MSB Review
SULZBERGER ON THE SWEAT GLAND RICHARD L. DOBSON, M.D. From (he Department of Dermatology, State University of New York at Buffalo, School of Medicine, Buffalo, New York
Marion Sulzberger's interest in the sweat gland and its disorders seemed to have begun during World War II when he was a naval medical officer on Guam. No one would have predicted that one of the most formidable enemies to be faced by the American military in the South Pacific would not be malaria or dysentery but rather the impact of a tropical environment on an unacclimatized sweat apparatus.
sistence or deepening of the obstruction could lead to tropical anhidrotic asthenia, a condition whose clinical manifestations were remarkably similar to those of patients with an anhidrotic ectodermal defect on exposure to a hot environment.^
World War 11 Interest
Postwar Research
In an epidemiologic study of naval personnel on Guam in 1945, Sulzberger and Emiki found that two-thirds were affected by prickly heat at one time or another during the previous 7 months. An important observation with important preventive implications was that a small group of men who worked 8 hours daily in air-conditioned rooms had a significantly lower incidence. Glinical and histopathologic investigations revealed that sweating was inhibited or absent in areas of skin affected by miliaria due to a failure in the delivery of sweat to the skin surface.2 This was apparently caused by a horny plug in the distal sweat duct or by obstruction secondary to inflammation and edema. Although this process generally resolved without difficulty, per-
On his return to civilian life, Sulzberger's interest in disorders of sweating continued. He and his collaborators established that inability to sweat as a result of keratotic obstruction of the pore secondary to atopic dermatitis, ichthyosis or atrophy of the skin could result in paroxysmal pruritus on exposure to heat. This led to the development of a new concept, the sweat retention syndrome, as a generic term for the constellation of signs and symptoms resulting from failure to deliver sweat to the skin surface.-* With this study, a long and productive collaboration with Franz Hermann began which was to influence greatly all future research in the field. Sulzberger and his associates were particularly interested in elucidating the mechanism by which obstruction of pores occurred. Physical plugging seemed to be too simple an explanation and did not
Address for reprints: Richard L. Dobson, M.D., Department of Dermatology, SUNY-Buffalo, 50 High Street, Buffalo, NY 14203.
373
374
INTERNATIONAL JOURNAL OF DERMATOLOGY
conform to many of their observations. Stimulated by the observation of Shelley et al.5 that electrophoretic production of anhidrosis could only be produced at the anode, they embarked on a series of studies to determine the effect of various polar compounds on sweating.*^ Electropositive substances, such as cationic wetting agents, were found to reduce sweating and could often induce an eruption resembling miliaria while electronegative materials increased the rate of sweating. Since the distal pore could be vitally stained with electropositive dyes, they advanced the hypothesis that the electronegativity of the distal duct facilities and expedites the movement of sweat toward the skin surface by a process of electroosmosis. Research Begins Again Sulzberger's interaction with the sweat gland seemed to conclude in the early 195O's with the publication of a book in 1954, summarizing his many studies.'' However, his retirement from the research arena was destined to be shortlived. The United States again became involved in a war in the tropics and heat and humidity were once again exacting their toll from our armed forces. Sulzberger was persuaded to embark on a new career and join the U.S. Army Medical Research Unit in San Francisco. During the period 1967-72, his interest in miliaria was rekindled. Together with a group of gifted young collaborators, he formulated fresh insights into its pathogenesis. To simulate a tropical environment, the skin of volunteers was occluded with Saran wrap for 48 hours.s Miliaria generally occurred and its severity appeared to correlate well with the degree of anhidrosis. The depression in sweating reached a maximum 7 days after occlu-
June 1977
Vol, 16
sion and was still significant after 3 weeks. This indicated that a single episode of miliaria can be accompanied by a rather prolonged period of hypohidrosis. Since restoration of sweating was complete by 28 days, it was suggested that this might be related to epidermal turnover time. In other words, integrity of the pores depends on their regeneration after initial injury. Subsequent studies showed that profound physiologic disturbances could be induced by a single episode of widespread miliaria.5 Two weeks after occlusion of 60% of their body surface, heatacclimatized volunteers became severely disabled on exposure to heat, although their miliaria had long since healed. These results imply that some heat casualties may result from widespread, no longer apparent miliaria and its subsequent long-lasting hypobidrosis. In a career or, more properly, careers, spanning virtually all of the era of contemporary dermatology and documented by more than 400 scientific publications, Marion Sulzberger's contributions to our knowledge of the eccrine sweat gland, its functions and its disorders, occupy a small but significant portion. Perhaps the most important of these was his pragmatic approach to the problem which relied on critical observation rather than elaborate instrumentation for important insights into the relationship between sweat gland dysfunction and its systemic consequences. As is often the case with significant research, the data raise more questions than answers. No one was more aware of this than Sulzberger, for in his penultimate publication on this subject he poses a number of significant questions regarding the possible role of inapparent miliaria and an impaired capacity to work in the heat. Further studies will be needed, he said, and that, unfortunately, is still the case.
SWEAT GLAND
No. 5
References 1. Sulzberger, M. B., and Emik, L. O.: Studies on prickly heat. I. Clinical and statistical findings. J. Invest. Dermatol. 7:53, 1946. 2. Sulzberger, M. B., and Zimmerman, H. M.: Studies on prickly heat. II. Experimental and histologic findings. J. Invest. Dermatol. 7:61, 1946. 3. Sulzberger, M. B., Zimmerman, H. M., and Emerson, K., Jr.: Tropical anhidrotic asthenia (thermogenic anhidrosis) and its relationship to prickly heat. J. Invest. Dermatol. 7:153, 1946. 4. Sulzberger, M. B., Hermann, F., and Zak, F. C : Studies of sweating. I. Preliminary report with particular emphasis on a sweat retention syndrome. J. Invest. Dermatol. 9:221, 1947. 5. Shelley, W. B., et al.: Experimental miliaria in
Dobson
375
man. I. Production of sweat retention anhidrosis and vesicles by means of controphoresis. ]. Invest. Dermatol. 11:275, 1948. Sulzberger, M. B., et al.: Studies of sweating. II. Experimental factors influencing the function of the sweat ducts. J. Invest. Dermatol. 14:91, 1950. Sulzberger, M. B., and Herrmann, F.: The Clinical Significance of Disturbances in the Delivery of Sweat. Springfield, Charles C Thomas, 1954. Griffin, T. B., Maibach, H. I., and Sulzberger, M. B.: Miliaria and anhidrosis II. The relationship between miliaria and anhidrosis in man. ). Invest. Dermatol. 49:379, 1967. 9. Sulzberger, M. B., and Griffin, T. B.: Induced miliaria, postmiliarial hypohydrosis, and some potential sequelae. Arch. Dermatol. 99:145, 1969.
Why Surgery? It is of course inconceivable that a specialist in any "organ specialty," such as dermatology, should be allowed to use only certain specified techniques and be forced to eschew others. To be forced to restrict himself to the use of only systemic measures, only intralesionally injectabie drugs, only topical applications, only radiation, only scalpel surgery, chemosurgery, or electrosurgery would deprive the dermatologist of the very raison d'etre of his specialty and rob his patients of the optimal application of his professional competence. For a dermatologist is a dermatologist precisely because he is better equipped than others to diagnose skin diseases and skin lesions and precisely because he is familiar with more things that can be done for them. Therefore, the dermatologist must know more than any other physician not only about local and systemic medical procedures applicable to the skin, but also about the available surgical approaches. For this reason he must have access to up-to-date, authoritative information about every surgical technique that science has to offer for the treatment or eradication of an abnormality of the skin. Only in a textbook which is, as the title proclaims, devoted exclusively to dermatologic surgery will the skin specialist find assembled extraordinarily diverse and increasingly numerous surgical approaches now assembled under one cover, the skin specialist might have to learn about them or refresh his recollection of them in dozens of different texts and in many recent issues of journals; and even then some might be inaccessible to him or escape his notice. — Sulzberger, M. B.: Why a textbook on dermatologic surgery? In Skin Surgery, edited by Epstein E. and Epstein, E., Jr. Springfield, Charles C Thomas, 1977, pp. 5, 6.
SULZBERGER ON THE SWEAT GLAND RICHARD L. DOBSON, M.D. From (he Department of Dermatology, State University of New York at Buffalo, School of Medicine, Buffalo, New York
Marion Sulzberger's interest in the sweat gland and its disorders seemed to have begun during World War II when he was a naval medical officer on Guam. No one would have predicted that one of the most formidable enemies to be faced by the American military in the South Pacific would not be malaria or dysentery but rather the impact of a tropical environment on an unacclimatized sweat apparatus.
sistence or deepening of the obstruction could lead to tropical anhidrotic asthenia, a condition whose clinical manifestations were remarkably similar to those of patients with an anhidrotic ectodermal defect on exposure to a hot environment.^
World War 11 Interest
Postwar Research
In an epidemiologic study of naval personnel on Guam in 1945, Sulzberger and Emiki found that two-thirds were affected by prickly heat at one time or another during the previous 7 months. An important observation with important preventive implications was that a small group of men who worked 8 hours daily in air-conditioned rooms had a significantly lower incidence. Glinical and histopathologic investigations revealed that sweating was inhibited or absent in areas of skin affected by miliaria due to a failure in the delivery of sweat to the skin surface.2 This was apparently caused by a horny plug in the distal sweat duct or by obstruction secondary to inflammation and edema. Although this process generally resolved without difficulty, per-
On his return to civilian life, Sulzberger's interest in disorders of sweating continued. He and his collaborators established that inability to sweat as a result of keratotic obstruction of the pore secondary to atopic dermatitis, ichthyosis or atrophy of the skin could result in paroxysmal pruritus on exposure to heat. This led to the development of a new concept, the sweat retention syndrome, as a generic term for the constellation of signs and symptoms resulting from failure to deliver sweat to the skin surface.-* With this study, a long and productive collaboration with Franz Hermann began which was to influence greatly all future research in the field. Sulzberger and his associates were particularly interested in elucidating the mechanism by which obstruction of pores occurred. Physical plugging seemed to be too simple an explanation and did not
Address for reprints: Richard L. Dobson, M.D., Department of Dermatology, SUNY-Buffalo, 50 High Street, Buffalo, NY 14203.
373
374
INTERNATIONAL JOURNAL OF DERMATOLOGY
conform to many of their observations. Stimulated by the observation of Shelley et al.5 that electrophoretic production of anhidrosis could only be produced at the anode, they embarked on a series of studies to determine the effect of various polar compounds on sweating.*^ Electropositive substances, such as cationic wetting agents, were found to reduce sweating and could often induce an eruption resembling miliaria while electronegative materials increased the rate of sweating. Since the distal pore could be vitally stained with electropositive dyes, they advanced the hypothesis that the electronegativity of the distal duct facilities and expedites the movement of sweat toward the skin surface by a process of electroosmosis. Research Begins Again Sulzberger's interaction with the sweat gland seemed to conclude in the early 195O's with the publication of a book in 1954, summarizing his many studies.'' However, his retirement from the research arena was destined to be shortlived. The United States again became involved in a war in the tropics and heat and humidity were once again exacting their toll from our armed forces. Sulzberger was persuaded to embark on a new career and join the U.S. Army Medical Research Unit in San Francisco. During the period 1967-72, his interest in miliaria was rekindled. Together with a group of gifted young collaborators, he formulated fresh insights into its pathogenesis. To simulate a tropical environment, the skin of volunteers was occluded with Saran wrap for 48 hours.s Miliaria generally occurred and its severity appeared to correlate well with the degree of anhidrosis. The depression in sweating reached a maximum 7 days after occlu-
June 1977
Vol, 16
sion and was still significant after 3 weeks. This indicated that a single episode of miliaria can be accompanied by a rather prolonged period of hypohidrosis. Since restoration of sweating was complete by 28 days, it was suggested that this might be related to epidermal turnover time. In other words, integrity of the pores depends on their regeneration after initial injury. Subsequent studies showed that profound physiologic disturbances could be induced by a single episode of widespread miliaria.5 Two weeks after occlusion of 60% of their body surface, heatacclimatized volunteers became severely disabled on exposure to heat, although their miliaria had long since healed. These results imply that some heat casualties may result from widespread, no longer apparent miliaria and its subsequent long-lasting hypobidrosis. In a career or, more properly, careers, spanning virtually all of the era of contemporary dermatology and documented by more than 400 scientific publications, Marion Sulzberger's contributions to our knowledge of the eccrine sweat gland, its functions and its disorders, occupy a small but significant portion. Perhaps the most important of these was his pragmatic approach to the problem which relied on critical observation rather than elaborate instrumentation for important insights into the relationship between sweat gland dysfunction and its systemic consequences. As is often the case with significant research, the data raise more questions than answers. No one was more aware of this than Sulzberger, for in his penultimate publication on this subject he poses a number of significant questions regarding the possible role of inapparent miliaria and an impaired capacity to work in the heat. Further studies will be needed, he said, and that, unfortunately, is still the case.
SWEAT GLAND
No. 5
References 1. Sulzberger, M. B., and Emik, L. O.: Studies on prickly heat. I. Clinical and statistical findings. J. Invest. Dermatol. 7:53, 1946. 2. Sulzberger, M. B., and Zimmerman, H. M.: Studies on prickly heat. II. Experimental and histologic findings. J. Invest. Dermatol. 7:61, 1946. 3. Sulzberger, M. B., Zimmerman, H. M., and Emerson, K., Jr.: Tropical anhidrotic asthenia (thermogenic anhidrosis) and its relationship to prickly heat. J. Invest. Dermatol. 7:153, 1946. 4. Sulzberger, M. B., Hermann, F., and Zak, F. C : Studies of sweating. I. Preliminary report with particular emphasis on a sweat retention syndrome. J. Invest. Dermatol. 9:221, 1947. 5. Shelley, W. B., et al.: Experimental miliaria in
Dobson
375
man. I. Production of sweat retention anhidrosis and vesicles by means of controphoresis. ]. Invest. Dermatol. 11:275, 1948. Sulzberger, M. B., et al.: Studies of sweating. II. Experimental factors influencing the function of the sweat ducts. J. Invest. Dermatol. 14:91, 1950. Sulzberger, M. B., and Herrmann, F.: The Clinical Significance of Disturbances in the Delivery of Sweat. Springfield, Charles C Thomas, 1954. Griffin, T. B., Maibach, H. I., and Sulzberger, M. B.: Miliaria and anhidrosis II. The relationship between miliaria and anhidrosis in man. ). Invest. Dermatol. 49:379, 1967. 9. Sulzberger, M. B., and Griffin, T. B.: Induced miliaria, postmiliarial hypohydrosis, and some potential sequelae. Arch. Dermatol. 99:145, 1969.
Why Surgery? It is of course inconceivable that a specialist in any "organ specialty," such as dermatology, should be allowed to use only certain specified techniques and be forced to eschew others. To be forced to restrict himself to the use of only systemic measures, only intralesionally injectabie drugs, only topical applications, only radiation, only scalpel surgery, chemosurgery, or electrosurgery would deprive the dermatologist of the very raison d'etre of his specialty and rob his patients of the optimal application of his professional competence. For a dermatologist is a dermatologist precisely because he is better equipped than others to diagnose skin diseases and skin lesions and precisely because he is familiar with more things that can be done for them. Therefore, the dermatologist must know more than any other physician not only about local and systemic medical procedures applicable to the skin, but also about the available surgical approaches. For this reason he must have access to up-to-date, authoritative information about every surgical technique that science has to offer for the treatment or eradication of an abnormality of the skin. Only in a textbook which is, as the title proclaims, devoted exclusively to dermatologic surgery will the skin specialist find assembled extraordinarily diverse and increasingly numerous surgical approaches now assembled under one cover, the skin specialist might have to learn about them or refresh his recollection of them in dozens of different texts and in many recent issues of journals; and even then some might be inaccessible to him or escape his notice. — Sulzberger, M. B.: Why a textbook on dermatologic surgery? In Skin Surgery, edited by Epstein E. and Epstein, E., Jr. Springfield, Charles C Thomas, 1977, pp. 5, 6.
