On Bromidrosis or Fetid Perspiration. By DR. FOOT. 327

their illness, contracted diphtheria about the same time, and died of it. In her case the disease was presumably traceable to the fact that a niece of the lady in Case I I I . had left the house in this city on the occurrence of her aunt's illness and had gone home, taking with her a sore throat. She slept with the young lady of whoso death I am now writing.

In both these instances the apparent propagators of the disease recovered, while those apparently taking it from them died. Them were no other eases of diphtheria in that neighbourhood, save in a small island some miles off the coast of Schull, where there were five cases. Since the occurrence of the above deaths, epidemic sore throat seemed to have prevailed to some extent. Immediately on my going to the town of which mention is now made, I fell ill with ulcerated sore throat, plus an ash-coloured pharyngeal exudation, which a sound practitioner in that neighbourhood burned out in three days by applying to it a strong solution of nitrate of silver.

ART. X V I I . - - O n Bromidrosis or Fetid Perspiration. By ARTHUR WYN~E FOOT, M.D., Fellow of the King and Queen's College of Physicians.

TEE term Bromidrosis (~p~/~0~$, a stink, especially of beasts at rut, ]~p~, sudor) is employed to signify that, under various conditions the secretions of the skin which in health are almost inodorous become remarkably tainted and offensive; the circumstances under which this phenomenon appears are various, and may be convenient]y arranged into three groups, each worthy of a short consideration. The first group of eases are those in which the smell from the skin is the result of the introduction into the body, for the purposes of Food or medicine, of some substance which may be itself inodorous; the second group of cases are those in which the smell from the skin indicates disease, existing and progressing internally, some of whose products or results are carried outwards, dissolved in the perspiration or sebaceous secretion; in the third group of cases the cause of the phenomenon is generally unknown or very obscure, which fact is one of the reasons that this form, which is not the least frequent of the three, is often long and unsuccessfully treated. The perspiration secreted in health from the surface of the body, when cleanliness is as scrupulously attended to as it ought to

328 On Bromidrosis or Fetid Perspiration. By DR. FOOT.

be, is almost inodorous, or at least rarely appreciable by the organ of smell, as constituted in the higher mammals, so that it has long been the practice of physicians to look upon any odorous condition of this secretion as a symptom of ill health deserving their serious attention; for this reason Paulus Egineta has handed down four prescriptions for fetor of the perspiration.

Examples of the first class of cases, in which the fetor of the perspiration is dependent upon certain articles used as food or medi- cine, arc sufficiently common; the fetor in these cases ceases when, or soon after, the cause is removed; there is no disease on illness necessarily in the case, and the worst result is that the individual becomes personally and publicly obnoxious. Aristophanes alludes to the disgusting emanations from Asiatics who consume assafetida daily. The volatile oils contained in this gum-resin, as well as those contained in the genus allium, including the garlic, onion, shallot, and leek, being absorbed by the veins, taint the exhalations and secretions of those who use them. The perspiration of the inhabi- tants of parts of the Arctic regions, as the Samoiedes and Esqui- maux, smell strongly of whale oil; this animal oil, often not in its freshest state, forming their chief food. The leguminous odour of the sweat of Greenlanders is attributed to the quantity of peas they eat. During the administration of phosphorus, sulphur s and tellurium, the compounds of hydrogen with these substances are emitted from the skin in an unmistakable manner. That the exhalations from the lungs are not alone impregnated with these gases is proved by the fact that silver articles become blackened in the pockets of persons undergoing a course of sulphurous medicines. The results of the union, within the body, of hydrogen and tellurium, are so offensive that it is improbable that this substance, first used medicinally by Sir James Simpson, will ever be a favourite remedy. The odour of telluretted hydrogen cannot be distinguished from that of sulphuretted hydrogen. Dr. Aquilla Smith has recorded (Dub. Quart. Jovr. Med. Sci., Vol. XVI. , p. 194) the effects he witnessed subsequent to the administration of the nitrate of tellu- rium in some experiments on its action, undertaken at the suggestion of Sir James Simpson. Tuesday, August 31st, 1852, at noon, one half-grain pill was administered to each of the following patients in Sir Patrick Dun's Hospital :--Christopher Connor, aged 32, under treatment for chronic pleurisy~ and John Shalvey, under treatment for a venereal eruption. The two patients lay in beds about five feet apart~ in a spacious and well ventilated ward. September ls t . - -

On Bromidrosis or Fetid Perspiration. By DR. FOOT. 399

A peculiar odour was perceived from Connor's breath, but none from Shalvey. A_ pill was administered to each patient at noon. September 2nd.--_A_n alliaceous odour was very perceptible; two physicians noticed it immediately on entering the ward. 2k third pill was administered to each of the patients at noon. September 3rd.-- The odour to day was very strong, and so offensive that the nurse and the other patients in the ward complained of it; the two patients also were very sensible of it, and remarked that they had a very disagreeable taste in their mouths. Shalvey, who was a sailor, said the taste was like garlic. One of the physicians, who saw the patients the day before, was so disgusted that, on entering the ward to-day, he retired immediately. The odour was very like that emitted by metallic arsenic when volatilized. Each patient having taken three pills, and the effect being so palpable, Dr. Smith did not consider it necessary to pursue the experiment. On questioning the patients minutely, he could not ascertain that any other particular effect had been produced by the pills. Shalvey said, they made him perspire more than usual. September 4th.-- The smell through the ward was diminished, but the exhalations from the patients' lungs were very offensive. September 5th.--The peculiar odour less evident on entering the room. September 8th.-- Connor's breath still retained the peculiar smell very strongly; Shalvey was quite free from it. The latter patient, during the experiment, did not emit so strong an odour as Connor. The increased perspiration may have eliminated the tellurium more rapidly than in the case of Connor, who did not perspire more than usual. September 16th.--Connor's breath still retains the odour, which is not perceptible when standing close over him.

In the second group of cases, an ill smell from the skin is a symptom of disease, obvious and serious, and they deserve a passing notice. A fetor is observed not unfrequently from the skin in lunatics as diagnostic as that from a variolous patient, it may be perceived on entering a room where the person has been for some hours, and especially during the night. Dr. Tuke remarks that the room smells like a mouse trap. In the fourth visitation of the sweating sickness, the smell of the perspiration is described as "odoris teterrimi." During this epidemic in the course of a short time, and in many cases at the very commencement of the disease, the "stinking sweat" broke" out in streams over the whole body. In the next visitation it was described as being thick and of various colours, but in all cases of a very disagreeable odour, which

330 On Bromidrosis or Fetid Perspiration. By DR. FOOT.

when it broke out again after any interruption to its flow, was far more offensive than at the first, so that the body dripped as it were with a foul fluid, and it seemed as if the inward parts wanted to disburthen themselves at once of their putridity by an immoderate effort (Hecker, Epidemics of the Middle Ages, p. 260-1.) An unpleasant and peculiar smell is given off from the slcln in typhus fever after the first week, which exhalation Murchison is inclined to believe to be a chief vehicle for the transmission of the typhus poison, and with which some fever nurses are so familiar as to be able to distinguish typhus from typhoid fever by the smell alone. This smell was noticed three centuries ago by Salius Diversus ; it has been frequently alluded to by subsequent writers, by whom it has been compared to the "odour of rotten straw," or to " the disagree- able affecting scent from a person labouring under the confluent small-pox," to the smell given off by deer, or by rubbing the leaves of rue between the fingers, and to the smell of mice (Murehison on Fever, p. 134). Whenever perspiration, sensible or insensible, occurs during the active dissolution of the morphotic constituents of the body, it bears more or less the odour of the putreseenc~e which is going on internally, thus during electrlzation of a limb affected with spontaneous gangrene, a fetid perspiration has been observed over the electrified part (Gaz. Hebdom. Jan. 28, 1859). The extreme fetor of the sweat in the sweating sickness may also be thus explained, as in that disease decomposition was most rapid, and the cadaveric odour so intense that the bodies of its victims had to be buried in graves unusually deep (Hecker, op. cir., p. 262, note). Dr. Donovan writing of the effects of the famine of 1846-7, among the peasantry of Skibbereen, describes the skin as exhaling a peculiar and offensive fetor, and being covered with a brownish filthy-looking coating, almost as indelible as varnish, which he was at first inclined to regard as incrusted filth, but which further experience convinced him was a secretion poured out from the exhalants on the surface of the body, (Dub. Med. Press. Feb. 2nd.,

Murchlson also remarks that other observers have 1848, p. 67). " ' noticed that during starvation the body exhales a putrid odour, not unlike that of a corpse, and that after death putrefaction is immediate and rapid. Among other examples of odorous perspira- tion depending upon constitutional causes, and indicating serious disease, are the sour-smelling sweats of rheumatic fever, and the amoniacal perspiration, of the face especially, in disorganization of the kidney. The fetid secretion from the skin which attends

On Bromidrosis or Fetid Perspiration. By DR. FooT. 331

eczema mercurlale, mucous tubercles (although the sweat of syphilitic people is said to smell sweet), and favus, is not solely due to perspiration, as the skin is in such cases more or less broken, but to the fluids formed on the surface of superficial ulcerations.

The third group of cases in which the cause of the ill odour of the perspiration is obscure or unknown are of great importance~ because an individual who is affected with fetid perspiration, while suffering from no actual bodily disease, is tormented by an infirmity which, in many cases, makes him so unpleasant to society that he lives in practical banishment. In these cases the fetid secretion is more usually confined to certain regions of the body, so that the term bromidrosis localis has been given to this form of odorous perspiration. This complaint usually affects adults of fair com- plexion and sanguineous temperament, more usually of the female than of the male sex; it is chronic and rebellious to treatment, not necessarily accompanied by profuse secretion from the skin, nor obviously, connected with any particular kind of food or special state of health, excepting sometimes with deranged menstruation. In many cases the most strict attention to cleanliness and the greatest care of the skin seem to have little influence upon it. In women it is said to be cured permanently by marriage. I t was well known by the ancients; and to this complaint Paulus Eglneta referred in his prescriptions "fbr fetid smell and sweating at the armpits" (Book III. , Sec. XXXVI . ) . The Greek physicians considered that an indulgence in figs was one of its causes; Eustatius, the commentator on Homer, makes mention of two sophists, called Anchimolus and Mochus, who lived solely upon figs for food, and water for drink ; he adds that their perspiration was so fetid that when in the bath everybody shunned them (Ad Iliad, XIII . , 6). The parts of the body generally the seats of bromi- drosls localis are the axillm, the pubes, perlneum, and feet; it may occur about the f~et alone and not elsewhere, and though nearly always partial may affect the entire cutaneous surface. The parts usually affected with fetid perspiration have some conditions in common which throw light upon its pathology and indicate treatment; they are parts in which the sudoriparous glands are numerous and large, where the temperature is continually high, where the secretion of the skin is confined and evaporation pre- vented, and, with the exception of the feet, where the presence of hair follicles involves the presence of sebaceous glands. There are reasons for believing that the sebaceous glands play an important

332 On Bromidrosis or Fetid Perspiration. By DR, Foo t .

part in the production of this smell, one of which is that where they are absent, as on the palm of the hand, fetid perspiration is not observed, notwithstanding the common occurrence of profuse swcatings from that part of the body, upon which, according to Krause, the sweat glands are more numerous than anywhere else. His calculations give from 400 to 500 glands on a square inch of the skin upon the dorsal surface of the trunk, on the cheeks, and the first two segments of the lower extremities; 924 to 1,090 on the anterior aspect of the trunk and neck, on the forehead, the fore-arm, and on the back of the hand and foot; 2,685 on the sole of the foot, and on the palm of the hand 2,736 (KSlliker, Man. Micros. A nat., p. 125). Another cause for the freedom of the hands from this complaint is thai evaporation from them is un- impeded. The confinement of the secretion of the skin by boots, shoes, and other coverings for the feet is the real cause of its ill odour in that quarter. Hebra remarks that persons who go bare- foot or wear but a light covering for the feet, and change it often, will have little trouble from "fetid foot-sweat," and that hence this seldom occurs in the female sex, although the perspiration is more copious in women. The odour in bromidrosis localls seems fre- quently due to a local decomposition of the perspiration, or of the united secretions of the sudoriparous and sebaceous glands on the surface of the body, the predisposing cause of the decomposition being some primarily unhealthy state of the blood, and the actually exciting cause retention of secretion in places where the temperature is high. Those who regard the sebaceous glands and their secretion as most at fault explain the immunity of the hands from fetid perspiration by the total absence of these glands in those parts, whereas they are large and numerous in the axilla and about the pubes and perineum, where developed contemporaneously with the hair follicles, they are constantly secreting a colourless fat, semi- fluid at the temperature of the body, designed to prevent .chafing and maceration of the skin in those parts of the body. While the ordinary sweat glands contain a clear transparent fluid, without structural constituents, those of the axilla, whose tubes also possess muscular walls, are rich with cells containing fat and protein, so different from the contents of the others that K(illiker is inclined to exclude the axillary sweat glands from the class of sudoriparous glands, and to regard their secretion as peculiar (op. cit., p. 127). Horner also considers these large axillary glands to be specially concerned in the elimination of the odoriferous secretion of that

On Bromidrosls or Fetid Perspiration. By DR. FOOT. 333

region, and is confirmed in his opinion by ~inding them of re- markable size in this situation in the negro. I t has frequently been observed that light-halred persons of either sex, but especially women, are more subject to fetid perspiration than those of a darker type; and in connexion with this circumstance the remark of Hecker is interesting: that those nations were visited by the sweating fever which are characterized by a fair skin, blue eyes, and light hair--the marks of the German race; he considered himself entitled to assume that these peculiarities in the structure of the bodies of the northern nations rendered them susceptible of the disease of which he was the historian, that they caused a proneness to fluxes of all kinds, and made sweating diseases endemic in the north of Europe, while the dark-haired southern nations, and the blacks in topical climates, remain, under similar circumstances, more free from them. Yet there are dark-haired persons who suffer from fetid perspiration almost to the same degree as do the light-haired; and the axillary odour of the negro is strong and distinctive.

The treatment of fetid perspiration, when not due to the use of food or medicines, known to affect the secretion of the skin in this peculiar manner, should be both internal and external. The sudden arrest of the secretion of the skin, which is sometimes the consequence of violent measures to check bromidrosis, has been followed by neuralgia and other constitutional disturbances, whence the com- plaint was formerly regarded as an endeavour on the part of nature to eliminate, per cutem, a materia peceans with whose excretion no therapeutical interference was allowable. Like fetor of the breath, it can sometimes be traced to derangement of the stomach and digestion, which having been remedied, perspiration will return to its natural condition, but the causes being generally subtle and various the treatment will differ with each individual case. Among the remedies most successful is arsenic, highly spoken of by Milton, who also recommends that, in the oldest cases, the hair of the arm-pits should be cut short or pulled out, and these parts, with the folds of the groins and the feet, to be washed every day with soap and hot water, and then dusted, after being dried, with rlce powder; if any smell remains after this, the free use of chloride of zinc or permanganate of potash in lotion should be resorted to. Small pads stuffed with animM charcoal and secured in the arm-pit absorb and deodorize the secretions of this region; and arrangements of the inner clothing, adapted to the exigencies

334 On Bromidrosis or Fetid Perspiration. By DR. FOOT.

of the case, should be made with the view of facilitating evaporation, as the more confined the perspiration the more concentrated and powerful is the odour. M. Stanislaus Martin (Bull. de T]~erap., T. 65, p. 143) has contrived a mode of applying charcoal as a local deodorizer in fetid perspiration of the feet. A paste composed of forty parts of powdered charcoal, forty of water, and fifteen of gum should be thickly spread over a peice of filtering paper, flannel, or felt, stretched over a board or pasteboard ; the paste is then covered over with another piece of paper, which is to be smoothed with the hand so as to remove all asperities; the whole is submitted to com- pression during an hour, after which the water is to be allowed to evaporate; when quite dry the sole may be cut out of the required size; the soles, being inexpensive, can be changed once or twice a day if necessary. Gaffard, of Aurillac, recommends the use of a lotion composed of fifteen grains of red oxide of lead and seven and one-half drachms of solution of acetate of lead; his directions are, to pound the oxide of lead in a porcelain mortar, add the acetate by degrees, and keep in a phial, and to shake the bottle whenever the remedy is used. In most cases it is sufficient to apply a few drops once a week to the parts affected. I t will be seen that in three of the prescriptions for this complaint, given by Paulus Egineta, preparations of lead were used:----R. 1. Of liquid alum, two parts; of myrrh, one part--dissolve in wine, and use. ]~. "2. Plunge heated molybdena (oxide of lead) into fragrant wine, triturate with the wine, adding a little myrrh until it becomes of the thickness of the sordes in baths ; then use. ]~. 3. Of litharge, dr. xv. ; of myrrh, dr. iii. ; of ammom (cardamoms), dr. i.--mix with wine. R. 4. Of liquid alum, dr. viii. ; of ammom, of myrrh, and of spikenard--of each, dr. iv. ; triturate with wine, and use. The commentator remarks: all the authorities concur in recommending for the cure of this complaiht a combination of astringents and aromatics; they, therefore, direct us to mix alum with storax, myrrh, and the like (Paul. Eg., Book 3, Sect., X X X V I . ) . To render the perspiration fragrant was one of the toilet duties of the upper classes in Greece; it was generally done by the use of an ointment, in which were mixed the leaves of the cypress pounded dry, and the bark of the pine. That the breath also might be very agreeable, Paulus Egineta says :--" One ought also to remem- ber, in the morning, immediately after being dressed, to taste a small quantity of cassia or savin."