Aust. J. Derm. (1976), 17, 87
THE PSYCHOLOGICAL ASPECTS OF SWEATING* R. S. GlLLENf
" The sorrow which has no vent in tears may naake other organs weep."
It has been said that the urge to neutralize body scents today derives from an innate desire to prevent sexual arousal of strangers, because odour is a form of sexual signalling, and Sweating, a common presenting sign of body today's hordes of people, signals would anxiety, whether acute, chronic or free-floating, with become far too numerous and therefore confusing has received scant attention in the literature. and socially disruptive, or productive of guilt, In the index of the most recent American shame and embarrassment. It has been text book of psychiatry ^ the word is mentioned suggested that there may even be a special only twice, and even more suprising, in the odour of guilt, shame and embarrassment. index of the 25 volumes of the Psychoanalytic Police dogs, after some months or years of Study of the Child,^ the word "sweating" apprehending criminals, can recognize a special does not appear at all. There is, however, an class of odours emanating from persons who interesting paper on the relationship between are in an emotional state, combining the elements sweating and crying, where it had been found of fear, hostility and resentment.^ that palmar sweating may first be provoked It has often been recognized that there is a by vigorous cr5dng two to three months after birth.^ Sweating, crying and bed-wetting in characteristic odour of mental hospitals, and childhood are the water works which signal all of schizophrenia,'^ and in fact. Smith et al.,^ have now identified this odorous substance in is not well with the psyche. as trans 3 methyl 2 hexenoic acid. Doctors, like the general public at large, schizophrenia Gas chromatographic analysis of the acidic have been conditioned from birth to show more components of sweat from seven schizophrenics interest in the odour of sweat, which big business ten controls showed this acid to be present has taught us to be self-conscious of, since as and early as 1870, when the first commercial under- only in the specimens from schizophrenic arm product was marketed in the United States, patients. Apart from this one component, the and in 1888 the first trade mark brand " Mum " sweat from patients and controls was identical. was introduced.* Presumably it was introduced Further support for this identification being to seal off the smells from the hair tufts in the correct came from a panel of trained sniffers, armpits, and the pubic region, which sociologists who agreed that the odour produced when and anthropologists looked upon as scent traps crystals of the acid were added to normal which served in antiquity to bring together sweat, was identical to the characteristic males and females by arousing sexual interest. schizophrenic odour. Pheromones, or insect You all know how Italian males dislike their smells, are now being studied in the hope of wives shaving their armpits, and Krafft-Ebings, making insect sexual behaviour deviant and wrote, "it is worthy to note that a whole row so upsetting their breeding patterns.^ of well known perfumes imitate the genital Primitive man was ambivalent about sweating, smell of women, and that of man too. Very and anthropologists write how axiUary sweat much diluted of course ".^ was used by aboriginals, medicinally, to relieve the pains of childbirth,^" and even to cure * Presented at the Annual Meeting of the Australasian snakebite.^^ However the sweat of recently dead College of Dermatolgists, Adelaide, May, 1976. t Senior Visiting Psychiatrist, Queen Elizabeth men,i2 ^nd the sweat of enemies, has a malignant property, 13 and was best avoided. Hospital, Adelaide. —HENRY MAUDSLEY.
R. S. GiLLEN Pliny notes that the Greeks used the scrapings of the bodies of athletes to cure rheumatism, sprains, and uterine trouble. Folk medicine had examples of the transference of disease by putting one's sweat on a dog. The Nubians supposed they were given strength by applying the sweat of their horses to their bodies. After a ride they scraped the sweat from theii horses' backs, with their hands, and rubbed it about their person, as if it were one of their ordinary greasy ointments.^^ All through the ages, man has looked upon sweating as a way of purifying himself, in preparation for great events, from initiation to preparation for battle,^^ and regularly in preparation for riding the winner of the Adelaide Cup. The practice of exposing the body, or some part of it, to heat so as to produce sweating, is found in almost every culture studied by anthropologists. In ancient times sweating it out together was not necessarily a shared fearful experience, but a shared social event. The sweat houses of Ireland suggest that the practice is ancient in Northern Europe, and that the modern Russian and Turkish forms are only improved forms of an old and indigenous Celtic or Teutonic practice. Among the Pueblo Indians in Ameiica, the sweat house was described as, at once, the bathroom, town hall, council chamber, clubroom and church of the people. By the look of the number of advertisements for sauna baths and massage, available in Adelaide at the drop of a telephone number, it may be that the practice is common in our contemporary culture too. A field study of sweating in these establishments, illustrated with appropriate slides, could liven up this presentation considerably. Kuno^^ suggested that there was a link between sweating and sexual excitement, and Masters and Johnson-'-'' have shown us that both men and women, post orgasmically, sweat from top to toe, as a way of showing their appreciation of their experience of togetherness. They show that as sexual tensions rise, a sweating phenomenon may be observed, developing on the walls of the vaginal barrel. Individual droplets of transudation-like mucoid material appear scattered throughout the rugal folds of the normal vaginal architecture. These individual droplets present a picture somewhat akin to that of the perspiration-beaded forehead. As tensions increase, the droplets coalesce to form a smooth glistening coating for the entire vaginal barrel. This sweating phenomenon provides complete lubrication for the vaginal
walls, early in the excitement phase of the human female's sexual response cycle, and certainly is the first evidence of the vaginal barrel's physiological response to sexual stimulation. In a matter of seconds, the sexually responding woman may develop sufficient lubrication for coital readiness. An interesting fact is that this phenomenon can appear in women who have been subjected to complete hysterectomy and bilateral salpingo-oophorectomy, and even in those women who have had an artificial vagina created for them.^^ It is a well-known fact that the problem of pruritus vulvae appears only in those women who do not enjoy this normal vaginal sweating sensation. The problems of pruritus ani are a little more complicated, to discuss here. There is evidence of a difference in the degree of sweating from one type of mental disorder to another,^^ and in certain types of depressed patients the response to E.C.T. can be gauged by their response to sweating. There is a relationship between salivation and sweating in some mental disorders. Depression lowers both measures, and alcoholics tend to lie at the other end of the continuum. Some psychotropic drugs depress salivation, but not sweating. There are consistent changes in both salivation and sweating following E.C.T., which can prove of some value in monitoring therapeutic change. 20 Treatment with the tricyclic anti-depressants can produce the side effects of a feeling of excessive warmth, flushing, and especially sweating, and according to Simpson, there is a correlation between sweating and a favourable response to imipramine.^^ In one type of depression, patients wake early in the morning sweating profusely. This phenomenon is increased by treatment with tricyclic anti-depressants, and it is an interesting clinical observation that these depressed patients simply cannot cry. There is a group of patients who can cry profusely, but do not feel depressed, and these people have been called ' shower' and ' stream' weepers.22 By ' shower ' weepers I mean those people who weep copious tears, with very little provocation, and without much sobbing or crying. Sometimes these fioods of tears appear indiscriminately, without any emotion. In the ' stream ' type of crying there is little obvious emotion evident, but a stream, or trickle of tears rolls down the cheek when only certain specifically sensitive areas are touched on.
THE PSYCHOLOGICAL ASPECTS OF SW^EATING
It was thought by Kuno that the palms and soles were the main sites of mental sweating in normal people, but Allen et al.,^^ under experimental conditions, found the sldn of all regions appears to participate in mentally induced sweating. Just as there are ' shower ' and ' stream' weepers, we see often in our clinical work, ' shower ' and ' stream ' sweaters, and it is well to realize there is a relationship between crying and sweating and other fluid discharges from the body, like urinating frequently under stress.24 These ' shower ' and ' stream ' weepers, or ' shower ' and ' stream ' sweaters, as 1 like to call them, are usually described in the psychiatric literature, amongst the group of personality disorders, and the commonest presenting type is the so-called hysterical personaHty disorder. There is a group of patients who have problems with their body fluids, which they show both externally with tears, sweating, weeping lesions, or streaming noses and urinary difficulties, and internally, by the manifestation of various forms of oedema. When they sweat excessively or show variation in degree and localization of sweating and exhibit ' La Belle Indifference', psychiatrists see them as suffering from a type of hysterical conversion phenomenon. In the literature,^° there is an interesting case study of a patient with sweaty hands who failed to beneflt by psychological treatment. There is some work being undertaken by Kuypess and Cotton,^^ who have found that, under experimental conditions, the subjects in their work learn to decrease their sweat rate markedly. However, whether their learning was autonomic, cognitive, or only a side effect from some other learned activity that effects sweating, could not be described. The fact that these people find it difficult to benefit by psychological treatment is to be shown by Jepson^'' who shows that these people present to surgeons when everything else has failed to be of any help to them. Not all bizarre sweating is psychological; in fact, it is more likely to be the result of some neurological lesion in the medulla, pons or elsewhere. 28 Therefore, perhaps one of the reasons why there is not an extensive literature about sweating is that clinically there are so many variations on a single theme, and as Socrates said in about 400 B.C. " As you ought not to attempt to cure eyes without head, or head without body, so you ought not to treat body without mind."
In psychiatry we teach that each symptom has meaning, and clinically every case of sweating must be judged on its individual merits, because sweating can mean different things to different people, at different times in their life history. 28 Ward Street, North Adelaide, S.A. 5006. REFERENCES ^ Arieti, Silvano (1974): American Handbook of Psychiatry, Basic Books Inc., New York. »The Psychoanalytic Studies of the Child, Abstracts and Index to Volumes 1-25, 1975, Yale University Press. 3 Verbov, Julian and Baxter, Jane (1974) : " Onset of Palmar Sweating in Newborn Infants ", Brit. J. Derm., 90, 269. * Cella, John A. (1971) : " Personal Deodorants ", American Perfumer and Cosmetics, 86, 84. « Krafft-Ebing (1965) : "The Psychopathia Sexualis," Panther Books Ltd., London, p. 144. « Wright, R. H. (1974): " Is there an 'Odor of Guilt'?". Soap, Perfumes, and Cosmetics, United Trade Press Ltd., London, p. 398. ' Skinner, Kathryn, Smith, Kathleen, and Rich, Edith. (1964) : " Bacteria and the ' Schizophrenic Odor ' ", Amer. J.Psychiat., 121, 64. * Smith, Kathleen, Thompson, Geoffrey F., and Koster, Harry D. (1969) : " Sweat in Schizophrenic Patients : Identification of the Odorous Substance ", Science 166, 398. a Editorial (1970): " Odor of Sanity", JAMA, 212, 472. " Roth, Walter (1897) : " Ethnographical Studies among North-West Central Queensland Aborigines ", Government Printer, Brisbane, Queensland., p. 162 and 183. " Op. cit.
12 Frazer, J. G. (1910) : Totemism and Exogamy, MacMillan and Co. Ltd., London, 3, 486. 3 Frazer, Sir J. G. (1920): The Golden Bough, MacMillan & Co. Ltd., London, 1,, 206 206. * Crawley, Ernest (1920) : The Mystic Rose, Methuen & Co. Ltd., London, 1, 144. Rivers, W. H. R. (1924) : Medicine Magic and Religion, Kegan Paul, Trench, Trubner & Co. Ltd., London, p. 102. " Kuno (1952): as quoted in 9th Edition, Samson Wright's Applied Physiology, Oxford University Press, p. 467. 1' Master, William H., and Johnson, Virgina E. (1966) : Human Sexual Response, Chap. 6, Excitement Phase, Little, Brown & Co., Boston, p. 69. " Masters, WiUiam H., and Johnson, Virginia E. (1970) : Human Sexual Inadequacy, Little, Brown & Co., Boston, p. 269. i» Kelly, Desmond (1971) : " Emotion and Physiological Changes on the Arm", J. psychosom.Res., 15, 445. »«Peck, Robert E. (1966) : " Observations on Salivation and Palmar Sweating in Anxiety and Other Psychiatric Conditions ", Psychosomatics, 7, 343. 21 Tofranil, Geigy Publication.
R. P. JEPSON AND J . D . HARRIS
'•'^ Greenacre, Phyllis (1965) : On the Development 26 Kuypers, B. R. M., and Cotton D. W. K. (1972) r " Conditioning of Sweating", a Preliminaryand Function of Tears, in Emotional Growth, Report, Brit. J. Derm., 87, 154. International Universities Press Inc., New York, 1, 249. "Jepson, R. P., and Harris, J. D. (1976) : "Surgical i* Allen, Judith A., Armstrong, Janet E., and Roddie Aspects of Hyperhidrosis", Aust. J. Derm.,. I. C. (1973) : " The Regional Distributes of Emotional Sweating in Man ", / . Physiol. 235, 17, 90. 749. '* Greenacre, Phyllis (1952) : Urination and Weeping, 28 List, Carl F., and Peet, Max M. (1939) : "Sweat Secretion in Man; Disturbances of Sweat in Trauma Growth and Personality, International Secretion with Lesions on the Pons Medulla and Universities Press Inc., New York, p. 106. Cervical Portion of Cord", Arch. NeuroL '5 Seidenberg, Robert (1961) : " Palmar Hyperhidrosis Psychiat., 42, 1089. and Linking ", Arch. gen. Psychiat, 89, 283.
SURGICAL ASPECTS OF HYPERHIDROSIS* R. P. jEPSONf AND J. D. H A R R I S J Adelaide SUMMARY
Experience has demonstrated that severe hyperhidrosis, resistant to medical therapy, can he cured permanently by sympathetic denervation of the hands or feet, or by skin excision for axillary problems. The technique and results of these procedures is discussed. The clinical profile is so characteristic that differential diagnosis is not a problem. Whether a condition which is socially embarrassing rather than life threatening warrants surgery, is discussed.
Our accumulative experience, over the past twenty-five years, involves several hundreds of patients referred by physicians and dermatologists for excessive sweating, often after extensive and expensive attempts have been made to control this condition by pharmacological and local therapies. Frequently, these patients have sweated excessively since birth, or from the date of body-image awareness; occasionally a strong family history was present, either through a parent or a sister. It is even more common to find a parent of a severe hyperhidrotic sweats freely in excess of normal, but is not a true hyperhidrotic. Predominantly the sufferer is female, in ratio of at least 10 : 1 , and although the youngest was eight-years-old and the eldest 38, the majority clustered in the 17-23 year age group. It is interesting to note that Cloward,^ reporting from Hawaii with a different ethnic population, found a female/male
ratio of 45 : 37, with a heavy loading towards those of Japanese ancestry. Occupationally, as might be expected with the Australian sample, they were mostly students or clerks, though we number several doctors among our patients. The clinical profile is a fairly standard one. Patients get excessive sweating in bursts,, occasionally spontaneously, but usually provoked by fine movements, touch or emotionally charged situations. The change from a dry skin to a glistening, beaded, dripping one, is dramatic. The hands, the most commonly affected part, may literally run in rivulets with sweat and need constant blotting and wiping to control. The school child, student and typist smudge and snail-track their scripts, the salesgirl is shame-faced with her client. From the axilla the sweat cascades down the chest wall, soiling blouses and shirts and creating an odour problem that even " M u m " can't solve. The feet may perspire to a degree that requires regular removal of shoes * Presented at the Annual Meeting of the Australasian to pour out the water. With such a degree of College of Dermatologists, Adelaide, May 1976. t Senior Visiting Vascular Surgeon, Royal Adelaide contact moisture, the skin becomes blistered Hospital, Adelaide. and sodden, with subsequent secondary J Honorary Vascular Surgeon, Queen Elizabeth infections. Without having recourse to any Hospital, Adelaide.