Dermatology

DERMATOLOGY (from the Greek derma - skin and logos - word, science), the science of skin diseases. Skin diseases have been known since ancient times. In Chinese medical literature, more than 2500 years before the Christian era, there are descriptions of scabies, leprosy, ichthyosis, and itch. In the so-called Leipzig Egyptian Ebers papyrus, from 1700 B.C., and the Berlin Brugsch, from 1350 B.C., mention is made of itching and scabies, as well as ointments, plasters, and compresses. In the book of Moses, 1500 years before the Christian era (Leviticus, chap. 13), there is a description of scabies, loss of pigment, loss of hair, and leprosy. In ancient Greece, Hippocrates described a large number of skin rashes: scabies (achor, kerion), loss of pigment (aephos), freckles (ephelis), itch (psora); he called tumors phymata, dry rashes - scaling (pityriasis* lepra, leichen), rashes with vesicles and blisters - phlyktaina, pompha, rashes with a tendency to peripheral growth - herpes. He saw the cause of many skin diseases in the corruption of humors (black bile, yellow bile, blood, and phlegm). The disappearance of the rash, in his opinion, can cause the transfer of the disease to internal organs; conversely, various secretions and discharges, for example hemorrhoidal, can cure some diseases. This is the so-called humoral theory, which held until the middle of the 19th century. It was later replaced by cellular pathology, but nevertheless in modified forms it has survived to our time. The outstanding physician of ancient Rome Celsus also described many skin diseases: furuncle, carbuncle, phlegmon, gangrene, acute condylomas, elephantiasis, vitiligo, sycosis, corn. These disease names are still used today. Circular loss of hair to this day bears his name - area Celsi. Galen (2nd century A.D.) drew attention to the connection of skin diseases with arthritic diseases - an idea that received wide development in the French dermatological school of the 19th century. Arab scientists (9th, 10th, 11th and 12th centuries A.D.) translated medical works of Greek and Latin authors into Arabic and themselves quite accurately described smallpox, measles, leprosy, elephantiasis, scabies, and itch. Avenzoar (1162) even speaks of the itch mite. In the 13th and 14th centuries in Europe, leprosy spread widely (significantly weakened by the 15th century), and at the end of the 15th century a strong epidemic of syphilis developed; nevertheless, doctors were also interested in other skin diseases. Thus, Hieronymus Mercurialis (Hieronimus Mercurialis) compiled a textbook on skin diseases (De morbis cutaneis; 1572); the same was done in German literature by Haffenreffer (Haffenreiferus; 1660), in French by Riolan (Riolan; 1610) and in English by Willis (Willis; 1682). In Riolan there are already the beginnings of a morphological classification of skin diseases; he divides all skin diseases into three classes: pustulae, difformitates and tuberculi. The end of the 17th century and the beginning of the 18th century are marked by the research of Malpighi, Morgagni, Boerhave on the finer anatomical structure of the skin. In honor of Malpighi, the layer of covering epithelium to this day bears his name. The textbooks of the end of the 18th century by Plenck and Lorry (Plenck, Lorry) are already much higher compared to those mentioned. Plenck (1776) accurately distinguishes the morphological elements of the rash: spot, papule, vesicle, blister, pustule, crust, and, using purely morphological data, divides all skin diseases into the following 14 classes: 1) maculae, 2) papulae, 3) vesiculae, 4) bullae, 5) pustulae, 6) crustae, 7) squamae, 8) callositates, 9) excruascentiae, 10) ulcera cutanea, 11) vulnera cutanea, 12) insecta cutanea, 13) morbi unguium, 14) morbi pilorum. Lorry (1777) draws attention to physiology, pathology, etiology, prognosis and therapy. He describes the skin not only as an outer covering, but also as a physiological organ standing in close connection with other organs. In the pathogenesis of skin diseases, he notes the influence of mental experiences, sexual activity, air and climate. He described skin diseases depending on food (toxidermias) and gave clear indications of rheumatism as a cause of skin diseases - an idea already expressed by Galen. Lorry adhered to the humoral theory first expressed by Hippocrates and believed that the skin glands secrete corrupted humors. Although many authors worked in the field of D. for many centuries, it still could not develop into a coherent science and remained a collection of facts and theories not connected by a unifying diagnostic principle. Only at the end of the 18th century (1798) the English physician Willan and his student Bateman widely spread the basic principles of diagnosis, already indicated by Plenck. All the extraordinary at first glance diversity of skin rashes Willan reduced to only 9 initial changes of the skin: 1) macula, 2) exanthema, 3) papula, 4) vesicula, 5) bulla, 6) pustula, 7) squama, 8) tuberculum, 9) excruascentia. Accordingly, all diseases were placed in 9 classes - a morphological classification. Thus, a common dermatological language was found, a kind of alphabet for reading the writings that appear on the skin in diseases. At the same time in France the dermatologist Alibert emerges. He remained alien to Willan's classification and built his classification of skin diseases in the form of a dermatological tree (arbre des dermatoses), in which the trunk represents the skin, the first branches - families, the second twigs - species, and the leaves - varieties of diseases. This classification, based on speculative principles, did not find acceptance. At the same time Alibert paid great attention to the connection of skin diseases with diseases of internal organs and proposed for the therapy of skin diseases the application of externally irritating agents. After Alibert came a large number of physicians of the Hospital of St. Louis, who created the French dermatological school. - Biet, a student of Alibert, was imbued with the teachings of Willan and from 1820 read a course in dermatology parallel to his teacher Alibert, but in a different direction. Lugol, a contemporary of Alibert and Biet, proposed the use of potassium iodide for scrofula; he also proposed for the treatment of syphilis the so-called Biet's mixture (see). Cazenave (Cazenave, 1795 - 1877), a student of Biet, attached great importance to temperaments, with the difference of which the same cause causes different diseases (thus, in persons with a nervous temperament it causes papular rash - lichen, prurigo; in persons with a lymphatic temperament - pustular rash - impetigo; in persons with a sanguine temperament - vesicular rash - eczema, etc.). Cazenave described pemphigus foliaceus and lupus erythematosus. In the lectures of Cazenave, published in 1853, skin diseases are divided into 8 classes; the division is based not on morphological, but on physiological, anatomical and pathological-anatomical data: 1) inflammations of the skin, 2) anomalies of secretion, 3) hypertrophies, 4) degenerations, 5) hemorrhages, 6) disorders of sensitivity, 7) parasites, 8) diseases of the skin appendages. - Gibert (Gibert, 1796-1866), another student of Biet, described the disease pityriasis rosea, which to this day bears his name. In the field of syphilidology, he proved by inoculations on humans the contagiousness of secondary manifestations of syphilis, contrary to the opinion of his famous contemporary syphilidologist Ricord. - Devergie (Devergie, from 1841) belongs to the description of a severe skin lesion - pityriasis rubra pilaris Devergie. - Rayer (Rayer, 1793-1867), also a student of Biet, compiled a textbook of skin diseases (1826-1827-1835), illustrated with an atlas, and gave an exact description of the different stages of eczema, often taken for different diseases. He attached great importance to the study of the connection of skin suffering with diseases of the blood, nervous system and other internal organs. His classification is also based not on morphology, but on anatomical and physiological data (inflammations, changes in secretion, neuroses, etc.). Bazen also paid great attention to the connection of skin diseases and internal organs, trying to study the whole organism of the patient and clarify the complete picture of all disorders in the body, among which skin diseases constitute only a part of the whole. All skin diseases depending on internal causes, Bazen distributed among four basic constitutional diseases: syphilis, scrofula, arthritis and herpes. Each of these diseases has four periods, of which the first is the mildest, and the last is the most severe and often fatal. In syphilis in the first period - primary sclerosis, in the second - condylomatous rash, in the third - gummas, in the fourth - lesions of internal organs. In scrofula in the first period - tumors of lymph glands, mild forms of eczema, inflammation of mucous membranes (eyes, bronchi, entrance to vagina), in the second period - lupus, in the third - tumor albus, in the fourth - tuberculosis of internal organs. In arthritis in the first period - bronchitis, mild and fleeting rashes, in the second - acute rheumatism of joints and more persistent rashes: psoriasis, eczema chronicum, in the third period the suffering of joints continues, in the fourth - lesions of internal organs: heart (endocarditis) and brain (delirium, dementia, apoplexia).

In herpes (especially abundant with skin ailments), in the first period—widespread rashes: eczema universale, urticaria, zona, pemphigus; in the second period—persistent rashes: eczema chronicum in the popliteal and cubital fossae, psoriasis, pityriasis, lichen and various neuralgias; in the third period—metastases in internal organs: capillary bronchitis, asthma, dropsy; in the fourth period—general severe skin lesions (herpetide exfoliatrice) and severe lesions of internal organs, including cerebral hemorrhage and softening. To Bazin's teaching adhered Hardy (1811-93), who called the predisposition to skin diseases dartrose diathesis (diathese dartreuse), which combined herpes and Bazin's arthritis. Among German physicians, Schönlein (1837) described the vegetable fungus of ringworm, Achorion Schönleini, and Eichstedt (1846) described another fungus Microsporum furfur in pityriasis versicolor. German physicians also adhered to the theory of humoral corruption (dyscrasia). Thus, Schönlein and Fuchs speak of rheumatic, catarrhal, and erysipelas dyscrasia. In skin diseases, they distinguished periods of growth, development, flowering, maturity, fruiting, and fading of the rash. In Vienna, in the large hospital at the department of chest diseases, which was headed in 1841 by Skoda, there was a large neglected department of skin diseases, known as the 'scabies' department. Skoda proposed to the young physician Ferdinand von Hebra to take up skin diseases. Hebra soon transformed the 'scabies' department into a world-renowned dermatological clinic, and himself became the founder of the Vienna dermatological school. Under the influence of his teacher, anatomist Rokitansky, he compiled a patho-anatomical classification, dividing skin diseases into 12 groups: 1) hyperemias, 2) anemias, 3) abnormalities of gland activity, 4) exudative processes, 5) hemorrhages, 6) hypertrophies, 7) atrophies, 8) benign neoplasms, 9) malignant neoplasms, 10) skin ulcers, 11) skin neuroses, 12) parasitic diseases. Hebra compiled an excellent textbook, which to this day can serve as a dermatologist's handbook. He described a number of rare forms of skin diseases: lichen ruber, lichen scrophulosorum, impetigo herpetiformis, pityriasis rubra, rhinoscleroma. His debates with the French dermatological school, which adhered to the humoral theory and considered most skin diseases as an expression of humoral corruption in the body or a special dyscrasia, diathesis, constitutional disease, are remarkable. From Hebra (1880) to our time, the following outstanding facts in the field of D. can be noted: in skin anatomy, the structure of connective tissue—its cells and fibers (Langer, Unna, Ehrlich and others); the structure of elastic tissue (Zenthoefer, Secchi, Meissner and others); the distribution of skin vessels (Tomsa, Spalteholz); nerve endings in the skin have been studied (Merkel, Meissner, Pacini, Ruffini, Dogel, Smirnov, Timofeev, Leontovich and others); the structure of the epidermal covering, layers of keratinization and skin pigment (Ranvier, Waldeyer, Unna, Buzzi, Ehrmann, Karg, Aeby and others). In the field of skin physiology, observations have been made on lacquering (Fourcault, Gerlach, Edenhuizen, Sokolov, Becquerel, Lashkevich, Lomikovsky, Winternitz, Ugryumov, Anfimov, Tekutyev, Mertens); on special nerve endings for each type of sensation—pressure, pain, heat and cold (Schlesinger, Blix, Goldscheider, Frey); on hair sensitivity (Osipov, Neushevsky); on segmental innervation of the skin (Head, Blaschko); on the secretion of sebum and sweat and their composition (Arnozan, Leubuscher). In the clinical field, there has been a clear tendency toward comprehensive examination of skin patients using various methods of studying the nervous system, blood, secretions, heart, respiratory organs, digestive organs, etc. Russian dermatologists played a prominent role in the development of this clinical direction. Such are the 'Dermatological Studies' from the clinic of Professor Polotebnov (St. Petersburg, 1886-87). Among experimenters on animals, one can mention Max Joseph, Moskalev, and Ter-Gregoryants, who removed cervical intervertebral nodes, resulting in hair loss in the corresponding areas, and Kozhevnikov, who proved by injections of mercury and bismuth preparations into animal arteries the dependence of deep gangrene in humans, when these preparations are injected, on entry into the artery. In pathological anatomy of the skin, enormous progress has been made, thanks to frequent intraoperative excision of skin pieces. Entire textbooks of histological changes in the skin have been compiled (Unna, Friboes, Kyrle, Lebedev). Pathological autopsies established the dependence of herpes zoster (Baerensprung, Head, Campbell and others) on diseases of the nervous system, Addison's disease—on diseases of the adrenal glands. Bacterology brought a broad stream of light, clarifying the causes of pyoderma, erysipelas, leprosy, rhinoscleroma and other skin diseases. In the field of therapy, enormous progress has been made first with the introduction into practice of chemical substances and special forms of their application (Chrysarobinum, Acidum pyrogallicum, Oleum lithanthracis, Empyreolum album, Anthrasol, Thiomm, Thigenomm, Lanolinum, Resorbinum, pastes, gutta-percha bandages Unna, etc.), and then with physical methods of treatment (massage, electricity, heat, Viru's hyperemia, freezing with liquid carbonic acid) and especially with the introduction into therapy of concentrated light according to Finsen (1895), X-rays (1896) and radium (1896). The French and Vienna schools, having lost sharp contradictions, although still remaining each with its own special coloring, widely developed their activity. In France, dermatologists continue to concentrate in the Hospital of St. Louis, but alongside this school, schools of southern France developed—in Lyon, Bordeaux, and in recent years in Strasbourg. The most outstanding authors of French dermatology textbooks are Hardy (1886), Dubreuilh (1899), Brocq (1906-1921-1924), Darier (1909-1923), Sabouraud (1924). Especially valuable is the edition under the editorship of Bénier, Brocq, and Jacquet 'La pratique dermatologique' (1900, 1904), in 4 large volumes, with the participation of many famous French dermatologists. Also interesting is the translation from German into French of Kaposi's textbook, edited by Bénier with a mass of notes almost equal to the text, clarifying the difference in views between the French and Vienna schools. The French dermatological school finds its expression in the journal 'Annales de dermatologie et de syphiligraphie', founded in 1868, and in the French Dermatological Society (La Société française de dermatologie et de syphiligraphie), founded in 1889, which has its own records (Bulletins de la Société française de dermatologie et de syphiligraphie). In the Vienna dermatological clinic, the successor to Hebra was Moriz Kaposi (1837-92), who described many rare diseases (sarcoma multiplex idiopathicum haemorrhagicum, dermatitis papillaris capillitii, xeroderma pigmentosum) and compiled a textbook and atlas of skin diseases. The influence of the Vienna dermatological school spread from Vienna to all university cities of Austria and Germany. German literature is rich in authors and textbooks (Neumann, Behrens, Hebra, Wolf, Lang, Lesser, Finger, Jessner, Jarisch, Mracek, Pinkus, Krohgauzer, Scheussler). Since 1926, a multi-volume textbook 'Handbuch der Haut- und Geschlechtskrankheiten' has been published in cooperation with a number of prominent German authors under the chief editorship of Jadassohn. Especially important is the publication of the journal 'Archiv für Dermatologie und Syphilis', founded in 1869 and supplied with numerous valuable illustrations. The German dermatological society works fruitfully. In English, Italian, American, and Japanese literature, there are also their own guides and journals. Dermatologists unite at world dermatological congresses. The World Congress of Dermatologists was held in Paris in 1889, one of the subsequent ones in 1897 in Moscow. The war of 1914-18 interrupted the work of world congresses, the last of which was convened in 1912 in Rome. After an 18-year interruption, the next world congress is convened in Copenhagen in 1930. In Russia, dermatology began to develop with the formation of dermatological departments, which were opened in 1869 in Moscow (in the Novo-Yekaterininskaya Hospital) and in Warsaw, and 2 years later—in 1871—in the Military Medical Academy. Russian dermatologists studied in both Vienna and Paris and avoided the extremes of both schools. The general direction of Russian dermatology can be called clinical, with a constant tendency to supplement clinical research with patho-anatomical and bacteriological data. Professor of the Military Medical Academy A. G. Polotebnov (1839-1907), the first Russian dermatologist, published the above-mentioned 'Dermatological Studies'. His brilliant work on erythemas has been translated into German. Professor of Kiev University M. I. Stukovenkov (1843-97) described a number of rare skin diseases (rhinoscleroma, Kaposi's pigmented sarcoma, Pender's ulcer, atrophic skin stripes, mycosis fungoides Alibert's). Professor of Kazan University A. G. Ge left to his successors a well-organized clinic. Professor of Moscow University A. I.

Pospelov (1846-1916) made great contributions to dermatological science, collected a large museum of artistically executed models, founded the Moscow Dermatological Society, and compiled 'A Guide to the Study of Skin Diseases' (1905). Prof. of Kharkov University I. F. Zelenyev (1860-1918), besides numerous works, published the 'Russian Journal of Skin and Venereal Diseases' from 1900 to 1916. Prof. of the Higher Women's Courses (now 2nd Moscow State University) in Moscow A. I. Lyants (1856-1920) left a number of works on skin diseases. Prof. of Tomsk University A. A. Lindstrom (1858-1920) left works on scleroderma and lichen planus. Prof. of the Institute for Advanced Medical Studies in Leningrad O. V. Peterson (1849-1919) left more than 100 scientific works. He is responsible for the establishment of the leprosarium 'Krutyye Ruchi' in the Yamburg district of Leningrad Province. Prof. of Turkestan University A. I. Lebedev (1887-1923) compiled a guide to the study of histopathological changes in skin diseases and syphilis. Prof. of the State Institute of Medical Knowledge in Leningrad G. F. Fridman left works on psoriasis and ringworm. Prof. of the Women's Medical Institute in Leningrad S. Ya. Kulnev (1868-1926) was interested in women's education, and from his clinic during his 20 years of leadership, many women emerged who dedicated themselves to the study of dermatology and syphilology. Director of the State Venereological Institute S. L. Bogrov (1878-1923) together with E. I. Martsynovsky discovered the causative agent of cutaneous leishmaniasis (pentine ulcer). The family of Russian dermatologists quickly grew, and at the Pirogov Congresses, since their inception in 1885, the dermatology section has gathered a large number of members. Questions of dermatology are also included in the program of all-union congresses to combat venereal diseases, the first of which was held in 1923 in Moscow, the second in 1925 in Kharkov. The convening of the III Congress is planned for 1929 in Leningrad. At present, there are a number of dermatological societies: Moscow, Leningrad, Kiev, Odessa, Kharkov, Don, Kuban, and others. Two dermatological journals are published: 'Russian Herald of Dermatology' and 'Venereology and Dermatology'. The development of D., according to modern views, has moved away from the exclusively morphological study of skin diseases and requires a comprehensive study of the patient, both of his skin and all internal organs, including the endocrine system and metabolism, as well as the study of the working and living conditions of the patient, which often have a considerable influence on the occurrence and spread of various dermatoses. The special study of these professional and domestic harmful factors has created a whole chapter in D.—'professional dermatoses,' which has attracted particular attention in the West and among us in recent decades. The teaching of D. should be predominantly visual, using patients and well-executed models. In modern teaching of D., great progress is noted. While in dermatological clinics in the prerevolutionary period, the teaching of D. was reduced exclusively to the lecture system and the care of one patient, at present practical classes are conducted, and the study of all patients in the clinic is mandatory. Along with becoming acquainted with the clinic of skin diseases, it has also become customary to become acquainted with laboratory methods of their research (see also Venereology). The practical significance of D. is very great, since besides rare diseases it covers a number of social contagious diseases such as: leprosy, pentine ulcer, trichophytia, which currently has epidemic distribution, scabies, which counts in the USSR annually more than 5,000,000 patients, as well as professional diseases (eczema, dermatitis, etc.). Similarly, D. has great significance for the recognition of syphilis. The development and teaching of D. in the USSR is carried out mainly in dermatological clinics of universities and medical institutes, as well as in special dermatovenereological institutes.

P. Nikol'sky. DERMATOMYOSITIS, dermatomyositis, more often acute than subacute or chronic disease of unknown origin, characterized by a number of muscular, skin, and nervous phenomena. It affects both sexes equally, more often children. It is observed more often in winter. The disease is rare: about 60 cases have been described. In etiology, infection (staphylococci or streptococci and others) apparently plays a role. There are indications of a connection with tbc, especially chronic forms of the disease. The toxic theory (poisoning by fish and others) has few followers. Oppenheim associates D. with the influence of cold. The first observations of D. date back to 1887, when Unverricht, Wagner, and Hepp independently published their cases. The term D. was introduced in 1891 by Unverricht because of the combination in the picture of the disease of skin and muscular phenomena. At autopsy, an enlarged soft spleen and changes in the muscles and skin are usually found. Histologically—interstitial myositis with degeneration and disintegration of muscle fibers and having nothing typical inflammatory phenomena in the skin; in neuromyopathic forms, in addition, from the side of the nerve trunks in acute cases edema, in chronic forms proliferation of connective tissue elements. More often the disease begins with a prodromal period lasting from 1 to 3 weeks and characterized by malaise, fatigue, drowsiness, rheumatoid pains, dyspepsia, etc.; more rarely acute pains in the muscles, more often in the calves, preventing movement, immediately occur. Soon muscle edema, their swelling and rigidity appear; many muscles may be affected, temperature rises. Over the affected muscles, the skin is edematous, tense, firm, does not pit on pressure; puffiness of the face may be added. When the muscles of the chest are involved, shortness of breath, asphyxia are observed. Later on the skin of the affected places, erythema, wheals, purpura, pigmentation, etc. may be observed. Itching is absent. Sometimes the mucous membrane of the mouth is involved in the pathological process. Gradually the edema of the muscles increases, preventing active and passive movements, contractures develop, the diaphragm and heart muscles may also be affected; the face takes on the appearance of a 'mask.' Nervous symptoms are also possible: paresthesias, neuromyositis, pareses; later—muscle atrophy with reaction of degeneration. Deep reflexes are weakened. The function of the bladder and rectum does not suffer. The spleen is often enlarged. Chronic D. are expressed by dermatomyosclerosis, which brings them very close to scleroderma. Whether D. and scleroderma represent similar processes is an open question. Diagnosis of D. in some cases is difficult between polymyositis, polyneuritis, and trichinosis. In polymyositis there is a quantitative decrease in electrical excitability, reaching complete extinction; in D. this is absent. In the reaction of degeneration with typical inversion of poles and in disorders of sensory nerves, one rather has to think of polyneuritis than of D. Trichinosis in the first days of the disease is more often characterized by localization in the muscles of the head than of the extremities, and it is more often encountered in the form of group diseases than single ones. The decisive significance is the finding of trichinae. Prognosis. D. is a severe disease, giving a high percentage of deaths. According to Steiner (1905), out of 28 patients, 17 died. With a benign course, recovery is possible. Sometimes D. was limited to one group of muscles or one limb. Death usually occurs in the first 3-4 weeks from asphyxia, progressive weakness, aspiration pneumonia, or cardiac complications. Treatment—symptomatic.