observing and treating cases and from experimenting on animals.

Continuous observation carried on since 1891 has not developed a single exception to the rule that persons affected with common baldness do not employ upper chest breathing, while those not affected with the disease as regularly do employ this form of respiration, tion.

And not only has this held true when it has been a question of individuals, but it has also held true when it has been a question of classes or groups of persons having distinctive habits of breathing in common. The following examples will serve to illustrate this point:

Women as a class are rarely affected with common baldness. Women as a class also practice upper chest breathing. There are two reasons for this. First and foremost, the ribs of women are more easily and more extensively movable than those of men. Works on anatomy and physiology all agree on this point. In the second place, the dress or most women is so arranged that abdominal breathing, if not prevented, is at least greatly hindered. Each of these circumstances alone, or both in combination tend decidedly to compel upper chest breathing.

Men, on the other hand, are frequently affected with common baldness. Men also, by reason of a range of motion and mobility of the ribs that is limited when compared with the conditions that prevail in women and also by reason of absence of obstruction to descent of the diaphragm, frequently practice abdominal to the exclusion of upper chest breathing.'

Victims of pulmonary tuberculosis not only are immune as a rule to common baldness, but also as a rule are conspicuous by the luxuriance of their hair growth. This condition of affairs supports the theory that is being discussed, since with part of their lungs destroyed the unfortunate members of this class are driven to the necessity of utilizing whatever normal lung tissues is left to them in order to support life, or, in other words, to breathe in such a way that air is not allowed to lie stagnant in any part of their lungs.

Persons leading sedentary lives are particularly prone to suffer from common baldness. This in the light of the theory under consideration, is because they require less air for the purpose of oxygenating the blood than persons following occupations calling for considerable muscular exertion. And also because they are prone to assume cramped positions of the body, especially when working over desks, positions that slacken the muscles that elevate the upper ribs.. Both these circumstances tend to eliminate upper chest breathing and by so doing to establish conditions that favor the habit of practicing inferior costal and abdominal, or abdominal breathing alone.

Aged persons also are particularly susceptible to common baldness. Both men and women are included in this statement, though the number of male victims is much greater than that of the female. The explanation of this condition of affairs calls for reference to an anatomical condition peculiar to the aged. In "Gray's Anatomy' the description of the articulations of the cartilages of the ribs with the sternum contains these words: "After middle life the articular surfaces lose their polish, become roughened, and the synovial membranes appear to be wanting. In old age the articulations do not exist, the cartilages of most of the ribs becoming continuous with the sternum."

This means that as age comes on the exertion necessary to carry on the upper costal type of breathing is constantly becoming greater, and this at a period of life when the muscles are constantly growing weaker. And, in consequence of these conditions, that the respiration if not already of the abdominal variety, is urged in the direction of this type by influences ever becoming more and more potent.

On account of the greater range of motion of the ribs in the female and also on account of the influence of a life-long habit of upper chest breathing, women in age contract the habit of abdominal breathing more seldom and more slowly than do men. In other words, in age women suffer from common baldness more frequently than in any other period of their lives, but even at this time they supply a far less number of victims of the affection than do men.

Tredtment of common baldness that included as a rule nothing but directions to practice continuously upper chest breathing has also been applied since 1891. Hundreds of per

sons have been thus treated. These persons carried out their instructions with widely differing degrees of thoroughness. Positive results were obtained only in cases in which the directions were followed to the letter. In all cases of this kind the results were as follows: After one week dandruff when present and caused by seborrhoea sicca (and this affection is present in about 80 per cent of all cases) disappeared. At this time, too, the hair which is frequently either dry and harsh or unusually oily when common baldness is present assumed a natural appearance. Then some weeks later, usually five or six weeks from the time of starting the treatment, new hair began to make its appearance. The new growth as a rule appeared first among the hairs about the margin of the bald area or areas, and after multiplying there invaded the bald patches by extension. The new growth, even after being well started developed slowly, so that months or even years were passed before even a moderately sized patch of uncovered scalp became covered with new hair. In all cases any interruption in applying the treatment was followed by a corresponding interruption in the progress of the case toward recovery. In cases treated in this way hair has appeared on portions of scalp that had been bald for upward of twenty years. ,

Experiments on animals have been carried en since 1900. These experiments consisted of injections of trichotoxin into the blood of various animals. The injections were made daily. Dogs hens and pigeons were treated. Fur-bearing animals, such as guinea pigs and rabbits, were found not to be adapted to these experiments. There is an anatomical reason for this that need not be entered into at this time. The injections consisted of a watery solution of trichotoxin and were continued in each case for a period of several months. They were made with an ordinary serum syringe. The injecting material consisted of from 5 to 10 c.c. of water from a sterile flask that had been charged with expired air and a small amount of distilled water and then kept at body temperature in an incubator for not less than four or five days. In these circumstances trichotoxin forms from a process of change taking place in some or all of the constituents of the expired air and becomes dissolved in the water. The apparatus here described might be referred to as an artificial lung. If a person should fill an ordinary laboratory wash bottle with water and then by forcing his breath through the shorter glass tube in the stopper crowd out all but a small portion of the inclosed water, he would demonstrate the manner in which in the experiments the flasks were charged with expired air and water. .

Animals were treated in the manner above described in dozens of instances and in every instance without exception the result was the same. The shedding of the coat began in a few weeks and became complete in from three to five months. The shedding also followed a fixed rule. It involved, in order, the abdomen, sides and back. In several instances crystals of trichotoxin were secured by evaporating the mother liquor then redissolved in distilled water, which was used as the injecting material. The results from this procedure were identical with those obtained from injecting the mother liquor. During the time they were being treated the animals showed no signs of disturbed health, and in five or six weeks after the injections had been discontinued all had gained new coats to take the place of those lost. One of the treated animals was made to lose and allowed to regain its coat three different times.

Control experiments were applied also to other like animals. In one water from a flask in which atmospheric air was made to take the place of expired air was used. In another distilled water was used. And in still another water impregnated each time the injection was made with freshly expired air constituted the injecting material. The injections in these experiments were given daily and continued for five months. At the time they were discontinued no effect of any kind had been observed in any of the treated animals.

These control experiments showed that in the original experiments the shedding of hair and feathers had been caused not by the water as such, nor by the expired air as such, but by something that had developed in the expired air during the time it had been in the incubator.

Treatment Of Common Baldness.—Persons suffer from common baldness because they breathe improperly. The particular error that brings bout this result is bound up in the circumstance that instead of practicing a method of breathing that causes all the lobules of the lungs to become aerated with each breath, they practice a form of breathing that causes only a part of such lobules to become aerated with each breath. The correcting of this error constitutes the treatment of common baldness.

As has been explained, the only lobules of normal lungs that can remain non-aerated by the respiratory act are those situated in the upper portions of the lungs. The specific treatment of common baldness therefore calls

for a method of breathing that causes air to enter and leave the lobules of the upper portions of the lungs with each complete breath. There are two methods of breathing that cause this result—one characterized by the rise and fall of the upper ribs while the diaphragm remains stationary, the other characterized by the same behavior of the upper ribs with a synchronous fall and rise of the diaphragm added.

A method of breathing that includes both the upper chest and abdominal varieties may be described as normal breathing. This type of breathing is practiced by infants and children. It aerates the lobules more evenly than any other type, since it causes the thorax to expand and contract in all possible directions. When once lost, however, it is the most difficult to regain.

On the other hand a method of breathing that includes the upper chest variety with the abdominal left out of consideration distributes air throughout the lungs with sufficient evenness to prevent the forming of trichotoxin. This type when lost is more easily regained than the type above mentioned, and for this reason is the type that should be recommended by physicians to patients suffering from common baldness.

In treating a specific case of common baldness the physician should first explain to the patient the manner in which inspiration is to be performed. He should direct the patient to see to it that the upper ribs rise each time the breath is inhaled. He should inform him that the effort to accomplish this result may be greatly lessened by holding the shoulders well back and down, and by having the clothing about the upper part of the chest, particularly the waistcoat, worn loose. He should also advise him to cultivate the habit of utilizing the hip instead of the vertebral joints when engaged in writing or other occupation that tends to produce a cramped position of the body. Finally he should make it clear that moderate expansion of the chest is to be preferred to forced expansion.

As to expiration, the physician need not go beyond letting the patient know that advantage will come from the practice of concluding each exhalation with a moderate degree of forced expiration.

As to the value of local applications, little can be said. Various remedies, such as cantharides, trikresol, turpentine and other rubifacients have been used experimentally both in persons and animals. Portions of denuded scalp or skin treated once a day with oil of turpentine have seemed to regain new coverings somewhat more promptly than adjacent portions left untreated. Local remedies alone are valueless. As a measure to assist in keeping persons reminded of their treatment the applying of local remedies at fixed intervals is of undoubted value.

The treatment here described is both practicable and efficacious. By reason of the fact, however, that it imposes on the patient the necessity not only of keeping in mind but also the necessity of making continuous muscular effort to carry on, a vital function that has always been automatic, the treatment is diffcult to follow. Experience shows that the chief difficulty lies in having the patient persist in the treatment long enough to get promising results. When this has been accomplished the rest of the way is plainer sailing, not only on account of the encouragement the prospect of success gives, but also on account of the changed mode of respiration becoming gradually more fixed and natural.

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