CLINICAL CALORIMETRY.

XL. THE EFFECT OF THE ABSENCE OF SWEAT GLANDS ON THE ELIMINATION OF WATER FROM THE SKIN AND LUNGS.

BY HENRY B. RICHARDSON.

WITH THE TECHNICAL ASSISTANCE OF G. F. SODERSTROM.

(From the Russell Sage Institute of Pathology in Ajiliation with the Second Medical (Cornell) Division of Bellevue Hospital, New York.)

(Received for publication, December 8, 1925.)

INTRODUCTION.

The rare condition known as congenital ectodermal defect, in which the sweat glands are totally absent, gives opportunity to study the excretion of water by these glands as distinguished from the epithelium of the skin. The patient to be described, Chas. R., was studied both at rest and during exercise, by means of the respiration calorimeter of the Russell Sage Institute of Pathology. The effect of external heat was also noted, as well as the partition of water elimination between skin and lungs. Opportunity to observe this patient was given through the courtesy of Dr. George M. MacKee.

LITERATURE.

Du Bois (1) has discussed the vaporization of water and a review of the literature on this subject may be found in Paper XXV of this series (2). The observations on congenital ectodermal defect have been summarized in the paper by MacKee and Andrews (3), which includes a summary of our calorimeter findings. Additional reference need be made here only to the work of Loewy and Wechselmann (4), who made an exhaustive study of three patients, with observations on the excretion of water through the skin. They found that these individuals, though devoid of sweat glands, were able to give off a normal quantity of water vapor from the skin under ordinary resting conditions, but not when either the heat production or the external temperature was raised. Corresponding to this inability to meet changed conditions, an undue elevation of the body temperature was ob- served. Evidence of a compensatory mechanism was found in the increased volume of respiration observed under the influence of direct heat.

397

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398 Clinical Calorimetry. XL

Case History.

The detailed history and physical findings will be found in the paper of MacKee and Andrews (3). The patient, Chas. R., schoolboy, was born on Sept. 5, 1908, and was admitted to the metabolism ward on Dec. 28, 1922. He was therefore 14 years of age when under observation. His weight was 45.5 kilos and his height 160.9 cm. He complained that he could not play in the summer time because if he did so he became hot and had to stop, though he had no difficulty so long as he remained still. As might be ex- pected, he was not affected by damp or muggy weather, but only by the increased temperature of the air. He made a practice of wetting his shirt on hot days and was thereby enabled to exercise with less discomfort. The physical examination showed the findings and appearance characteris- tic of congenital ectodermal defect, and three sections of the skin, taken by MacKee and Andrews (3), one from the extensor surface of the left forearm and two from the left cheek, showed no trace of sweat glands. In spite of this the skin felt normal as to moisture.

Preliminary Remarks.

The total heat produced by an individual, as measured in the calorimeter by the direct method (5), comprises three parts. The first is given off by radiation and conduction, and is removed from the calorimeter by means of a radiator through which runs a current of cool water. A small correction for change in temperature of the walls of the calorimeter is required. The second portion is lost by evaporation of water from the skin and lungs, and for every gm. of water vaporized at 20°C. 0.586 calo- ries are removed (6). For slightly higher temperatures the figure is 0.584.l The sum of the heat of radiation and conduction, plus that of vaporization, constitutes the heat eliminated. When the total heat production is to be ascertained a third factor must be introduced, the correction for the change in body temperature. This change, multiplied by the weight of the body and by its specific heat, gives the calories stored in or lost from the body. The specific heat is assumed to be 0.83.

Method.

By means of the calorimeter, the entire metabolism could be studied, including the respiratory exchange, the direct heat, and

1 When a subject is exposed to hot air the cooling effect produced by evaporating a gm. of water is less than 0.584 but the difference is negligible for our purposes.

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H. B. Richardson 399

the elimination of water from the skin and lungs. The method has the further advantage that the whole body could be included, instead of only one leg, as in the work of Loewy and Wechselmann (4). The usual technique of the calorimeter was employed (5) and the accuracy can be judged by the alcohol checks of the year, as published in Papers XXX111 (7) and XXXIV (8) of this series. The latter shows an average error in the water determination in 3 hour periods of plus 5.6 per cent, the varia- tions being from plus 2.2 per cent to plus 8.6 per cent. The error in the heat measured varied from -2.0 per cent to plus 5.2 per cent and averaged plus 0.3 per cent. Another check on the accuracy of the apparatus is the comparison of the heat measured directly with that calculated from the respiratory exchange. Using the latter as a standard, we have found, as may be calculated from Table I, that with Chas. R. at rest the direct heat was 6.6 per cent too low, and in the second observation for the effect of exercise, 3.4 per cent too low. With the control, E. F. D. B., the direct heat was 2.3 per cent less than the indirect. It will be seen from Columns 11 and 9 of Table I that the heat, directly measured, was consistently lower than that calculated from the respiratory exchange, and nearly parallel to it.

Both subjects were studied at rest and during exercise, the latter consisting of voluntary movements in imitation of shivering. The temperature of the calorimeter was kept between 24 and 25°C. The latent heat of water vaporized by the subject was considered to be 0.584 calories per gm. In one experiment the vapor from the lungs was measured by passing the expired air by means of a gas mask through a container one-third full of pumice stone saturated with concentrated sulfuric acid. The vessel employed was the ordinary water absorber used for the calorimeter. The increase in weight of the absorber gave the quantity of water vapor expired.

For the study of the effect of external heat an apparatus de- signed by Mr. 0. Newhouse was used, for a description of which the paper of Benedict, Benedict, and Du Bois (10) may be con- sulted. By means of this device a current of hot dry air could be delivered at the rate of about 500 liters a minute, to a bag in which the patient lay. This bag was made of cloth treated with oil, and was tied around the patient’s neck, with no attempt

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402 Clinical Calorimetry. XL

at an air-tight joint. Part of the air escaped here but most of it through an opening provided for the purpose. The quantity of water eliminated from the skin and lungs combined was de- termined by weighing the patient before and after on a scale which was sensitive to 10 gm. The change in weight due to the gaseous exchange was neglected, since it came within the error of the scale. Rough though this method may seem, it sufficed to show a marked difference between patient and control.

Results.

The calorimeter data are shown in Table I. The observation on the patient Chas. R. at rest on January 2, 1923, gave the same results as with the control E. F. D. B. during the 1st hour of the observation on May 10, 1922. The former eliminated from skin and lungs in 3 hours an average of 31.1 gm. of water vapor, a quantity which in evaporating would cool the body 18.2 calories, or 28 per cent of the total of 65.2 calories as measured by the direct method. In the control observation 17.3 calories were given off as water vapor out of a total of 66, or 26 per cent. The average for normal individuals is 24 per cent (2).

In the second observation dated January 4, 1923, the patient rested an hour in the calorimeter, and then in the second period, which lasted only 35 minutes, he performed exercise for 203 minutes. This consisted of movements in imitation of shivering. There followed two resting periods of 4 and 1 hour respectively. For comparison we used the normal data obtained from a previous observation of E. F. D. B., who performed the same type of exercise for a similar period. This subject had a height of 178.5 cm., a weight of 78.0 kilos, and a surface of 1.97 sq. meters, ac- cording to the formula of Du Bois and Du Bois (II), or con- siderably more than the 1.46 sq. meter surface of the patient. In order, therefore, to make the figures comparable, they have been divided through by the respective surface areas and ex- pressed in quantities per hour. These may be found in Table II and Fig. 1. The work performed was similar, being 100 calories for the patient as compared to a basal of 39.7, and 88.6 for the control, as compared to a basal of 33.7.

Much the most striking feature of the exercise is the similarity of the curves of the two individuals. Certain differences, however,

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H. 13. Richardson 403

can be detected. In the absence of sweat glands, as shown on the left of the graph, the elimination of water remained at much the same level throughout, whereas with the normal control it rose during exercise from 8.8 to 19.5 calories. There is a dif- ference of 6.5 calories per hour in favor of this individual in the 125 minutes beginning with the exercise period. This may be expressed in another way by means of the percentage of total

TABLE II.

Effect of Exercise in Absence of Sweat Glands in Terms of Calories per Sq. Meter per Hour.

%E’

(1)

Chas. R. Jan. 3, 1923

E. F. D. B. May 10, 1922

(2) (3) (4) (5) (6) ----

“C.

Prelimi- 38.X nary.

I 32.312.344.637.9: II 52.717.370.038.6:

III 39.214.453.638.5: IV 40.513.954.438.B

--

Prelimi- 36.6! nary.

I 27.7 8.836.536.6: II 46.319.565.837.0:

III 33.5 18.752.236.9! IV 31.613.945.536.81

Congenital ab- sence of sweat glands.

-5.0 39.7 Rest. i-29.9 100.0 Exercise. -7.6 46.0 Rest. -8.6 45.8 “ ~-

Normal con- trol.

-2.8 33.7 Rest. k22.8 88.6 Exercise. -2.3 49.9 Rest. -6.1 39.4 “

All of the data have been converted into calories and divided by the body surface to give the results in calories per sq. meter per hour.

heat given off as water vapor. This was 22 per cent during the exercise, and 37 in the period following, the figures for the patient being 17 and 30 respectively. Except for this faulty elimination of water vapor, no difference between the two individuals was noted. The curves showing the heat lost by radiation and conduc- tion are practically identical, though at different levels. No evidence was found that the patient could compensate, by means

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404 Clinical Calorimetry. XL

of increased peripheral circulation, for the defective elimination of water vapor. As a result of the latter the heat eliminated was somewhat less in proportion to the total than was the case

-PATI [NT- -CONT ROk- I

C” 3B0--

I

PEROID I II III IT I II m IY

FIG. 1. All the data (except the body temperature) have been converted into calories and divided by the respective body surfaces to give results in calories per sq. meter per hour. Curve 1, body temperature by rectum. Curve 2, total heat production. Curve 3, heat eliminated. Curve 4, heat lost by radiation and conduction. Curve 5, water vaporized.

The patient without sweat glands is shown on the left and the normal individual on the right.

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H. B. Richardson 405

with the control, and the body temperature rose 0.68 degrees, as against 0.41. This fact may be expressed in another way by saying that the storage of heat was greater, 30 instead of 23 calories.

It is evident, therefore, that the patient was able to eliminate enough water through the skin and lungs to maintain body temperature within safe limits, even though his metabolism increased 250 per cent. The results demonstrate how efficiently the normal needs of the organism were cared for without aid from the sweat glands. The only difference noted was a moderate deficiency in the elimination of water vapor, accompanied by a greater increase of body temperature than in the normal individual.

The above results deal entirely with the water vapor elimi- nated by skin and lungs combined. It was of interest to find out the quantity given off by the skin alone, and this was done by measuring the water given off in the breath by the patient when at rest. The protocol and the calculations follow.

January 8, 1923, Chas. R. Water vaporized from lungs. Gas mask attached to rubber tubing and thereby to sulfuric acid bottle one-third full of pumice stone saturated with sulfuric acid.

Period I. Weight of bottle at end. . . . . 14:?39

“ ‘I “ “ start. . . . . . 1435.77

Gain................................ 1.62

Period II. Nose clip applied. Weight of bottle at end. . . . . . . . 1439.64

“ “ “ “ start. . . . . . . 1437.39

Gain . . . . . . . 2.25 Relative humidity, 50 per cent. Temperature, 25°C.

Period III. Weight of bottle at end. . . . . 1441.57

“ “ “ “ start . . . . . . 1439.64

1.93 Period IV. Mouthpiece in.

Weight of bottle at end.. . . . . . . . . . . _ 1443.74 “ “ “ “ start.............. 1441.57

2.17 7.97 in 40 min. = 12.0 per hr.

3.38 p.m. 3.28 “

10 min.

3.55 p.m. 3.45 “

IO min.

4.12 p.m. 4.02 “

10 min.

4.28 p.m. 4.18 “

10 min.

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406 Clinical Calorimetry. XL

Thus 7.97 gm. of water vapor were given off in 40 minutes or 12.0 gm. per hour. In a subsequent test this apparatus was found to allow 0.34 gm. to pass through per hour, therefore the total output was 12.3 gm. A deduction must be made for the intake of vapor, the quantity of which may be calculated from the relative humidity (50 per cent) and the temperature of the inspired air (25”C.), provided the minute volume of respiration is known. The latter may be estimated from the output of carbon dioxide (22.8 gm. per hour) and the proportion of this gas normally present in the expired air under basal conditions, i.e. not more than 5 per cent, according to the figures published by McCann and Hannon (12). On this basis the maximum net output of water from the respiratory tract of our patient was 9.3 gm. Reference to Table I, Column 7, shows an average elimination of 31.1 gm. of water vapor from all sources, and of this not more than 30 per cent came from the respiratory passages, and the rest from the external surface of the body. It is evi- dent that even in the absence of sweat glands a large amount of water is eliminated from the skin.

The effect of external heat was studied by means of the hot air bag above described. The output of water vapor was measured by the loss of body weight. The temperature of the body was taken by mouth. The protocols follow.

Protocol I.

Chas. R. Jan. 3, 1923. Congenital absence of sweat glands. 10.00 a.m. Voided urine. 10.03 “ Body weight, 46.41 kilos. 10.08 “ Hot air connected with bag. 10.12 “ Mouth temperature, 37.5”C. 10.26 “ Mouth temperature, 37.6”C. Temperature at outlet of bag,

48.O”C. 10.30 “ Temperature at outlet of bag, 48.8”C. 10.35 “ Mouth temperature, 38.0%. Pulse, 88. Temperature at out-

let of bag, 48.8”C. 10.42 “ Mouth temperature, 38.4”C. Pulse, 102. Temperature at, out-

let of bag, 49.2”C. Jays that he feels hot now. 10.44 “ Body weight, 46.39 kilos.

a&?. Weight at start.. . . . . 46.41

“ “ end . . . . . . 46.39 --

Loss, . . . . . . . . . .0.02 kg. = 33 gm. per hr. fl6.

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H. B. Richardson 407

After removal from the bag the body temperature rose to 39°C. at 10.50 a.m. and declined gradually, reaching 37.O”C. only after about 4 hours, i.e. 3 p.m.

Protocol II.

H. B. R. Jan. 3,1923. Normal individual. Height, 180 cm. Surface, 1.90 sq. m. Age 34.

11.34 a.m. Voided. 11.35 “ Weight, 70.67 kilos. 11.39 “ Mouth temperature, 37.O”C. 11.40 “ Ventilation of bag with hot air started. 11.43 “ Pulse, 62. 11.45 “ Temperature at outlet of bag, 43.3”C. 11.50 “ Temperature at outlet of bag, 45.3”C. to 44.2”C. 11.55 “ Mouth temperature, 37.0%. 12.05 p.m. Mouth temperature, 36.8”C. Temperature at outlet of bag,

50.572. to 48.372. kg.

Weight after voiding. 70.48 Urine voided. . . . . . . 0.05

Weight at end. . . . . . 70.53 “ “ start.. . . 70.67 “ “ end.. . . . . 70.53

Loss,. . . . . . .0.14 kg. in 25 min. = 336 gm. per hr. f16 gm.

The elimination of water by the normal subject was near the average observed by Benedict, Benedict, and Du Bois (10). It may be of interest. to calculate how much of the evaporation of water represented elimination of heat by this individual, and how much went to cool the air in the bag. The subject, male, age 34, had a surface of 1.90 sq. meters, an estimated metabolism of 39.5 calories per sq. meter hour, or a total of 75.0 calories to which need be added not more than 10 per cent (10) for the effect of the heat,, or 82 calories in all. Since only the head of the subject was exposed to a lower temperature than that of the body, the bulk of the heat was eliminated by the evaporation of water. Even if all of it were so eliminated, only 82 calories would be accounted for out of a total of 197 calories estimated from the loss of water vapor. The remaining 115 calories served to cool the surrounding medium. It is obvious, therefore, that the elimination of water vapor cannot be used in calculating the total metabolism when the surrounding air exceeds the tem- perature of the body.

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408 Clinical Calorimetry. XL

These experiments bring out the functional defect even more clearly. The normal individual, H. B. R., was able to tolerate air at a temperature of 49” as measured at the outlet of the bag, and this with an actual decrease in the mouth temperature from 37.0 to 36.8”C. In so doing he lost in 25 minutes 140 gm. of water from the skin and lungs, or 336 gm. per hour, equivalent to 196 calories. Chas. R., exposed to similar temperature, sus- tained a rise in mouth temperature from 37.5 to 38.4”C. in 34 minutes, at the end of which period he had lost only 20 gm. in weight. It will be seen from Table I, Column 7, that in the calorimeter at rest he gave off 31.1 gm. of water in an hour, thus showing that comparable quantities were eliminated under the two conditions. The 33 gm. per hour eliminated in the bag corresponded to only 19 calories as compared to 196 in the normal.

In another experiment, the patient entered the bag partially dressed and was given a sprinkler with which to wet his under- clothing. Sprinkling was not begun for 30 minutes after the beginning of exposure to heat, during which time his temperature rose from 36.9 to 37.3”C. With the sprinkling the rise continued somewhat, but reached a maximum of 37.8%. in another 18 min- utes, maintained this level for 21 minutes, and slowly declined to 37.6 at the termination of the experiment 27 minutes later. Thus it was demonstrated that the sprinkler functioned as an artificial sweat gland, and though clumsy compared to the nor- mal apparatus, was quite capable of arresting the rise in tem- perature.

DISCUSSION.

The elimination of water vapor by an individual without sweat glands was found to be normal at rest. Of the total heat produced, 28 per cent was eliminated in the form of water vapor, or very close to the normal average of 24 per cent found by Soder- Strom and Du Bois (2). Less than 30 per cent of the vapor came from the lungs, and the remainder from the skin. The results confirm the observation of Loewy and Wechselmann (4) that vapor can be given off from the normal surface of the body without the aid of the sweat glands. The process is probably one of physical diffusion, although active excretion of water by the epithelium of the skin is conceivable. Whatever the

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H. B. Richardson

mechanism, sufficient heat was given off in this manner, in com- bination with other channels, to keep the body temperature within safe limits, in spite of exercise sufficient to raise the metabolism 250 per cent. Here again approximately normal conditions were maintained independent of the sweat glands.

The effect of exercise, though slight, could nevertheless be demonstrated. Considerably less heat than normal was given off in the form of water vapor, and no compensatory increase in radiation and conduction could be detected. As a result the body temperature rose somewhat higher than in a normal indi- vidual. That the patient tolerated the exercise as well as he did was due to the relatively low temperature of the air in the calo- rimeter (24’C.) which permitted the removal of a large amount of heat by radiation and conduction. If the air had been warmer than the body, heat would have radiated inward instead of outward. A rise of body temperature under these conditions has been noted by Linser and Schmid (13) and by Loewy and Wechselmann (4) who attributed their results to inadequate vaporization of water.

That this explanation is correct was shown by the quantity of water vapor eliminated by our patient in hot air. The amount lost from skin and lungs remained essentially the same as at 24°C. and the temperature of the body rose 0.9”C. in 30 minutes.

That the relation between these two findings was causal was shown by the fact that the rise of temperature could be arrested by sprinkling water on the skin. The normal individual sustained no rise of temperature, because of copious elimination of water vapor. The cooling effect of this amounted to 196 calories per hour, part serving to remove heat from the body, and the rest to cool the surrounding air.

The inference is that in normal individuals under ordinary resting conditions the liberation of water vapor likewise takes place without the medium of the sweat glands. This conclusion was reached by von Willebrand (14) and confirmed by Loewy and Wechselmann (4) who found with normal individuals that if either the heat production or the surrounding temperature was raised, there occurred at a certain point a sharp rise in the elimination of water, followed shortly by an outbreak of visible sweat. This may be considered evidence of the onset of activity

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410 Clinical Calorimetry. XL

of the sweat glands. In agreement with the foregoing, we may conclude that the sweat glands constitute an emergency apparatus which is called upon only under exceptional conditions.

SUMMARY AND CONCLUSIONS.

1. An individual in whom the absence of sweat glands had been demonstrated by microscopic examination was studied with reference to the elimination of heat and water vapor.

2. At rest a normal quantity of water vapor was liberated. Of this less than 30 per cent came from the lungs and the re- mainder from the skin. Vaporization of water from the skin independent of the sweat glands was thereby demonstrated.

3. The quantity of water so eliminated was sufficient in com- bination with heat lost in other ways to keep the body tempera- ture within safe limits even with exercise which increased the metabolism for a period of 35 minutes to two and a half times the resting value.

4. During this exercise the elimination of water did not increase as in a normal individual and the body temperature rose somewhat higher.

5. With exposure to external heat there was no increase in quantity of water vaporized, and the body temperature rose sharply.

6. The study of this patient confirms the theory that the sweat glands constitute an emergency apparatus which is called upon only under exceptional conditions.

BIBLIOGRAPHY.

1. Du Bois, E. F., Basal metabolism in health and disease, Philadelphia and New York, 1924.

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Henry B. RichardsonWATER FROM THE SKIN AND LUNGS

GLANDS ON THE ELIMINATION OFEFFECT OF THE ABSENCE OF SWEAT CLINICAL CALORIMETRY: XL. THE

1926, 67:397-411.J. Biol. Chem. 

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