The History of Sweat and Prickly Heat, 19th–20th Century1

THE HISTORY OF SWEAT AND PRICKLY HEAT, 19TH-2OTH CENTURY* E. T. RENBOURN, B.Sc., M.D., M.R.C.P. rash—the 'echauboullure' ('chaude bouillure') of From the time of Hippocrates (1) and Galen de Sauvage (1734) (3) and Astruc (1759) (4)— corresponding to the Spanish 'calor picante' and (2), hidroa ('öpwa from 'u5pws or sweat) has been recognized as the rash associated with profuse to prickly heat—an expression which had apsweating during a hot summer. The early writers peared, about the same time (1744) (5), in the also used the word miliaria (Greek, 'kenchros'; English literature. English and German physicians generally Latin, 'milium' or 'miliarus') to mean almost any accepted two varieties of sweat rash. These were, fine rash resembling millet grains. the febrile sweat rash—miiaria or sudamina— During the middle ages, and later, the expres-. sions 'sudationes' or 'desudationes' (Latin, and prickly heat or 'Schweissblatterchen,' 'hitz(sweat or heat pimples). There were, of 'sudatio,' a sweat), 'essera' (Arabic, ash- blattern' course, great individual variations in nomenclashära, a pimple), hidroa (often mis-spelt as ture. Hardly two physicians use the same expreshydroa, 'v&pwa, meaning water), 'bothor' (the sions and often were prepared to coin their own. 'boa' of Pliny) and miiaria were common synonyms for the sweat rash. It was often claimed If it appears surprising that sudamina had lost that the Roman physicians had used 'sudamina,' much of its earlier identity, it is well to remember but it appears that this word was coined during that, from early periods onwards, both miliaria the early part of the 16th century as an irregular and sudamina had often been confused with febnile disorders. Latin derivative of 'sudationes.' Pinel (6) was somewhat of an exception After the 1665 Leipzig epidemic of miliary amongst French physicians in that he used the fever ('Friesel,' 'Schweissfriesel'; 'suette Miliare') the term miliaria was, in general, reserved for the word sudamina to mean the sweat rash of hot fine papular and vesicular rash of this apparently climates. This, he said, was the same as 'essera' or 'porcelaine' (also of Astruc (4)) which occurred new disease. At the turn of the 19th century there was in France as a harmless condition in the summer widespread confusion surrounding the nature and time. Pinel did not use the old French expression nomenclature of the varieties of 'sweat rash.' 'echauboullure.' INTRODUCTiON

French physicians were, on the whole, convinced of the identity of the 'suette miliare' and regarded

wflTERnOTroM, WILLAN, JOHNSON AND BATEMAN

John Winterbottom was physician to the West it as a specific exanthematous disease. English physicians continued to write on the disorder, African Settlement of Sierra Leone before it but believed that the rash of miliary fever arose became a Crown Colony, and must have had from the still widely-used 'hot regimen' or abundant experience of disorders of the humid sweating treatment, and was, hence, a 'miliaria tropics. In the 'Medical Directions for Settlers in clinica.' The Germans were now undecided as to Hot Climates' (1803) (7) he wrote briefly on prickly heat, but his superb dissertation on the the nature of 'Schweissfriesel.' French physicians accepted a sweat rash 'triad.' matter was to appear five years later in the text The first of these—miliaria (alba, rubra, crystal- book of Robert Willan. Willan's classification of skin disorders (8) was lina, pustulosa)—was the exanthem of 'suette a modification of that of Plenck and based on the miliare.' Sudamina had lost much of its earlier appearance of the lesion, each representing a identity with hidroa and become the sympto-. separate disorder. Thus, his 'lichen' was a variety matic rash of sweaty fevers such as typhus, of papule, and 'eczema' a bulla or vesicle due to rheumatic fever, puerperal fever and consumpexternal or internal irritation. Willan made such tion. The third of the triad was the tropical sweat a 'strophulus'—a condition that would nowadays * From the Directorate of Physiological and be accepted as a lichen or prurigo state—but Biological Research, Ministry of Supply, Farn- the word was later used to mean prickly heat. borough, Hants, England. Speaking of the latter he said: Received for publication August 10, 1957. 249

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"I think that the more appropriate title for that disorder is Lichen (tropicus) and Eczema (so-. lare). . . . A vivid eruption of papulae somewhat analogous to the prickly heat sometimes appears

ever the eruption continues for any length of time, the papulae throw off minute scales and are suc-

in our own climate, on the arms, face and neck of

"Persons of a fair complexion, with red hair,

ceeded by a fresh crop, no vestiges being left in

the skin,...

labourers and other persons who use violent

and soft skin, are most liable to this eruption, and exercise during the hot weather of the summer." have the greatest quantity of it. Those who are of a dark complexion, either remain wholly free from Neither lichen tropicus nor eczema solare was the eruption or are affected with it very slightly. however, a happy choice of expression to replace As soon as settlers are habituated to the climate, prickly heat. For, the first suggested that the this complaint becomes less troublesome, and at condition was characteristic of the tropics and length entirely disappears. . "The sudden disappearance of it, which frethe second that it arose from the rays of the sun. This may throw light on the confusion which quently happens, is rather an effect than a cause later existed between sunstroke, sunburn and of internal disorder as of fever of any slight complaint of the stomach. . . . Its appearance on the prickly heat. However, such was the esteem in skin of persons in a state of convalescence from which Willan was held that the new terms were fever etc. is always a favourable sign, indicating soon widely adopted by European dermatologists. the return of health and vigour. The following are extracts of Winterbottom', "The black natives are subject to the eruption article as found in Willan's text: in a less degree than Europeans. In them the small papulae are of a dull white colour, and therefore "The Prickly Heat appears without a preceding less striking to the eye. . . . The favourite remedy disorder. It consists of numerous papules about at Sierra Leone is the juice of lime rubbed into the the size of a small pin's head and elevated so as to skin, which however has no considerable effect. I produce a considerable roughness of the skin. The have found it advantageous to use a light, cool papulae are of a vivid red colour, often exhibiting dress, and to avoid the drinking of warm liquors." an irregular form, and two or three of them are in -

many parts united together; but no redness or

James Johnson (1813) (9) had no doubt read

breast and about the wrists; but they terminate

couch with no small precipitation, and if there was any water at band to sling it over me for the

inflammation extends to the skin in the intestices Willan's book, for he also used the new expresof the papulae. Tbe eruption is usually diffused sion, lichen tropieus. Speaking from personal over those parts of the body which are usually experience Johnson said: covered. - . . It does not appear on the face, except "Many a time I have been forced to spring from a the upper part of the forehead contiguous to the table and abandon a repast which I had scarcely head; neither is it found on the palms of the hands, touched, to writhe in the open for a quarter of an soles of the feet, nor the hairy scalp. The number hour, and then returning to the charge, with no of the papulae is much increased by wearing flansuccess against my ignoble opponent. nel or clothes too warm and thick for the climate. better For some weeks after arriving in India, I When the papulae are very copious, small vesicles seldom could obtain more than an hour's sleep at containing a limpid humour, are often intermixed with the Prickly Heat, more especially on the any one time, before I was compelled to quit my

in scales and have no disposition to ulcerate purpose of allaying of the inexpressible irthough violently scratched. A troublesome itching ritation." attends the Prickly Heat and prevents sleep Bateman (10) followed Wifian closely in the during the night. There is likewise a frequent sensation of pricking, as if a number of pins were classification of skin diseases, and readily acpiercing the skin. It often takes place suddenly, cepted lichen tropicus as a suitable name for after drinking a dish of tea or any warm liquor, so prickly heat. As for eczema solare, Bateman's as to cause the person affected to start from his seat.

description suggests that the disorder he had in

"The eruption is generally stationary and

called hydroa aestivale. On eczema solare he

appears equally vivid in the day and in the night.

mind was not prickly heat but is nowadays

It does not leave one part and arise in another said: unless the former be much exposed to cold and the "Hence it affects most exclusively those parts of latter be heated by clothing or friction. . . . They the surface which are exposed to the direct rays sometimes disappear of a sudden and return again of the sun, the face, neck and forearms, but paras suddenly without any other cause, but when- ticularly the back of the hands and fingers."

HISTORY OF SWEAT AND PRICKLY HEAT, 19TH—2OTH CENTURY

251

Neither Winterbottom, Willan nor Bateman had the fluid was not sweat, the cause of the vesicles anything to note on the morbid anatomy of could not be ascribed to block of the ducts of the prickly heat nor made reference to earlier writers sweat glands—the existence of which was, in any who had ascribed it to block of the sweat ducts case, doubtful. He concluded (with Andral) that sudamina arose from an accumulation, under or pores. Monfalcon, in 1815 (11) referred to 'essera' the epidermis, of 'condensed insensible perspira(probably urticaria) as a rash of pale papules tion.' Hasper, in 1831 (20) used Lichen Tropicus resembling midge bites which, because of their as the equivalent of 'Hitzblatterchen,' but the delicate transparency, was known in France as term 'Rote Hund' is not to be found. Alibert (1832) (21) is often regarded as the 'porcelaine.' This was, however, not the meaning of 'porcelaine' as first given by Astruc in 1759 founder of modern French dermatology, but, on (4). However, in both the earlier and later the matter of the sweat rash; he did nothing to literature, 'essera' was often identified with the lessen confusion. Miliaria, he said, was the 'hydroa' (hidroa) of the Greeks, the miliary papules sweat rash. Kraus (1826) (12) spoke of 'bothor' as a rash of the Arabs, the sweat papules of the Latin of 'Blätterchen' on the face. Hidroa was referred writers and the 'febris esserosa' of Zacutus (22); it to as 'Hitzblattern' or 'Schweissblattern'—Ger- was, nevertheless, the same as the rash of 'suette man expressions as least as old as Samuel Hafen- miliare.' Sudamin should, he added, be disreffer (13). It is a point of interest that although carded as an unacceptable expression; in its place 'echauboullure' and prickly heat date to the he offered 'olophlyctis hydroique' a term which, early part of the 18th century, the corresponding as expected, found no favour amongst dermaGerman (and Dutch) colloquial expression— tologists. The massive medical 'Encyclopadisches 'Rote Hund' (Roode Hond) or 'red dog'—does Worterbuch' of 1837 (23) discussed "Hidroa, not appear in the literature until late in the 19th Hitzblätterchen oder Ekzem," but the exprescentury. It is possible that 'Hund' refers to sion 'Rote Hund' was not used. Erasmus Wilson (1842) (24) was fairly char'Hundtstaghitze' or the heat of the dog days, but the resemblance of the rash to canine scabies is acteristic of the English school of dermatology less clear (14). A more likely explanation of 'Rote and accepted miliaria and sudamina to mean one Hund' lies, perhaps, in its origin from the old and the same—the symptomatic febrile sweat Dutch synonyms of the sweat rash—'roothon' of rash. For synonyms he gave (the incorrect) Forest (1614) (15), 'rootvont' of Bontius (1642) 'hydroa,' herpes miiaris and the German expres(16) and the 'roothont' of Piso (1648) (17)— sion 'Schweissblattern.' The vesicles of miliaria which, themselves, arose from the ancient expres- were, he said, lnrger than those of eczema, but sion 'bothor' (18a). Kraus did not use the expres- smaller than those of herpes. Lichen tropicus or prickly heat was described separately under sion 'Roth Hund'. 'eczematous affections.' Although characteristic THE SWEAT RASH. FRENCH, ENGLISH of the tropics, prickly heat did occur in England

as he could testify from personal experience. In 1828 Barbie du Bocage (19) of Paris wrote a Under 'affections of the sudoriparous system,' doctoral thesis on sudamina or hidroa (spelt Wilson referred to neither miliaria nor to lichen incorrectly as hydroa), a rash occurring in tropicus. Nevertheless he wrote on 'sudatoria rheumatic fever and phthisis. He brought up miliaris,' a condition which was, apparently, the old observation that the superficial sudamina nothing else but non-tropical prickly heat. The vesicles closely resemble the 'transparence crys- greater incidence of prickly heat in England talline' of the dew drops of a critical sweat. His during hot summers of the 19th century than main contribution was a study of the content of today, is probably related to the prevailing sudaminal vesicles which, he said, "was colour- practice of overdressing and to the low state of AND GERMAN SCHOOLS

less, limpid, odourless, tasteless, non viscous and

personal hygiene.

In Algeria, wrote Armand in 1854 (25), the did not redden litmus paper (II ne rougit point tropical sweat rash was well known, and because le papier tient de l'infusion de tournesol)." How these remarkable findings were obtained is, how- of its resemblance to itch or scabies (gale), was ever, not clear. Having convinced himself that called, locally, 'gale Bedouin' or Bedouin itch.

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From earliest times scabies had been confused He did not use the terms prickly heat or lichen with the sweat rash; Sennert (1632) (26) had tropicus. It had long been known among physicians of distinguished them, but Pringle, in 1775 (27), pointed out that in the English Army the miliary the East India Company, and Indian Medical rash and scabies were sometimes confused. Service, that sunstroke was associated with a dry Armand put forward 'lichen miliaris pruriginosa' skin and an ardent fever. Writing in 1860 on the as a more suitable expression than lichen tropicus. sweat rash and on heat disorders, Surgeon Major James Ranald Martin (1856) (28), an experi- Barclay of Calcutta noted that (30): nced practitioner of India, wrote thus on lichen "When the heat of the weather became intense, tropicus: one of the first symptoms of its producing an effect

"From mosquitoes, cockroaches, ants and the was a partial disappearance of the cutaneous rash, numerous other tribes of depredators on our the skin becoming rough and scaly and perspirapersonal property, we have some defences by day, tion ceasing, and at the same time the bowels and, in general, a respite by night; but this un- becoming obstinately constipated." welcome guest attacks us all, particularly, at Barclay added that in such cases a not uncommon

the most unseasonable hours.

"The eruption often disappears to a certain finding was the frequent passage of abundant degree when we are sitting quiet and the skin is pale urine. The dry 'rough' skin and disturbed cool; but no sooner do we use any exercise that brings on a perspiration, or swallow some warm stimulating liquids such as tea, soup or wine, the pimples become elevated so as to be distinctly seen, and all but too sensibly felt. Prickly heat

kidney function bespoken by Martin and Barclay may, perhaps, be early references to what is now

known as 'mammilaria,' miliaria profunda' or

thermogenic anhidrosis (31). There is also peribeing a symptom rather than a cause of good odic reference in the literature to febrile sudamina health, its disappearance has been erroneously occurring without sweating. Moore (1861) (32), accused of producing much mischief; hence some also of the Indian Medical Service, believed diet of the earlier writers on tropical diseases, harping to be of consequence in the sweat rash for: too much on the humoral pathology, speak very seriously of the danger of repelling, and the ad- "Prickly Heat or Lichen Tropicus (Willan) . . . is vantage of encouraging the eruptions. Even Dr. rather a manifestation of a healthy and vigorous Moseley retains the puerile and exaggerated habit than the reverse. . . It has also been known dangers of his predecessor Hillary. . . . The truth to follow a disordered stomach, and in children to is that the only means of producing good effects come on during teething, which may therefore be in mitigating its violence . . . are light clothing, an additional cause. It may also be a manifestatemperance in eating and drinking, avoidance of tion of too liberal or too carbonaceous a diet." exercise in the heat of the day, open bowels, and lastly a punkah or large fan during the night as is Hebra (1864) (33) is generally associated with now the ordinary practice in Bengal. . . . I have the introduction of pathological histology into seen men of the Bengal Pilot service . . in whom dermatology, but he was forestalled in the case the functions of the skin appeared at length to of the sweat rash. More than a century before, have been exhausted. They exhibited a permanent Astruc had ascribed 'echauboullure' to an irritadryness, roughness and scaliness of the surface of tion and inflammation of the sweat ducts arising the body. . . . With these men the functions of from the excess salt in the emergent sweat. the kidneys were always disturbed." Sudamina was, said Hebra, the same as lichen An interesting case of 'epidemic miliaria,' tropicus or 'Hitzblatterchen'; miliaria crystallina, occurring in England during the hot summer of on the other hand, was the febrile sweat rash 1859, was described by Gibb (29). A mother and (Duhring of Philadelphia was, later (34), to six children, otherwise quite healthy, showed a reverse this terminology). On the morbid anat"well marked sudaminal rash surrounded by a omy of sudamina, Hebra wrote: .

.

red base" accompanied by profuse sweating. The rash was also found between the fingers and backs of the hands. Gibb used the terms miliaria and sudamina as synonymous, but preferred the

latter as best expressing the general meaning.

"I am inclined to regard Sudamina as caused not so much by the perspiration poured out upon the surface of the skin, as by the hyperaemic state of the cutis and the consequent elevation of temperature which precedes the secretion of that fluid.

HISTORY OF SWEAT AND PRICKLY HEAT, 19TH-2&TH CENTURY

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• . . Hence, the perspirable fluid, being everywhere following experimental (albeit unconvincing) poured out in excess quantity and collecting proof. The application of "an irritating linseed beneath the epidermis, raises it in the form of oil poultice which contains much acrid resin" papillae or vesicles. . . . We should give up the old idea that these eruptions must not be rapidly produced mainly 'mifiaria,' but non-irritating

dressings such as a bread poultice or dry 'spongio'driven in' on account of the danger that metastapiline' (a species of rubberised dressing now long sis may occur."

forgotten) gave rise mainly to 'sudamina'

Even at this late period it was still believed that

vesicles. It may be noted that some eighty years

obstruction to the skin excretions (insensible before, Rigby (36) had already referred to the perspiration, liquid sweat) or to rashes 'driven local production of miliaria. In 1876, French in,' caused the excess or morbid humours to (also of the Indian Medical Service) wrote 'metastasize' and cause disease elsewhere (18b). Hebra regarded sudamina as a variety of eczema,

(37):

were usually alkaline.

surrounding them. The irritation and tingling etc., a particular symptom of ordinary lichen is prob-

and put forward "eczema sudamen" as a more "I believe that the little elevation to be true suitable expression. As proof of the eczematous inflammatory papules caused by irritation • . . that the real seat of the eruption is not in nature he added that the contents of the vesicles the sudiparous glands but in the boundary layer Sidney Ringer (1866) (35) was by no means convinced of the identity of miliaria and sudamma, but his arguments may, perhaps, baffle the modern student of dermatology:

ably due to irritation of nervous filaments in an inflammatory product. Sudamina, which some-

times appear together with the papules, is, I believe, a distinct affection, having no connection

"Although the sudamina and miliaria occur at whatever with Prickly Heat.. . . Linen, which the same time," he said, "they differ so much in allows a freer evaporation and greater drying of respect to their appearance and method of development that they require separate descriptions.

the surface, is to a certain extent unfavourable for

development of the eruption. If no clothing be It may be said that, while the sudamina often worn on the upper part of the body and the peroccurs without miliaria, the latter, on the other spiration be, from time to time, wiped off, no hand, are generally accompanied by sudamina. Prickly Heat will develop." The contents (sudamina vesicles) are colourless and transparent, are generally acid, occasion-

ally neutral and very rarely alkaline. . . they contain chlorides and a few epithelial cells According to some authors they are due to accumula-

tion of sweat in obstructed and distended sweat ducts. Others, Barensprung for instance, hold they are produced by an exudation of the perspirable fluid between the two layers of the cuticle, the exudation being caused by the obstruction of the ducts from accumulation of effete epithelial cells. "The vesicles of miliaria . . . never present the tense appearance of sudamina . . . are almost invariably surrounded at their base by a narrow rim of redness . . their contents from the first are turbid, opaque and white, are acid in reaction .

THE HISTORY OF THE SUDORIPAROUS SYSTEM. PRICKLY HEAT IN THE SECOND HALF 19TH CENTURY

Steno, in 1664 (38), had noted the 'fontes sudores' or sweat glands; Boyle (in 1685) (39), accepted the existence of 'miliary glandules' of

the skin and, with the aid of his "indifferent glass," Turner, in 1714 (40), had undoubtedly seen the sweat pores. Nevertheless, at the beginning of the 19th century, there was controversy on the old Galenic idea of the dual origin of sweat. Thus, some assumed that sweat arose from the glands and passed out through their ducts and pores. Others, however, disbelieved

and contain a large number of granular cells. the existence of any of these structures, and To the author it appears that the vesicles of insisted that sweat drops arose from 'condensamiliaria are not formed in the act of sweating but tion' of insensible perspiration when it reached result from the irritation which the sweat pro- the skin surface (18b). Bichat (1802) (41) also duces."

believed he had found the skin pores, but as late Although Ringer did not actually say so, 'sudam- as 1827 Walter Dendy wrote (42): "The sweat

ma' would appear to correspond to prickly appears to arise from the perspirable matter of heat and 'miiaria' to the febrile sweat rash. In Sanctorius (or insensible perspiration) being too order to prove their difference be offered the much increased in quantity and from its hydro-

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THE JOURNAL OF INVESTIGATIVE DERMATOLOGY

gen combining with oxygen of the atmosphere had been well known to the ancients but were and assuming the liquid state." looper (1831) studied more carefully in the 19th century (43) said of the sweat glands: the "excretory (Thurnham 1848 (54), Bouveret 1880 (55), Unna organ is composed of the extremity of the cuta- 1882 (56)) An important but forgotten chapter in the neous arteries." In 1833 Purkinje and Wendt (44) demonstrated history of prickly heat was the publication, in the spiral duct of the skin glands. Two years 1875 (57), of a 'Report' on skin diseases by later Breschet and Roussel de Vauzème (45) Tilbury Fox and Surgeon Major Farquhar of the proved the existence of the whole sudoriparous Bengal Medical Service. The report arose as a system or appareil diapnogéne—strangèly enough recommendation by the Army Sanitary Authora derivation of the old Greek '&alrvofl', 'diapnoe,' ities (1872) for the collection of new facts on or insensible perspiration (18b). The detailed tropical disease. The chapter on prickly heat work of Gurit (1835) (46) showed that sweat represented a collection of opinions from experiwas produced only in animals with sweat glands. enced tropical practitioners in various parts of One might assume that the origin of sweat was the world. We find that a Dr. Green of Seramnow quite clear. Krause (1844) (47) agreed that, pore, India (57), noted that: in the main, sweat came from the glands ('Drusen-

schweiss') but, nevertheless, believed that, in a

"The papular manifestations take place more in the strong and robust with an excess of fibrinated

number of common circumstances, it could blood in the vessels. Prickly heat is not a thing arise from condensation of transpired water peculiar to India or other Eastern climates, and vapor ('Dunstschweiss'). By 1845 Robin (48) had proved the existence of the large apoerine glands of the axilla and elsewhere. For long it was to be disputed as to how much of the gland sweat passed through the pores and how much oozed diffusively through the epidermis; whether the fat content of sweat came partly from the sweat glands or completely from adjacent sebaceous glands. The more important early investigations on the composition of sweat were carried out by Anselmino (1827) (49)and Bostock

cases are seen in fair abundance in England when the weather is hot and sultry and the air is humid.

Lichen tropicus is not a lichen papule but a hyperaemic duct papule. The so called vesicle of prickly heat. . . is simply an imprisoned drop of sweat."

A number of practitioners (57) insisted that the condition occurred in Indians, but with less

frequency and intensity than in Europeans.

Native clinicians pointed out that it was known (1828) (50). Favre in 1859 (51), believed that to the people of the country as Ghum-Gur, the 'aeide sudorique' was neither the acetous or Ghamachi or Ghamoree (sweat pimple). Surgeon-

the lactic acid of Scheele but a nitrogenous General Cannon of Lucknow, (57) said: substance resembling uric acid. Arguments "Prickly heat is only seen in the hot and rainy

persisted to almost the end of the century as to season when sweat cannot easily evaporate and the reaction of normal or disordered sweat, or tends to accumulate in the ducts. It is due to that of liquid from the vesicles of sudamina, inflammation or congestion of the sweat follicles miliaria or eczema. With the demonstration by and retention of secretion. Flannel next the skin Goltz, in 1875 (52), of a nervous control of the encourages the prickly heat, as also does the sweat glands, the physiology of the sudoriparous drinking largely of liquors and the use of muscular system may be said to have entered the modern exertion in hot weather."

period. However, the 'dew' theory of sweat Surgeon Major Moffatt, of Calcutta (57), noted formation was to persist to the end of the cen- that wearing a woollen belt often led to a sotury. Verneuil and Bazin (1854) described hydro- called 'flannel' rash (18c) limited to the belt adenitis and, in 1873, Tilbury Fox (53) salvaged area. Like Ringer he was well aware that a rash 'dysidrosis' (which he believed was an inflamma- could arise from local causes for: tory distension or blocking of sweat ducts) from the rubbish heap of eczema. Unfortunately the "Let a wound or bubo be dressed with a water dressing, and covered with gutta percha tissue, expression 'dysidrosis' was sometimes used to and a plentiful crop of prickly heat papules will

mean prickly heat. Chromidrosis, anhidrosis, soon appear corresponding to the limits of the hyperidrosis and nervous disorders of sweating gutta percha."

HISTORY OF SWEAT AND PRICKLY HEAP, 19TH-2OPH CENTURY

255

Bertherand of Algeria (57) noted that 'echauboul- glands (whether anatomical, physiological or lure' was known as 'seabies falsa' or Bedouin metabolic) as a cause of the sweat rash, may still itch; as 'boutons rougeatres,' 'boutons de be worth consideration.

chaleur,' 'boutons du Nil' or 'bourbouiles.' In

The word hydroa had been used since the

Egypt it was called 'harara' (heat), 'habb lareng' middle ages, in error for hidroa, but during the (sweat pimple) or 'hammen Nil' (Nile heat). 19th century it was revived by Franck, Bazin and English physicians practicing in China (57) others to designate herpes and other vesicular agreed that, during hot damp weather, the and bullous eruptions (hydroa febrile, aestivale conditions occurred not only in the white resi- vacciniforme, gestationis) unrelated to sweating. dents but also in about thirty per cent of Chinese Besnier (1883) (59) continued the French of all classes. It will be remembered that Winter- concept of the sweat rash 'triad.' Sudamina

bottom (7) had described the occurrence of was, he said, the symptomatic sweat rash of prickly heat in negroes.

In a chapter on 'Rare Skin Diseases' (1879), Jonathan Hutchinson (58) wrote on sudamina.

febrile disorders; its synonyms were 'hydroa' and

'miliaria crystallina' (a term more frequently heard in the previous century). In spite of the

"The commonly received theory of its cause is fact that the renowned Littré (60) had converted that it in some way results from the soaking of the hidroa of Hippocrates into sudamina, Besnier the skin in hot perspiration. . . . It is probable argued that this was but a poor translation, and, as a suitable alternative, suggested 'miliare that many have suspected that the orifice of the ducts of some of the sweat glands are obstructed sudorale.' Prickly heat was briefly described as and that the vesicles in question result from ac- 'lichen tropicus.'

cumulation of sweat in the distended ducts; another theory is that some of the sudiparous glands do not usually act in physiological excite-

THE MODERN PERIOD. ROBINSON, CROCKER AND POLLIPZER

ment of that function, which, under abnormal It is sometimes put forward by modern stuconditions of disease, assume for the first time dents of the sweat rash that its morbid anatomy secretory activity and then find their apparatus was first investigated by Robinson (61). Howimperfect. Professor Niemeyer distinctly recognises that the fluid is sweat, and at another place ever, early in the century Barbie du Bocage and he distinguished it from that of eczema by re- Andral had carefully considered the matter; and marking that the latter is alkaline. . . . Nor can Hebra, Ringer, Cannon and others appear to we accept the statement of this author that what have been conversant with, or carried out work is known as miliaria rubra is distinct from the on, the histological changes. Ideas on the nature commoner forms and has nothing to do with the of the sweat rash existing during the 18th cenretention of perspiration but consists of an inflammatory exudate arising by excessive diaphoresis, and for this reason is to be placed with eczematous affections. "I think we may safely believe that miliaria or sudamina—for the terms are equivalent—are small drops of sweat collected in the obstructed ducts, and that the only difference between the red and white forms is that, in the one, the adjacent tissues

tury and earlier have been noted elsewhere (18a).

In 1884 Robinson (61) concluded that miiaria rubra and alba were not inflammatory conditions

of the sweat glands but of the skin around the duct orifice. Section through a sudaminal vesicle showed it to be the corneous layer and in direct

connection with the duct. Glands and ducts

appeared to be normal. The disease was, thereare not congested, and in the other they are so. fore, not an exudative affection (Hebra), but The eczema vesicle is formed beneath the epi- arose from an increase in production of sweat dermis ... it contains alkaline sticky fluid and, (resulting from hyperaemia) with some obstrucafter it is ruptured, the abraded surface continues to secrete. The sudamina vesicle, on the contrary, tion (caused by detached or swollen epithelial contains sweat which is acid, is developed in the cells). Robinson objected to the word miliaria, gland duct; its fluid is not in the least sticky, and and suggested that sudamina was a more suitable it is never secreted except in connection with the term for the dew-drop eruption. Like most obact of sweating. A good lens, I think, always servers of the century he gave little or no referenables the observer to say with confidence ence to earlier workers. On histological grounds whether vesicles are sudamina or eczema."

Török (1891) (62) was not able to show a commu-

Hutchinson's idea of a local defect of the sweat

nication between vesicles of sudamina and the

256

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sweat ducts, a finding stressed in the recent

Unna did not accept Pollitzer's 'fat deficiency'

literature on prickly heat. Coats (1892) (63) examined, histologically, a

theory but believed that sudamina (miliaria

of micro-organisms (diplococci) in the lesion,

tion cysts in the stratum corneum (the swelling

alba and rubra) was an infectious type of eczema

sudaminal vesicle from a case of rheumatic (morococcic eczema; eczema aigu disséminé). fever, and found blocking of the duct with an Miiaria crystallina, he said, was, however, a inflammatory exudate. He noted the presence separate condition, and was due to sweat retenbut, wisely, drew no conclusions as to their of which, produced by a variety of causes, blocked significance.

the unlined spiral part of the sweat duct).

Pearse (1898) (67a), in India, carried the 'fat When, in 1893, Pollitzer (64) published his often quoted histological study of prickly heat deficiency' theory to an extreme. Prickly heat, he was, hence, by no means a pioneer in the he insisted, arose from a deficiency in sebaceous field. His conclusions were based on an examina- secretion due to friction of the clothing and the tion of vesicles from eight cases.

overuse of soap in washing the body. As a result of the deficiency, the sebaceous glands developed "If my view of the etiology of prickly heat (muhypertrophy which, he said, was iaria papulosa, miliaria rubra) is correct", he compensatory noted, "that it develops on a skin soaked in per- the cause of the papular rash. Thus he explained spiration and insufficiently supplied with fat, the lack of a rash on the palms and soles where we have at hand a means of preventing the sebaceous glands are absent. On the other hand, occurrence of the rash. I have advised anointing he added, the vesicles (sudamina)—an unfrequent the usually affected regions with a fat, after the occurrence in prickly heat—were caused by blockmorning bath . . for obvious reasons lanolin, to ing of the sweat ducts arising from a combination which a little almond oil is added. . . . The nature of the degreasing of the skin and the excess, of the obstruction in prickly heat appears to me sweating. Gray (1899) (68), of the West Indies, reasonably clear from microscopic examination. whilst accepting the 'fat deficiency' hypothesis I have described the cells of the horny layer as complained of the associated treatment saying:

swollen with nuclei preserved, and the resemblance to mucous membrane being especially "it can be undertaken only by those who are marked near the sweat ducts. Cells which are well either able to pay the big laundry bill or those impregnated with fat cannot imbibe water and willing to live in the state of those negroes who therefore will not swell up and occlude the sweat delight in rubbing themselves with tallow and ducts when soaked in perspiration. The negro in cocoanut oil. In the latter case it is better for them the tropics sweats profusely, yet does not acquire to retire into private life." A year later Pearse the rash; his skin is particularly well oiled. The wrote (67b): "I still think that prickly heat is a Englishman who takes the 'couple of tubs a day' form of acute seborrhoea—whether bacterial or suffers frightfully from prickly heat." fungus growth is the proximate cause, I have not Pollitzer's method of prophylaxis, by the use been able to determine." By this time a number of lanolin, was based, apparently, on the work of tropical practitioners were using oils and Unof Unna (1882), (56) which showed that diffusion guents with apparent success. After a lapse of of insensible perspiration was diminished in skin half a century the fat deficiency theory has been impregnated with fat. The idea was, however, by

resuscitated by O'Brien but it may be, as

no means new. In 1744 John Mitchell (5) said suggested by recent work (31), that the inherent that it was the unctuous sweat of negro skin metabolic anomaly is one of carbohydrate like which explained its "exemption from some dis- substance. Scheube, in 1896 (70), suggested that 'Rote eases such as the Itch, Prickly Heat or Essere." Hund' was but a severe form of eczema aestivuni Using the same argument Currie, in 1797 (65) advocated the use of unguents by the white resi- and was due to sunlight. Three years later Felkin dents of the West Indies. Combe (1834) noted, in (71) put forward the novel idea that the actinic, 1834 (66), that where sebaceous glands were or chemical rays, of the tropical sun were capable absent—the palms and soles—water was more of penetrating ordinary clothing to produce the easily taken up by the skin. This, he said, was "not to be despised acclimatising fever which the the cause of the wrinkled palms of laundresses Dutch call 'Roode Hund' or Red Dog." Using, who used much washing soda. as analogy, the protection of photographic plates

HISTORY OF SWEAT AND PRICKLY HEAT, 19TH—2OTH CENTURY

257

by red or orange glass, he advocated, as ment or even nomenclature of the sweat rash; prophylaxis, the use of similar coloured clothing for absorbing the harmful actinic rays (18d). In 1902 an anonymous author (72) put forward the viewpoint (unacceptable even to Bontius (16)

and Hillary (73)) that prickly heat was due to mosquito bites. Tendlau in the same year, (74) showed that, in anhidrosis, simple exposure to heat caused the body temperature to rise. This gave some objective proof to the remarks made,

and in spite of a recent voluminous literature, excellently reviewed by Sargent and Slutsky (31), the problem continues to tax the tropical hygien-

ist, dermatologist, physiologist, biochemist and histologist. To their disciplines the present essay will, doubtless, add but little to modern knowledge; but, if it brings to the forefront some of those illustrious names that have been concerned with the stifi incomplete knowledge of the oldest

in the first century A.D., by Galen ('Hygiene') recorded skin disease, and if once again we realize (2b) on the case of Premigines, who "on omission that, in spite of all our modern specialized techof a single bath . . . developed fever." Loewy and niques, much of our present ideas belong to our Wechselmann, in 1911 (75), demonstrated, for predecessors, the musty texts may be closed and the first time that, in the complete absence of put away without regret.

sweat glands, the human body was able to produce the expected amount of insensible perspiration. Castellini and Chalmers (1910) (76) and Byam and Archibald (1923) (77) noted that widespread prickly heat may be associated with

ACKNOWLEDGMENTS

I am greatly indebted to Mr. F. N. L. Poynter, Ph.D. and his assistants at the Weilcome Histori-

cal Medical Library for advice and unstinting oral and faucial hyperaemia, but earlier work- help in the search for some of the earlier texts. ers—Wilan (8), Bateman (10) and Rayer (78)— REFERENCES had, however, already pointed out that, in miiary la. HIPPOCRATES: The Genuine Works of Hipfever, vesicles could be found in the mouth or pocrates. Adams, F. Aphorisms sect. 3 No. palate. 21, p. 308. London, Balliere, Tindall & Cox,

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