4. DISEASES OF THE SWEAT-GLANDS
HYPERIDROSIS²

Synonyms.—Excessive sweating; Idrosis; Ephridrosis; Sudatoria; Polyidrosis;
Fr., Hyperidrose.

Definition.—A functional disturbance of the sweat-glands char­
acterized by an increased production of sweat, and which may be local
or general, slight or excessive, acute or chronic.

The general sweating, which may be a part of a serious illness,
symptomatic in character, and common in such diseases as acute rheu­
matism, malarial fever, tuberculosis, Graves’ disease,³ etc., although
especially interesting in view of the possible excretion of microbic ele­
ments or toxins, as indicated by Eiselsberg,⁴ Brunner,⁵ Geisler,⁶ and others,
scarcely belongs to the domain of dermatology. It is chiefly with those
cases which we, in the present state of our knowledge, look upon as
idiopathic that our interest lies, and more especially the local forms
which naturally gravitate to dermatologic practice.

Symptoms.—General hyperidrosis as an idiopathic affection is

¹ Lassar, “Ueber Rhinophyma,” Dermatol. Zeitschrift, 1895, vol. ii, p. 485.

² An extremely valuable contribution on hyperidrosis and the several varieties of
morbid sweating is that by Bouveret (“Des sueurs morbides”), These de Paris, 1880, with
a résumé of literature and references; also interesting paper and review of the entire
subject and several varieties by Pooley, “Anomalies of Perspiration,” Ohio Med. Re­
corder, 1880-81, vol. v, pp. 241, 289, 337, 385, and 441, containing a large number of
collected cases, with many literature references. Later literature will be referred to
in the course of the text.

³ Dore, “Cutaneous Affections Occurring in Graves’ Disease,” Brit. Jour. Derm.,
1900, p. 353.

⁴ Eiselsberg, “Nachweis von Eiterkokken im Schweisse eines Pyæmischen,” Berlin,
klin. Wochenschr., 1891, p. 553.

⁵ Brunner, “Ueber die Ausscheidung pathogenes Mikroorganismen durch den
Schweiss,” ibid., 1891, p. 505, and Arch. klin. Chirurg., vol. lxxx, No. 2.

⁶ Geisler, “Ueber die Ausscheidung der Typhusbacillen im Schweisse,” Wratsch,
1893—abs. in Baumgarten’s Jahresbericht, 1893, voL ix, p. 238.

HYPERIDROSIS

IO69

not uncommon, but mostly as a chronic condition, seemingly natural
to certain individuals. The sweating may be moderate or excessive,
and always more marked, as a rule, on those regions where local hyperi-
drosis is usually manifested, as axillæ, genitocrural region, hands, and
feet. The slightest exertion serves to increase it greatly, and while always
most profuse in the hot season, is quite excessive during the winter as
well. During the former period especially, an occasional associated
miliaria or erythema intertrigo, or even an eczema, due to the irritating
action of the moisture itself, as well as to the chemical changes which the
sweat may undergo, is not uncommon. Boil-formation also seemed to
be favored in such individuals. While the secretion may not have an
odor at first, unless frequent changes of linen are made and frequent
baths taken, it usually soon becomes offensive (bromidrosis). In rare
instances, instead of the sweating being general, it is limited to a small
portion of the surface or to the half of the body unilaterally, as described
by Teuscher¹ and others, or, as in a case reported by Kaposi,² to the
upper half or part of both sides. Cases of sweating limited to half the
face are less rare, and have sometimes shown an association of the lesions
of hydrocystoma.

The chief interest lies, however, in the local forms, especially the
excessive sweating of the hands and feet, and for which professional
advice is most frequently sought. It often exists on the hands or feet
alone, but not infrequently conjointly. The condition limited to both
hands (hyperidrosis manuum) is not uncommon, more especially about
the palms, and the sweating may be persistently copious or come on at
irregular times or in consequence of some excitement or perturbation.
The hands are noted to be clammy and cold. In a case recently under
my care at times the hands were perfectly dry, when suddenly, without
apparent cause, they would become rapidly wet, the sweat accumulating
in drops and dripping on to the floor. In exceptional instances a few
deep-seated vesicles are occasionally seen about the fingers and palms
(see Pompholyx). Such persons are unable to wear gloves more than
from a few minutes to an hour or so, without their becoming permeated
with moisture; and everything touched by them is apt to show a greasy
mark. As a rule, the condition is most marked when the patient is
tired, nervous, or exhausted. A slight or moderate tylosis of the palms
may be associated or develop gradually.

Sweating of the feet (hyperidrosis pedum) is a troublesome and often
a disgusting form of localized hyperidrosis. It varies in degree: some­
times moderate, at other times excessive. The feet are constantly
damp or wet, the socks or stockings become moist or drenched a short
time after they are put on, and the shoe itself often, in severe cases,
becomes rapidly water-soaked. It is especially pronounced on the sole

¹ Teuscher, Neurolog. Centralblatt, 1897, p. 1028, records several cases of his own
and cites other cases with literature references.

² Kaposi, “Hyperidrosis spinalis superior,” Archiv, 1899, vol. xlix, p. 321 (patient a
boy aged fifteen, sweating since six; kyphoskoliosis since his eighth year). See also
interesting paper by Caldwell (a review of the neuroses of the pneumogastric nerves,
with some account of the anatomy, physiology, and pathology of these nerves; also of
the vasocenters and sweat-centers), Virginia Med. Monthly, 1878-79, vol. v, p. 565.

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DISEASES OF THE APPENDAGES

and between the toes, and may be limited to these parts. The skin is apt
to be macerated and soggy, and exceptionally pompholyx lesions are
seen from time to time. In many cases—those of the more severe type—
the skin of the sole and neighboring parts is noted to be pinkish red,
sometimes with a violaceous tinge, somewhat puffy or irritated, and in
some cases at the border, which is usually sharply defined, slightly in­
flamed, and showing a few ill-defined vesicular or flattened bullous lesions;
or the skin at the edge may be simply macerated and abraded. Unless
the foot-wear is frequently changed an offensive odor soon arises, al­
though in these cases the sweat secretion as it is freshly poured out is
usually odorless.

In the axillary and genitocrural regions the sweat is often noted
to be excessive, and necessitates, more particularly in women, the wear­
ing of dress-shields to prevent soiling of the garment, but which, however,
tend to increase the secretion. In extreme cases maceration is also likely
to arise, and not infrequently chafing or an eczematous irritation presents
as a complication. In these regions the sweat often undergoes rapid
chemical change, and a heavy, offensive odor is developed. Hyperi-
drosis circumscripta is a name applied to the condition when limited to
a small area, examples of which have been occasionally observed.¹

The localized forms, just described, as with the general forms, may
be acute or chronic in character—more usually the latter. It is naturally
more marked during warm weather or after active work or exercise.
It may vary somewhat in degree from time to time.

Etiology.—Idiopathic excessive general hyperidrosis is, as a rule,
associated with debility, and probably in many cases is in reality merely
symptomatic of some underlying unrecognized disease, such as incipient
Graves’ disease, tuberculosis, malaria, etc The causes in the local
forms are doubtless varied from that of pure idiosyncrasy to grave sys­
temic disturbance; as an example of the former may be mentioned a
case of a woman reported by Hutchinson,² in whom the slightest indul­
gence in tea-drinking provoked hyperidrosis of the feet. In some
families there is a hereditary tendency to somewhat free general per­
spiratory secretion, and this is noted to be a factor in some of the
localized cases. It is a well-recognized fact that in those of impaired
vigor, and especially after some debilitating disease, such as influenza,
which leaves great prostration and nervous weakness, that excessive
sweating is most frequently observed—both the general and local forms.
Anything, in fact, which depresses the nervous tone may be of etio-
logic import. The tendency to abnormal sweating and excitability of
the perspiratory function is often observed in neurasthenics. Phys­
ical or mental excitement is apparently the starting impetus, and in
developed cases always an aggravating and exciting factor. Lesser,³
as also Morris, Norman Walker, and Pringle, has noted that most patients
with hyperidrosis of the feet are “flat-footed”; and Hardaway and Alli-

¹ Sutton, Jour. Amer. Med. Assoc, Sept. 28, 1912, p. 1193, describes an extremely
limited case, limited to a small area near the inner extremity of the left eyebrow.

² Hitchinson, Archives of Surgery, 1899, p. 56.

³ Lesser, “Schweissfuss und Plattfuss,” Deutsche med. Wochenschr., 1893, p. 1070.

HYPERIDROSIS

IO71

son¹ also believe that the malady is favored by malpositions of the feet,
especially flat-foot and Morton’s foot. While the local form may be
seen at any age, in both sexes, and in all ranks of life, in my experience
it is more common between the ages of twenty and forty, and more fre­
quent in males. Sweating of the feet seems most frequent in those whose
occupation necessitates prolonged standing. Circulatory disturbances
are observed to be influential in some instances. Some cases of the
localized forms have been recorded which were due to some nerve irrita­
tion or injury, central or truncal. It has also been noted in connection
with malaria.

Pathology.—The close relationship of the nervous system to
the sweat secretion, and therefore to its pathologic increase, is well
known, both clinically and experimentally. The observations of Fränkel,²
Raymond,³ and Ebstein⁴ show the association of unilateral sweating
with changes in the cervical ganglia; and those of Bloch,⁵ Bouveret,
and others with disease of the cerebral cortex, as well as by Windscheid;⁶
Bloch, and others in connection with facial paralyses. Cases of unilateral
sweating of the face associated with headache and flushings have been
observed by Campbell⁷ and Jamieson.⁸ It is also well known, through
the experiments of Claude Bernard, that hyperidrosis follows paralysis
of the sympathetic; and Brown-Séquard and others have shown that
excitation of the sensory nerves would provoke sweating. In addition,
Weir Mitchell’s⁹ observations as to localized sweat disturbances after
gunshot injuries, and also Remak’s¹⁰ after traumatic neuritis, are added
proofs. An added instance to many others not here referred to is that by
Dehio,¹¹ who found in a case of erythromelalgia with hyperidrosis that
after resection of the ulnar nerve not only did the excessive sweating cease,
but anidrosis followed. It is highly probable, therefore, as stated by
Crocker,¹² that injury or disease which, in any way, either directly or in­
directly, disturbs the function of the sympathetic of the affected region,
is the proximate cause of the excessive secretion. Very often, however,
the underlying pathologic factor is not demonstrable or discoverable.
Robinson,¹³ who examined a number of sections from the palm, failed

¹ Hardaway and Allison, “Warty Growths, Callosities, and Hyperidrosis and Their
Relation to Malpositions of the Feet,” Jour. Cutan. Dis., 1906, p. 127.

² Fränkel, Zur Pathologie des Halssympathicus, Inaug. Dissert., Breslau, 1874.

³ Raymond, “Des ephidroses de la face,” Arch, de Neurologie, 1888, pp. 51 and
212 (a good paper with review of the subject and bibliography).

⁴ Ebstein, “Ueber einen pathologisch-anatomischen Befund am Halssympathicus
bei halbseitigem Schweiss,” Virchow’s Archiv, 1875, vol. lxii, p. 435.

⁵ Bloch, “Contribution a l’étude de la physiologie normale et pathol. des sueurs,”
Thése de Paris, 1880.

⁶ Windscheid, “Ueber den Zusammenhang der Hyperidrosis unilateralis mit patho-
log. Zuständen des Facialis,” Münch, med. Wochenschr., 1890, p. 882 (several cases, with
review of similar cases and literature references).

⁷ Campbell, Flushing and Morbid Blushing, their Pathology and Treatment, London,
1890, p. 50.

⁸ Jamieson, Brit. Jour. Derm., 1893, p. 137.

⁹ Weir Mitchell, Injuries of Nerves and their Consequences, Philada., 1872, p. 172.

¹⁰ Remak, “Neuritis and Polyneuritis,” Nothnagel’s Specielle Pathologie und Thera-
pie, vol. xi, 1. Hälfte, 1899, p. 130.

¹¹ Dehio, “Ueber Erythromelalgie,” Berlin, klin. Wochenschr., 1896, p. 817.

¹² Crocker, Diseases of Skin, third edit., p. 1090.

¹³ Robinson, Manual of Dermatology, p. 77.

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DISEASES OF THE APPENDAGES

to detect any abnormality either in the size of the glands or in the glandu­
lar epithelium. Virchow¹ found, however, in cases of hyperidrosis con­
nected with phthisis, the glands enlarged and the epithelium in a state of
fatty degeneration. While the amount of sweat discharged in a day may
be considerable, it does not differ chemically from normal sweat.

Prognosis.—The prognosis must be expressed with reservation.
As a rule, nothing can be done in the moderate type of generalized
sweating, a condition apparently normal in some people. In the ex­
cessive generalized variety, usually insidious or acute in developing,
the outcome as to betterment depends upon the cause. Localized forms
are also persistent and obstinate, although many respond to treatment;
the foot cases, if not of too long duration, in my experience offering the
most promising chances for relief, in a number of such instances per­
manent cure having been effected. Change of treatment—local appli­
cations especially—is often necessary before a result is attained. Par­
oxysmal sweating is less favorable than the continuous type. Relapses
are, however, not uncommon. In all cases of these localized forms much
can be done in the way of improvement.

Treatment.—The excessive general sweating accompanying or
following the systemic fevers and debilitated states of the system de­
mands for its care or cure treatment of the particular predisposing or
causative condition. Limited areas of sweating occasionally seen in
malarial and nervous diseases are likewise to be treated upon general
principles. Astringent liquid applications, such as below indicated for
regional hyperidrosis, but usually somewhat weaker, are, in a measure,
palliative; they can be sprayed on or dabbed on; and sometimes, when
followed by one of the dusting-powders, the effect is more marked.
By such measures the tendency to miliaria and chafing noticed in these
subjects, especially in stout people, can often be kept in abeyance. In
generalized cases Fox² has had good effects from rubbing on the skin a
1 per cent, alcoholic solution of quinin. In instances of doubtful or
unrecognized cause, such systemic remedies as ergot, belladonna, gallic
acid, the mineral acids, quinin in full doses, and, when the health is en­
feebled, tonics should be tried. A teaspoonful of precipitated sulphur,
twice daily, with, if the laxative action is too marked, an astringent,
has been extolled by Crocker. I have noticed a favorable action in a few
cases.

In the localized forms external applications are essential and more
positive in effect than any constitutional treatment that may be pre­
scribed, but the latter should not be ignored in the management. Fre­
quent washing is essential. The external treatment consists in the use
of lotions, powders, and ointments. Astringent lotions of zinc sulphate,
tannic acid, and alum, from \ dram (2.) to an ounce (32.) to the pint
(500.) of water, are among the most useful at our command, especially
the last two. They are to be applied at least twice daily, the parts first
having been washed or sponged off; following the lotion a dusting-powder
of boric acid with from 5 to 30 grains (0.32-2.) of salicylic acid to each

¹ Quoted from Robinson, loc. cit.

² G. H. Fox, Philada. Med. Times, 1883-84, vol. xiv, p. 849.

HYPERIDROSIS                                  1073

ounce (32.) may be freely dusted over. The free use of a dusting-powder
alone, such as that just named, will be found beneficial and sometimes
gives considerable, and occasionally complete, relief, especially in the
axilla.

Weak lotions of formaldehyd or formalin (40 per cent, solution of the
gas), 1:100, can often be used with advantage for cleansing purposes,
and not infrequently with some therapeutic influence also; but for the
latter stronger applications can be carefully used, increasing the strength
gradually, the object in view being the production of a slight surface
hardening, rather than positive irritation. Duhring¹ warmly commends
the application of tincture of belladonna, diluted or full strength, care
being observed in its use as to toxic effects. Crocker also speaks well
of belladonna as an ointment or liniment. In foot cases, in which there
are no abrasions or irritation, Lesser² speaks highly of Frédéricq’s
method of dusting powdered tartaric acid in small quantity in the socks.
It is to be employed cautiously in those of delicate skin. I have person­
ally had no experience in its use. Morrow,³ after reviewing the several
methods, states that in foot-sweating he has obtained the best results
from the employment of foot-baths of a strong solution of extract of
pinus canadensis every night, and the use of powdered boric acid, or
salicylic acid mixed with lycopodium, oxid of zinc, or other inert powder
constantly applied inside the stockings and shoes. In fact this latter
use of boric acid, with or without the addition of salicylic acid, should
be employed as an adjuvant whatever the main plan adopted. This
is an essential part of Thin’s method, useful in this affection, as well as in
bromidrosis, for which he especially advises it.

The most valuable ointments in the treatment of hyperidrosis,
which are more especially applicable when the disease is about the feet,
are diachylon-ointment, advised by Hebra, and tannic acid ointment.
The latter I have used with success in a number of cases, and while
not equal in value to the diachylon salve, is more readily obtained than
a good preparation of the latter. The method of application is the same.
The tannic acid ointment consists of from 1 to 2 drams (4.-8.) of tannic
acid, with enough prepared suet and petrolatum to make an ounce (32.).
The parts should first be washed with soap and water, rinsed, and
rubbed dry with a soft towel; then the ointment selected, spread thickly
on lint or other suitable material, should be closely adapted to the surface,
and a bandage employed to keep it in place. This dressing is to be re-
applied at the end of twelve hours, but instead of washing the parts they
are then merely to be rubbed dry with a dusting-powder and towel;
this is to be repeated for a period of from ten days to two weeks. The
epidermis usually exfoliates after the tannic acid treatment—almost
invariably after that by diachylon ointment. At the end of this time
the parts may be again washed, and subsequently the dusting-powder
used freely twice daily for one or two weeks. This plan of treatment

¹ Duhring, Diseases of the Skin, third ed., p. 138.

² Lesser, Hautkrankheiten, tenth ed., 1900, p. 180.

³ Morrow, Jour. Cutan. Dis., 1887, p. 68 (gives a review of several methods—those
of Brandon (liquor antihidrorrhoicus), of Frédéricq (finely powdered tartaric acid), and
Stewart (permanganate of potassium solution and lead-plaster)).

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I074                   DISEASES OF THE APPENDAGES

is often successful, but at times a repetition is found necessary; in other
cases it relieves, but fails to cure. Davis¹ commends the following
method as an efficient substitute for this continuous ointment plan,
and much less troublesome: A lotion consisting of a dram (4.) each of
salicylic acid and resorcin to the ounce (32.) of alcohol is painted over
the parts twice daily, and in a week or so results in marked epidermic
exfoliation; this is then followed up with the free use of a compound
dusting-powder of 10 grains (.66) of carbolic acid, 10 grains (.66) of
camphor, 20 grains (1.33) of sodium salicylate, and 1 ounce (.32) of
talc. For other plans the reader is referred to Bromidrosis.

In the localized forms, but more especially of the hands, I have
observed in some instances benefit derived from local applications of the
f aradic and galvanic current. Occasional exposure to the x-ray has
also had a drying influence in the few instances in which it was tried.
Following Hardaway and Allison’s observation, any existing malposition
of foot should be corrected in cases of hyperidrosis of this region.

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