Further Observations and Discussions in Europe and Overseas

The disease described by Verneuil first received very little attention from dermatologists except from Bazin (Paris) who coined a syphilid under the name "hydradenite syphilitique" [8]. Bazin was actually convinced that this type of syphilid had its seat in the sweat glands. Therefore, he regarded the disease described by Verneuil as of possible syphilitic origin and pointed out that there is no need to make any differential diagnosis between gommous syphilid and hidra-denitis suppurativa.

In Vienna, Hebra denied the existence of sudoral tumors considering that, "up to the present time, the sudoriparous glands have not been shown to be subject of any structural affections" [9]. A few years later, Kaposi, Hebra's successor, did not admit the disease as a distinct affection either: "talking about hidradenitis that does not exist as a separate affection seems superfluous"

[10]. However, the translators of Kaposi's textbook into French, Besnier and Doyon, although admiring the master of Vienna, did not confirm the Austrian opinion. Although they admit the uncertainties on the histopathological aspects of the sweat glands, Besnier and Doyon insisted on the true existence of the dermal abscesses in the axillary area, which, according to them, represent the most perfect type of the hidrosadeni-tis described by Verneuil.

In London, Erasmus Wilson [11], a leading light in British dermatology, summarized Ver-neuil's description and indicated that the tumors, "differ from boils in their deep origin, in the absence of elevation and pointing and also in the absence of core." Wilson considered the affection as caused by external irritation of the skin from neglect of cleanliness, friction, and sweating. At the same time, Radcliffe Crocker described hidradenitis briefly as a type of furunculosis that begins in the sweat coil [12].

Probably the first histopathological study of hidrosadenitis was published in 1889 by Giovan-nini, who demonstrated the existence of an inflammatory process borne in the sudoral glands that led to their complete destruction [13].

However, despite this publication which seemed to demonstrate the origin of hidrosade-nitis, the existence of the disease described by Verneuil was highly questioned until the 1890s. In fact most authors denied it as a separate entity.

From the 1890s on the disease seemed to come into a new era of existence.

In Paris, Barthélémy authored a comprehensive study on the subject. He regarded hidrade-nitis as a part of the folliculitis that could be generalized or localized in the axillary, labia major or perianal areas. In Barthélémy's article, hidradenitis described by Verneuil disappears and is encompassed in a new nosological framework that includes acnitis and folliclis, terms coined by the author to designate follicular and perifollicular inflammation of unknown origin [14].

At the same time Pollitzer and Dubreuilh [7] (Bordeaux) independently described what they believed to be abscesses of the sweat glands.

In the North American medical literature, the disease described by Verneuil was not men tioned until Pollitzer (New York) [15] pointed out the fact that "the disease was in danger of being dropped from our dermatological nosology and even in Paris the affection was so forgotten that in a recent conspicuous example it was not diagnosed," alluding to the cases observed by Barthélémy (Paris) in Saint-Louis Hospital. Pollitzer regarded the observations made by Barthélémy as descriptions that coincided in every detail with Verneuil's first observations.

Pollitzer - who regarded Verneuil's description as "the admirable style of the French clinician" - added that the lesions could occur most commonly in the axilla, anus, nipple, scrotum, and labia majora. He insisted on the inflammation of the sweat glands (hidradenitis) as being the most characteristic pathological feature, "the complete destruction of the affected gland (destruens)."

Dubreuilh indicated that the lesions had their origin in the sweat coil and emphasized the fact that even the authors who considered hidrade-nitis as a disease of the pilosebaceous follicle did not dare to deny any responsibility to the sudoral glands. Dubreuilh rejected the terms folliclis and acnitis and preferred to keep hidrosadeni-tis, which, he said, attested to a pathological reality.

In 1902, Tórók (Budapest) had "the impression that the pathological process is located chiefly in that layer of the skin which encloses the glomeruli of the sweat gland" [16].

In fact the description of the apocrine sweat glands in 1921 [17] established the relationship between this type of sweat gland and the peculiar localization of the disease.

In the 1920s several papers were published in the North American medical literature that emphasized the existence of hidradenitis and its connection to the sweat glands.

On 27 September 1928, Cole and Driver presented at the Cleveland Dermatological Society the case of a "negro boy aged 3 who showed a peculiar folded and thickened axillary skin with small suppurating lesions in various stages." No discussion followed [18].

A few years later, on 20 December 1935, Cor-son presented at the Philadelphia Dermatologi-cal Society [19] the case of a woman aged 22 who presented in the axilla inflamed swelling, discharged sinuses, and scars. The condition had started 6 months beforehand. Corson regarded this case as a typical picture of involvement of sweat glands by pyogenic organisms. Knowles underlined the fact that these cases occurred mostly in women. During the discussion, the participants considered this observation to be the counterpart of the picture presented previously, with similar lesions in both axillae. This case was first thought to be bilateral tuberculosis but inoculations failed to support this hypothesis. Finally the observation was considered to be an infection due to some type of acid-fast organism probably involving the sweat glands.

In 1933 Lane, authoring a résumé of foreign literature, observed that "the disease is not uncommon and it presents a definite clinical picture but it is apparently not very well known probably because it is hardly mentioned in most works on surgery in the English language and it is not mentioned or is only briefly described in many textbooks on dermatology" [20].

Brunsting, presenting complementary descriptions of hidradenitis at the annual session of the American Medical Association [21], regretted that dermatology textbooks paid so little attention to the disease. He described its clinical appearance, insisted on the fact that the disease is characterized by its localization on cutaneous surfaces in which the apocrine type of sweat glands are situated, and emphasized the importance of a surgical treatment in the early forms of the disorder.

A few years later, Brunsting, reviewing the subject at the 71st Annual Meeting of the American Dermatological Association, indicated that hidradenitis, acne conglobata and dissecting cellulitis of the scalp should be considered as "regional counterparts in which the acne process is manifested in its variants and in its more fulminating forms" [22]. He emphasized the fact that these diseases have so much in common that a description of one disorder well fits another: the presence of comedones is common in the three diseases and in fact he endeavored to underline the common clinical and etiologi-cal factors of the disorders, namely the acne process. However, many attendees of the meeting denied Brunsting's attempt to group acne

conglobata, dissecting cellulitis of the scalp and hidradenitis.

In fact for the North American School of Dermatology, Verneuil's hidradenitis truly existed as a disease of the apocrine sudoral glands.

Shelley and Cahn's experimental work [23] supported this view. The authors applied a perforated belladonna adhesive tape to one axilla of 12 adults between 20 and 40 years old. In every subject, apocrine anhidrosis developed in taped areas. Three of the twelve subjects developed clinical hidradenitis suppurativa, presenting deep, small, and tender nodules located at the tape site. The biopsy specimens revealed kerati-nous plugging of the apocrine sweat ducts, dilatation of the duct, and severe inflammation limited to a single apocrine sweat gland unit. The authors also noticed that adjacent glands were entirely normal with respect to the hair follicles, the sebaceous glands, and deeper eccrine glands. They concluded from this study that the nodules clinically observed were simply an inflammatory change which had singled out the apo-crine glands and that hidradenitis suppurativa appeared to be a bacterial infection of an obstructed apocrine sweat gland.

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