TRICHORRHEXIS NODOSA

This name, proposed by Kaposi (1881), is employed for a peculiar
nodose condition of the hair, previously described¹ by Wilson (tricho-
clasia, clastothrix), and more fully by Beigel (1855) and Wilks (1857),
Beigel² usually receiving the credit for the first description. Devergie³
(tricoptilose) published the first French case. A number of cases have
been since reported—in this country by Sherwell, Bulkley, and others.
Its chief characteristic is that breakage or fracture of the hair, more or
less common to all atrophic hair diseases, always takes place through
the nodes. The region commonly the site of the affection is the mus­
tache, although the bearded parts, scalp, and exceptionally other regions
may show it. A single hair-shaft may be the seat of several nodes.
There are no symptoms except the disfigurement, and this is perceptible
only upon close examination. The patient usually becomes aware of
it first by feeling, in handling the part, knotty swellings along the hair;

¹ Colcott Fox, Lancet, 1878, vol. ii, p. 803, gives a review of the earlier literature;
Heidingsfeld, Jour. Cutan. Dis., June, 1905, p. 246, gives a résumé of the literature,
with bibliography.

² Beigel, “Ueber Auftreibung und Bersten der Haare,” Sitzungsbericht der Mathem.
Naturw. Klasse der Wien, 1855, vol. xvii, p. 612.

³ Devergie, Annales, 1870-71, p. 5 (cases communicated to him by Lagneau).

TRICHORRHEXIS NODOSA

975

in other cases the first discovery is that the hairs break readily and that
there are nodular formations on the shafts which suggest nits. On
inspection it is then noticed that the hair has apparently burst at the
nodular swelling, the fibrillæ being seemingly pushed asunder; it has an
appearance as if two small brushes had been jammed together end to end.
If the hair has completely broken off, which, when it occurs, is through
the middle part of the swelling, there is left a free end of a brush- or
broom-like character. While the fracture is usually transverse through
the node, Jackson states that sometimes, if there is an excessive amount
of medulla present, it is longitudinal. The swellings are whitish or gray­
ish, and, when broken and numerous, the hair at a little distance looks
as if it had been incompletely singed. The shafts being markedly brittle,
are readily broken by combing or handling. In some hairs the splinter­
ing may extend considerably along the length. The nodes are usually
most pronounced near the distal end, and although several may be
seated along the shaft, the hair remains in its proximal and root portion
apparently normal and firmly fixed in the follicle. Loss of hair, there­
fore, does not ensue, although the condition is persistent and chronic.¹

Etiology and Pathology.—The disease is rare, and seen usually
in males. Raymond, however, states that he has found it quite common
on the genital hairs in women. As a rule, the subjects are in good health.
I have met with 3 cases—all physicians. Various causes—atrophic and
mechanical—have been assigned, but the affection, nevertheless, remains
yet a mystery, although the belief is growing that the nodular swelling,
bursting, and consequent fracture are due to parasitic invasion. In
support of this various observers—Raymond,² Hodara,³ Spiegler,⁴

¹ Jackson, “Two Peculiar Cases of Fragilitas Crinium,” Jour. Cutan. Dis., 1903, p.
473, records 2 cases, in men, upon the scalp, characterized by several sharply defined
patches, in which the hair was short, broken off, and the remaining portion curled up
close to the scalp, presenting an appearance similar to the curly hair of a negro. The
malady came on suddenly, each case having been first noticed about four or five weeks
before seeking advice. Microscopic examination (G. W. Wende, Mewborn) of the
affected hairs in one of the cases disclosed many with evidences of trichorrhexis nodosa.
Recovery ensued, in the course of a few months, from application of an ointment con­
sisting of salicylic acid and tincture of benzoin, each 1 part, and neat’s-foot oil, 50 parts,
together with shampooings with tar soap.

Recently a rare condition of pseudoknotting and fraying of the hair has been described
by Galewsky (Archiv, 1906,’vol. lxxxi, p. 195; 2 cases), associated with thinning and
breaking of the hair-shaft; the hair tending to break off at a knot, leaving a trichorrhexis-
like stump; to this he gave the name trichonodosis; 1 case was a man, the malady affect­
ing scalp, beard and pubes, and lanugo hairs on trunk; the other case a woman, with
scalp hair only affected; Saalfeld (ibid., 1906, vol. lxxxii, p. 245) records 2 similar cases,
the pubic hair being affected, and later Macleod (Brit. Jour. Derm., 1907, p. 40) has
described and pictured an instance (girl, scalp hair) of true “knotting of the hair”’, the
hairs were dry and lusterless, their ends either split up or pointed and trophic, occasion­
ally bent up like a hook; the majority curled up at the ends, forming one or more loops,
but the most marked peculiarity were the small nodes, on considerable proportion of the
hair, easily detected by the naked eye; these were found to be true knots, mostly single
knots and slip knots; Kren (“Trichonodosis,” Wien. klin. Wochenschr., 1907, p. 916;
abs. Jour. Cutan. Dis., 1908, p. 438) states that out of 54 women, who had skin diseases,
whose scalp hair was carefully examined, in 35 nodes (hair-knotting) were found on the
hair, usually on the scalp hair and about the middle or terminal portion of the hair, some
times on the body hair; several varieties of knots are pictured in his paper.

² Raymond, Annales, 1891, p. 508 (diplococcus).

³ Hodara, Monatshefte, 1894, vol. xix, p. 173 (bacillus).

⁴ Spiegler, Wiener med. Blatter, 1895, p. 599 (bacillus—different from Hodara’s).

976                       DISEASES OF THE APPENDAGES

Essen,¹ and Markusfeld²—claimed to have found organisms, and, with
the exception of Raymond, state that they succeeded, by experimental
attempts, in producing the disease. Unfortunately, their findings do not
all agree, and others (Neisser, Jadassohn, Unna, Bruhns, Pringle, myself,
and others) have failed to discover bacteriologic evidence, although
personally I am disposed to believe that it is of microbic origin.

Hodara’s investigations are based upon a rather unusual form of
the disease, or possibly a distinct, though allied, affection, which he found
quite frequent in the scalp hair of women in Constantinople.³ The
nodules are extremely small and recognizable only upon close examina­
tion. It is associated usually with a splitting-up of the hair, which is the
first symptom noticed, and which is generally observed at the ends,
although it may also occur along the shaft. The hair frequently partly
breaks at a nodule, on one side of it, and may thus form an angle, some­
times quite acute, with the main part of the shaft. Either as the result
of combing or brushing or spontaneously the
hairs readily break off at the joint thus made.
Another fact which seemed to support the
parasitic view also was the observation by
Ravenel⁴ and myself that the tooth­ and shav­
ing-brushes of one affected (Ravenel himself)
displayed the same nodosities. This was found
to be so in another instance, referred to in
Ravenel’s paper. Since then the same obser­
vation has been made by others (Blaschko,
Jadassohn, Bruhns, Saalfeld, and Barlow). In
the brushes used by Ravenel and the other
patient referred to bristles were found to be
severally made up of different hair, one of the
shaving-brushes being what is called in the
shops “badger” hair, and the other a coarser hair,
resembling hog-bristles; while the tooth-brushes
were composed of still another kind. This
eliminated the suspicion that possibly one variety
of brush hair was subject to these changes. The supposition was that
the brushes were infected by the patients, inasmuch as numerous other
unused brushes examined did not show this condition, nor did it occur
in brushes used by our acquaintances. A barber’s brush, hair or mus­
tache brush, becoming thus affected, could readily be the means of
conveying the disease to others. Unfortunately, however, Barlow’s⁵

Fig. 244.—Trichorrhexis
nodosa.

¹ Essen, Archive, 1895, vol. xxxiii, p. 415 (bacillus—different from Hodara’s).

² Markusfeld, Centralbl. f. Bacteriol. u. Parasitenkunde, 1897, abt. 1, vol. xxi, p. 230
(bacillus—seemed similar to Spiegler’s): de Keyser, Verhandl. V. Internat. Derm.
Congress, Berlin, 1904, vol. i, part 3, p. 437 (micrococcus; this paper gives bibliography
to date).

³ Hübner and Walter, “Ueber Trichorrhexis nodosa,” München Med. Wochenschr.,
Jan., 1912, lix, p. 140, have, however, reported an epidemic of the malady in a school
for girls affecting scalp hairs, of apparently the usual characters.

⁴ M. P. Ravenel, “Trichorrhexis nodosa—a Preliminary Note,” Medical News, Oct.
29, 1892.

⁵ Barlow, Münch, med. Wochenschr., 1896, p. 651 (references, especially to papers
bearing upon bacteriologic findings, and cites the various culture methods employed).

TRICHORRHEXIS NODOSA

977

investigations do not accord with those by Ravenel and myself, as he
states that he found the same condition of the hairs in brushes used by
unaffected individuals. ‘This seems to give some weight to the belief
that these formations may be produced mechanically—by external
injuries, as Wolfberg’s,¹ Sabouraud’s, Lasseur’s,² and Adamson’s³
observations also indicate.

On the other hand, it is possible, as Beigel suggested, that the swell­
ings may be due to gaseous disintegration of the medullary portion
pushing out the cortical substance, which finally gives way. He found,
as have also Unna and others, that the first stage of the formation con­
sisted in spindle-like swelling of the medulla. A microscopic examination
discloses that the cortex is split up into filaments, with, in some instances,
changes in the medullary portion; in others the latter is practically un­
disturbed, or at least remains unbroken and continuous, although some­
what swollen. Pigment granules and other granular débris are usually
to be seen between the fibers.

Prognosis and Treatment.—The disease is persistent and rebel­
lious to treatment, and therefore the chances of permanent relief are
problematic, although cases do get well, but whether from treatment
or spontaneously cannot be definitely stated. If the parasitic view,
however, is the correct one, persistent measures should finally be suc­
cessful. Almost all plans advised—and they are numerous—are prac­
tically in line with this theory. If many hairs are involved, and the
disease is of the mustache or beard, as commonly observed, frequent
shaving and the application daily of a saturated solution of boric acid,
with ½ to 1 or 2 grains (0.03 5-0.13 5) of corrosive sublimate to the ounce
(32.), can be advised. Weak corrosive sublimate lotions have, in fact,
been advocated by several, strongly by Sabouraud, who, however, pre­
scribes it in equal parts of ether and alcohol (1: 500), and with 5 to 10
grains (0.35-0.65) of resorcin, and 2 or 3 grains (o. 13 5-0.2) of tartaric
acid to each ounce (32.). Besnier and Roeser and Brocq speak favorably
of extraction of the affected hairs, and touching the part daily with
tincture of cantharides, pure or diluted, according to the sensitiveness of
the skin, and continuing the application until the hair has well appeared.
A 1 per cent, pyrogallol salve has been commended by Jadassohn, and a
2 per cent, aqueous solution of the same drug by Veiel. Schwimmer
used an ointment composed of 15 grains (1.) of sulphur, 7½ grains (0.5)
of zinc oxid, and 2½ drams (10.) of unguentum simplex.

Crocker states that change of climate has been successful. If there is
anything in the trophoneurotic theory of its production, such remedies
as arsenic, strychnin, phosphorus, cod-liver oil, etc., should be pre­
scribed if at all indicated, and ought theoretically to have some influence,
but experience does not seem to afford substantial proof of their value.

¹ Wolfberg, Deutsch. med. Wochenschr., No. 31, 1884 (himself the patient).

²Lassueur, Annales, 1906, p. 911. Both Sabouraud and Lassueur say that these
formations can be produced on the moustache of any one with not too coarse hair by
frequent (three times daily) washing with soap and water and the associated traumatism
of this operation.

³ Adamson, Brit. Jour. Derm., 1907, p. 99 (probably only, as Adamson indicates,
when the nutrition of the hairs is impaired).

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