Skin Diseases

SKIN DISEASES, an extensive group of diseases with diverse etiology, the common feature of which are pathological changes in the skin, its appendages, and visible mucous membranes. These changes, which in their regression either disappear completely or leave indelible defects of the coverings, are located both symmetrically and diffusely, as well as in the form of limited and sparse eruptions, but can also acquire universal distribution. The concept of skin diseases is in certain cases conditional, since skin lesions often represent only one symptom of other diseases (infectious, internal, etc.). The causes of skin diseases are very diverse and complex. In particular, skin diseases can be divided into acquired and hereditary.- I. Acquired skin diseases are in turn caused by both external (exogenous) and internal (endogenous) factors.- External causes. 1. Mechanical trauma (friction, pressure, bruising), as a result of which edemas, blisters, erosions, hemorrhages, calluses, etc. may form on the skin.-2. The influence of high or low temperatures, causing erythema, chilblains, frostbite, burns.-3. The action of chemical substances directly contacting the skin, medicinal preparations or chemical agents, especially those related to occupation; this group should also include the influence of light irritants (sun rays, X-rays, etc.), since they act primarily through their chemical rays. As a result of all these chemical influences, dermatitis of varying intensity, proliferation of skin papillae, thickening of the horny layer, increase in pigment content (tanning) or, conversely, depigmentation occur. The qualitative and quantitative character of the listed changes depends not only on the properties of the irritant but also on the individual sensitivity of the patient's skin.-4. Animal and plant parasites and bacteria. Some of them (lice, fleas, bedbugs, botflies), when they get on the skin, cause severe itching, redness, swelling, and sometimes more significant disturbances. Others (Sarcoptes scabiei, Gastrophilus, Microsporon furfur, Achorion Schoenleini, etc.), settling in the epithelial covering of the skin and appendages (from where some of them, for example fungi, can penetrate into the general bloodstream), are the cause of specific, strictly isolated skin diseases (trichophytosis, favus, etc.), which as a rule do not significantly affect the general state of health. Finally, third ones, such as certain worms, yeast fungi, ray fungi, and especially bacteria, penetrating into the proper skin and subcutaneous tissue, can cause the formation of local acute abscesses, chronic suppurative processes with fistulous tracts, infectious granulomas, etc.; in other cases, entering the general bloodstream, spreading in various tissues and organs, they are the cause of severe general diseases often ending in death (blastomycosis, tuberculosis, leprosy, glanders, erysipelas, etc.). Internal causes. 1. Skin diseases based on diseases of the central or peripheral nervous system. Examples can be certain forms of eczema, pruritus, erythromelalgia, herpes zoster, etc. Confirmation of the "neurological etiology" of skin diseases are a) physiological justification - the presence in the nervous system of vascular, secretory, and trophic centers for the skin; b) some experimental data - experiments by Gaule, who by irritating the intervertebral ganglia of rabbits and frogs caused disappearance of skin pigment and proliferation of skin epithelium. Experiments by a number of authors (M. Joseph, Mibelli, Moskalenko, Ter-Grigoryan), who obtained areolar alopecia in dogs and cats upon extirpation of spinal ganglia or section of the corresponding roots; c) pathological-anatomical data indicating specific changes in nervous tissue in certain skin diseases (herpes zoster); d) clinical observations, for example, the location of certain skin diseases (herpes zoster, lichen ruber) corresponding to the branching of certain nerve trunks or the area of innervation of a particular segment of the spinal cord; symmetrical location of eruptions, the appearance of skin diseases often following psychic trauma and their recurrence upon repetition of this trauma; finally sometimes favorable outcome of skin suffering upon treatment of only the nervous system.-2. Toxic skin conditions, a) caused by auto-intoxication due to absorption of pathological products in diseases of the gastrointestinal tract and digestive glands (for example urticaria, certain forms of eczema, pruritus, etc.), associated with metabolic disorders and accumulation in the body of abnormal (under-oxidized) products, such as gouty eczemas, skin conditions in diabetes (diabeticides), prurigo, etc., associated with intoxication as a result of temporary special physiological states of the body, such as: dermatoses of pregnancy, menstrual, climacteric, etc.; b) caused by chemical substances introduced into the body per os in the form of medicinal or food products. This includes bromide, iodide, antipyrine rashes, as well as erythemas and urticaria in connection with eating crayfish, strawberries, cheese, etc.-3. Finally, an extensive but still little studied group of skin diseases consists of processes arising in connection with the loss or perversion of the functions of endocrine glands, such as: myxedema, Addison's disease, Dercum's disease, scleroderma, etc., as well as skin lesions depending on various blood diseases: leukemic and pseudo-leukemic conditions, skin changes in the course of Vaquez's disease, etc. Of Edouard Lambert, born in 1710. At present, although this question is by no means considered fully resolved, a large group of skin diseases has been established, the cause of which is a specific genotypic factor. The presence of the latter however does not yet necessarily imply the inevitable manifestation of skin diseases: some of them up to a certain period of time, and sometimes throughout life, may remain in a latent state, manifesting only under the influence of an external environment favorable for this. In some cases of epidermolysis bullosa, even slight trauma is a manifestation of the disease; in xeroderma pigmentosum, prolonged exposure to the open air and the influence of sun rays play a similar role. The heredity of skin diseases, like other human traits, obeys Mendel's laws. The study of hereditary transmission of skin diseases, as well as other diseases in humans, is very difficult, since for obvious reasons experimentation cannot be applied here; therefore it is carried out exclusively by genealogical and twin methods. At present, on the basis of material collected by a number of authors, it is possible to divide genotypic skin diseases into the following groups. 1. Dominant: acrodermatitis chron. atrophica, ephelides, epidermolysis bullosa simplex, keratosis palmoplantaris, Darier's disease, etc.-2. Dominant, limited by sex: alopecia praesenilis. - 3. Incorrectly dominant, i.e. with skips of individual generations: albinismus localis, ichthyosis vulgaris, morbus Recklinghauseni, monilethrix, elephantiasis congenita, etc.- 4. Recessive: albinismus totalis, epidermolysis bullosa dystrophica, hypertrichosis, ichthyosis congenita, xeroderma pigmentosum, etc.- 5. Recessive, sex-linked: anhidrosis.-6. Finally, a number of diseases (acne, adenoma sebaceum, dermatitis Duhringi, scleroderma and many others) belong to the group with not fully clarified role of heredity.- The role of genetics in the study of skin diseases is however not limited to elucidation of etiology alone. Genetics also renders enormous service in the differentiation of individual pathological forms. The fact is that skin diseases are classified mainly on the basis of clinical and pathological-anatomical (histological) similarity and difference. Modern biology however provides irrefutable evidence that however externally (phenotypically) similar two pathological cases may be, their biological identity is by no means thereby proven. In particular, the different character of inheritance in such two cases leaves no doubt that these are two completely different diseases, which upon more detailed analysis prove to be clinically different as well. Thus for example it was finally possible to separate ichthyosis congenita (recessive inheritance) and ichthyosis vulgaris (dominant inheritance). Pathological anatomy of skin diseases. The wide possibility of performing biopsy on any skin eruption without the slightest harm to the patient has led to the fact that the overwhelming majority of skin diseases have been studied in great detail from the pathological-anatomical side. Microscopic examination of biopsied elements is often a valuable diagnostic aid to which one usually resorts in practice. Both initial, insufficiently developed elements of the eruption and fully mature elements, then those in the stage of regression, and finally sites of former lesions are biopsied. In this case, evaluation of the microscopic picture should be done not in isolation but in conjunction with data from other methods of investigation, especially clinical. In some cases, differential diagnosis based on one histological picture is completely impossible: this should include dermatitis of various etiologies with identical histopathological pictures, eczemas, various bullous diseases, etc.

It is very difficult to recognize infectious granulomas of different etiologies that are similar in their anatomical structure, for example, syphilitic, tuberculous, and mycotic. They can only be distinguished by appropriate staining of the pathogen in the tissues. With greater likelihood, based on a single histological picture, a diagnosis can be made of some tuberculids, Bock's sarcoids, granuloma annulare, folliculitis, etc. Finally, there are a number of skin diseases where the histological picture is decisive for the diagnosis; these cases include nevus, benign and malignant skin tumors, urticaria pigmentosa, amyloidosis of the skin, Darier's disease, and Bowen's dyskeratosis. For a proper evaluation of the histological picture, it is also necessary to consider certain technical rules in preparing preparations from biopsied skin elements. The skin section should pass perpendicular to the epidermis; it should be as thin as possible. When evaluating the histological picture, it is also necessary to take into account the presence of certain artifacts associated with the use of anesthetic solution when excising the skin. General principles of diagnosis and therapy of skin diseases. The diagnosis of skin diseases consists of 1) a carefully collected history, personal and family, with mandatory consideration of the socio-domestic environment and data concerning the heredity of the patient, 2) detailed clinical (general and local) examination of the patient. The first is performed according to the general rules for examining patients, the second is reduced to a detailed examination (sometimes with the help of a magnifying glass) of changes on the skin and visible mucous membranes; it must begin with the study of the initial, youngest in appearance and time of appearance, uncomplicated element of the rash. To assist in simple inspection and palpation, the following are often used: 1) the method of scraping (scraping and rubbing) of both rash elements and apparently healthy skin; this method is often a very valuable diagnostic aid (Auspitz's sign in psoriasis, Nikolsky's sign in pemphigus, and Unna's sign in urticaria pigmentosa); 2) diascopy (see); 3) biopsy (see). Finally, the diagnosis of skin diseases in some cases cannot be made without auxiliary laboratory investigations (serological, bacteriological, microchemical). Therapy of skin diseases should be directed primarily to eliminating the main cause of the disease; if this is not possible, it is symptomatic. Thus, the treatment of skin diseases comes down to the use of medicinal substances that can be administered orally, parenterally, and topically in the form of various special pharmaceutical forms used mainly in dermatology, such as: compresses, powders, pastes, ointments, plasters, medicated soaps, etc. Vaccines, sera, hemo- and autogenous blood therapy, opotherapy preparations, etc., are also used. In addition to medicinal substances, various physiotherapeutic procedures (X-rays, ultraviolet, diathermy, d'Arsonval, hydrotherapy, etc.), as well as treatment at resorts, are used with great benefit and are extremely widespread in the treatment of skin diseases. Surgical intervention can be used much less frequently, only in some skin diseases. Along with the mentioned methods of treating skin diseases, in some dermatoses, especially those dependent on metabolic disorders, the prescription of an appropriate diet also plays no small role. For prevention purposes, it is necessary to recommend hygienic measures and the change or elimination (temporarily or permanently) of professional and domestic factors, which often play a dominant role in the origin of skin diseases. Statistics of skin diseases. Information on the morbidity of the population from skin diseases is far from exhaustive, since there is no mandatory notification of skin diseases, including contagious ones, in any country. When compiling statistical characteristics of the prevalence of skin diseases, it is customary to use materials from individual medical and scientific institutions. In relation to the most rarely occurring skin diseases, due to the description of almost every case, conclusions about the frequency of such cases are made independently of the total number of skin diseases registered in this institution or city. Statistical processing of skin diseases also encounters difficulties due to the diverse nomenclature adopted in different countries, and sometimes even in the clinics of one country, with respect to the same or related diseases. According to the Office of the Chief Physician Inspector in 1913, 8,509,655 cases of skin diseases (including diseases of the subcutaneous tissue) were registered in Russia (492.4 per 10,000 population); in addition, there were 5,475,494 cases of scabies (368.8 per 10,000 population); patients with impetigo were not included in the total number of skin diseases. From the entire group of skin diseases, tuberculous skin diseases (14,312 cases in total, or 2.1% of all forms of tuberculosis), leprosy-259 cases; scabies-1,451,930 cases; this number is underestimated, as information was not received from 20 out of 51 administrative centers. Reports from individual institutions allow only to judge the comparative frequency of individual forms of skin diseases. Data from the largest foreign reports are given (according to Spitzer) in Table 1. The statistical report of the American Dermatological Association covers over 700,000 cases over 34 years; the report of R. Crocker (London)-15,000 cases; the report of the Breslau skin and venereal clinic-35,117 cases over 10 years. Spitzer's data are supplemented by materials from the State Venereal Institute (Moscow), concerning 10,000 cases of skin diseases. According to these data, the most common among skin diseases (excluding parasitic ones) is eczema; followed by acne, especially frequently, as well as scaly lichen; the frequency of lupus is sharply expressed in Germany compared to America and England (4.7%-0.32%-1.22%), as well as compared to the data of the Odessa Venereal Institute, in which out of 66,765 cases of skin diseases, lupus was noted in 1%, and the data of the State Venereal Institute, in which out of 9,950 cases of skin diseases for 1925-29, lupus was registered in 1.1%. The entire group of tuberculous skin diseases occurs in Germany (Breslau clinic) much more frequently than in Moscow (State Venereal Institute): according to the first data, it constitutes 3.97% of all skin diseases, according to the second-2.12%. In England, ichthyosis occurs more frequently, and various alopecias are noted much more frequently. Table 1. Frequency of some skin diseases in various clinics (percentage ratio to all registered skin diseases). Table 2. Frequency of some contagious skin diseases in various clinics (absolute numbers and percentage of all registered skin diseases). The distribution of skin diseases in different countries depends on a number of factors, among which socio-domestic conditions, climatic and geographical influences are dominant. The influence of socio-domestic causes is particularly noticeable when studying the spread of contagious skin diseases. Spitzer provides data on the registration of patients with scabies, pyodermias, and mycotic skin diseases, comparing their frequency in clinics where usually less affluent population segments seek help with their frequency in his private practice, which was used by more affluent patients (Table 2). The data of Spitzer, as well as of Mgebrov and Khoroshin, indicate that among the less affluent population segments, the mentioned skin diseases occur much more frequently than among the wealthy, living in more favorable sanitary-hygienic conditions. This is also confirmed by the statistics of R. Crocker, who among 10,000 patients with venereal and skin diseases registered in the polyclinic and 5,000 similar patients of private practice, found: 796 (7.96%) cases of scabies in the first group and only 58 (1.12%) in the second. A known addition to the above are also the data on scabies in America: in 1876, scabies occurred there only in individual cases; in the following years, when emigrants began to arrive in America from Europe, who had lived in their homeland in poor sanitary-hygienic conditions, scabies sharply increased and in 1913 already constituted 5-6% of all registered skin diseases.

The absence of hygiene habits contributes to the spread of contagious skin diseases regardless of climatic conditions: Remlinger notes the widespread prevalence of pyoderma in Tangier, Spitzer among culturally backward segments of the population in northern countries (particularly Greenland), who rarely bathe. In the USSR, data from household surveys on the frequency of contagious skin diseases among peripheral nationalities and rural populations in Russian villages are characteristic in this regard. Bayburt, upon examining the Chechen plain in 1929, found ringworm and scabies in 11% of all examined individuals; among only the children examined, this percentage increased to 34. Voznesenskaya found in 1926 among 1,229 outpatient Kyrgyz patients 293 cases of skin diseases (23.8%), of which all skin diseases accounted for 51.8% for scabies and 26.2% for fungal diseases; during a complete examination of 1,535 Kyrgyz people, 34.1% were found to have skin diseases, among which pyoderma and scabies constituted 68.5%. A German, upon examining 1,540 Uzbek students in Khiva, found 558 cases of scabies among them (38.1%); he also found 10% of trichophytosis among Uzbek schoolchildren in Tashkent. Ostrovsky, upon examining 2,392 Ingush people, found among them 1,112 (47.6%) patients with skin diseases, predominantly parasitic. Okun, upon examining 6,265 peasants of the former Saratov province, found among them 472 cases of scabies (7.5%). According to data from Dobreytzer, about 10% of the rural population of the former Arkhangelsk, Cherepovets, and North Dvina provinces suffered from scabies in 1925. According to statistical reports of the Kazakhstan People's Commissariat of Health for 1925-27, based on examination of 65,387 nomads, skin diseases ranked first in frequency of distribution, with their total number averaging 9.9%. A team that examined the population of the former Ural province found among those examined 19.22% of skin diseases, of which the overwhelming majority were parasitic diseases: 72.5% scabies, 22.3% scab, 5.2% other skin diseases. Paskhalov among 959 Kyrgyz people of the Astrakhan province found 522 cases of skin diseases (54.1%), noting in passing that "it is generally difficult to find a Kyrgyz with healthy skin." The frequency of contagious skin diseases among rural and nomadic populations is explained by infrequent bathing, various harmful habits (e.g., constant wearing of hats by Uzbeks and others), infrequent changing of underwear and clothing, which some nationalities do not remove until completely worn out, close contact with domestic animals, etc. The spread of skin diseases is significantly facilitated by wars: the absence of conditions necessary to maintain proper body cleanliness, traumatic injuries (neuroses, etc.), improper nutrition, cold and other factors associated with being in a wartime environment create the ground for the widespread development of contagious and endogenous skin diseases. In armies fighting in 1914-18 on the eastern fronts, almost universal lice infestation was encountered; in the British army on the western front, it was noted in 96%. In France in 1915, the most common disease was scabies; in Germany it increased (according to data from the Breslau clinic) from 1911-13 to 1919-25 by 15.6%. According to data from the Budapest clinic, fungal diseases (microsporia), previously not encountered in Hungary, accounted for 20% of all skin diseases in 1919, upon the return of the army. Trichophytia became a mass disease in Germany in 1918; its variety (causative agent - Trichophyton rosaceum), previously not encountered, was brought by returning prisoners of war from France and Belgium; after the epidemic subsided, this variety of trichophytia is generally not observed in Germany. The influence of war on the frequency of scabies has been traced in the former Saratov province by Tappelzon, who found that its percentage among all outpatients (according to the Kamyshin district) was 2.1% in 1911, 10.5% in 1915, and in individual villages up to 20.0-24.99%; in absolute numbers, scabies increased throughout the province from 83,787 cases in 1914 to 236,359 in 1917. Some authors (V. Ivanov, Gennerich, Bruck, Kromayer) note the significant frequency of pyoderma (staphylodermias) during wartime, called by German authors "military dermatoses." Among skin diseases of endogenous origin, especially common during wartime, eczemas developing in the area of injuries are noted (observations of V. Ivanov during the Russo-Japanese War and the war of 1914). Among social factors determining the frequency of skin diseases among various population groups are harmful influences on the skin, depending on the working conditions and the nature of the material being processed. Rozhdestvensky provides comparative coefficients of eczema morbidity for textile workers in Tver in 1925/26: Table 3. Groups of workers Men (per 1,000) Women (per 1,000) 1. Workers dealing with paints and skin-irritating substances 5.93 6.29 2. In the city (without textile factories) 2.6 3.61 3. In all factory professions (without professions dealing with paints) 0.40 0.49 The influence of harmful agents is even more clearly evident in individual workshops, the most harmful of which is considered the dyeing department of the factory (sulfur dyes and aniline oils). Table 4. Groups of workers

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With a general morbidity rate from all skin diseases in the population of Kostroma in 1925 amounting to 143.6 per 1,000, the morbidity rate among workers employed in the flax-spinning industry rose to 202.3 per 1,000, in the paper-spinning industry to 156.9, and in the textile industry to 193.7. Ter-Zakharov, upon examining cooper workers in Astrakhan, found among the 820 examined persons, 95.12% had occupational calluses, 50.64% had acne and comedones developing as a result of deposition of dense layers of wood dust on the skin; and in 44.51% primary dermatoses were complicated by secondary infections, predominantly fungal. The professional factor also plays a role in the more frequent spread of parasitic skin diseases in families. According to data from the Kyiv Favosis Dispensary, fungal diseases are most frequently registered in families of persons engaged in tailoring and shoemaking crafts, among laborers and day laborers; these groups constituted about 30% of the fungal diseases and parasitic sycosis registered by the dispensary. Skin diseases associated with working conditions and the production process—see Professional dermatoses, Keratoses. The influence of climate and geographical conditions does not have great significance in the spread of skin diseases. Tropical skin diseases are mainly directly related to geographical conditions. For example, mycetoma pedis (Madura foot), which in the rarest cases is observed in Europe (by 1925 only 10 cases were known), is encountered very frequently in East India; Gelonesi observed it 14 times in Somalia (Africa) over 18 months. The group of skin diseases occurring in specific climatic conditions also includes the Pendi ulcer, most frequently encountered in the USSR on the eastern, Central Asian outskirts. As a skin disease resulting from climatic influences, lichen tropicus can also be mentioned, which is frequently encountered in persons coming to countries with tropical and subtropical climates, while among the native population this disease as a rule is almost never encountered. A comparison of the frequency of endogenous skin diseases among the white and colored races, cited by Fox (Fox, cit. by Spitzer), reveals a relatively lower frequency of skin diseases among the latter: a study of the spread of skin diseases, for example, among American Negroes shows that among them acne vulgaris, acne rosacea, psoriasis, lichen ruber planus, and eczemas are rarely encountered. Fox's observations are confirmed by the data of Hazen, who also notes that among Negroes alopecia, angiomas, and birthmarks are rarely encountered. Duncan Bulkley also notes a lesser spread of skin diseases in Japan, Korea, China, the Philippine Islands, Siam, Ceylon, India, and Egypt, refuting the existing opinion that skin diseases are significantly prevalent among the population of these countries. The morbidity rate from skin diseases by sex and age can be determined only from data of registration in individual institutions and special surveys. Thus, according to data on the morbidity rate of the population of the city of Kostroma in 1925, among the entire population there were patients with skin diseases per 1,000 of the corresponding population group: Table 5. Age Men Women 0-14 years 209.8 217.5 15-19 years 156.1 166.5 20-29 years 116.5 135.1 30-39 years 115.1 117.7 40-49 years 93.5 93.0 50-59 years 77.2 81.2 According to data from the State Venereal Institute (Moscow), the following number of skin disease cases were registered (Table 6): Table 6. Years Men Women Children Total 1924 994 686 653 2,333 1925 672 896 564 2,132 1926 450 391 3,410 4,251 Total 2,116 1,973 7,627 11,716 According to the presented data, a significant percentage of skin diseases are registered in children; the young age group is predominant in some places (Kostroma). Among women, skin diseases occur relatively less frequently than in men; thus, according to data from Rozhdestvensky, the general city coefficient for Tver for 1925 was by age: Table 7. Age Men Women 20-29 years 31.83 22.97 30-39 years 19.73 17.54 40-49 years 17.0 16.43 50-59 years 15.95 12.11 The frequency of registration of individual skin diseases by sex and age groups can be judged from data of the State Dermato-Venereological Institute named after Glauche (Odessa), where for 1919-26 a total of 66,775 cases of skin diseases were registered, of which 58.8% were infectious and parasitic skin diseases, and 41.2% were others, with more than half of the former occurring in children. Table 8. Infectious and parasitic skin diseases registered in the Odessa State Dermato-Venereological Institute for 1919-26. Name of disease Men Women Children Total Ringworm ... 861 5,967 1,309 8,137 Scabies ... 1,560 3,677 1,071 6,308 Pediculosis ... 1,086 1,086 Pyodermias ... 1,086 1,086 Lupus ... 579 579 Leprosy ... 3.677 3,677 Other diseases ... 1,071 1,071 Total ... 10,204 (27.6%) 7,050 (19.1%) 19,688 (53.3%) 36,942 Both among adults and children, parasitic diseases and infectious skin diseases were in first place, followed by pyodermias; among 673 lupus patients, women constituted about half of all patients (Table 8). The social significance of skin diseases is determined by the widespread prevalence of parasitic and infectious skin diseases, of which the former in particular, under poor sanitary-hygienic living conditions of the population, sometimes take a severe course (cases of death from scabies are known among peripheral nationalities). Pyodermias open the gateway for various infections and complicate the course of other diseases. In particular, under conditions of frequent household transmission of syphilis among the rural population, the abundance of skin lesions due to simultaneously existing or previously suffered skin diseases plays a certain role. Endogenous and exogenous skin diseases, with their sharp subjective sensations (pain, itching) and chronic, sometimes lifelong course, can reduce the work capacity of patients or make them completely incapacitated. Professional skin diseases have special significance. The average duration of incapacity for work due to skin diseases (and diseases of the subcutaneous tissue), for example, in the textile industry of the Moscow province in 1926-27 (according to Vasilievsky), was 10 days, while according to general morbidity indicators in 1927 it was 11.5 days. According to data from the Podolsk Insurance Fund (former Moscow province) for 1927, the number of days paid for incapacity for work due to professional skin diseases in the wood-polishing shop of the State Clothing Factory was 971, with an absolute number of cases of loss of work capacity being 41, i.e., each case of release lasted an average of 24 days; while release for skin diseases not associated with occupational hazards lasted on average 7 days. The social significance of some chronic skin diseases causing severe facial disfigurement is also determined by the difficulty of their outpatient treatment, the difficult position in communal living (for example, lupus patients) and the need to organize for them at the state's expense special hospital-colonies. The epidemic spread of fungal skin diseases in orphanages and schools requires isolation of patients in special institutions (isolation wards), and in the absence of such, children are sometimes removed from school for a long time. Organization of the fight against skin diseases. The close connection of skin diseases with syphilis and their study in general dermatovenereological clinics also necessitate including the fight against skin diseases, which is a state task in the Soviet health care system, in the practical work of all institutions conducting the fight against venereal diseases. In addition to special venereal institutions—dispensaries, detachments, and points—assistance to patients with skin diseases is provided in general outpatient clinics, polyclinics, and unified dispensaries. The scale of assistance provided to patients with skin diseases can be judged by the number of visits registered in venereal dispensaries. Thus, out of a total of 119,295 initial visits in 26 dispensary-type institutions (in the RSFSR) in 1927, 59,733 visits were for patients with skin diseases, or 50%. Inpatient treatment of skin diseases is carried out mainly in special departments of general city hospitals, in university clinics and dermatovenereological institutes (in Moscow, Kharkov, Odessa, Tiflis, Baku). The largest specialized hospitals for the treatment of skin diseases are: the Korolenko Hospital in Moscow, the Mechnikov and Tarnovsky Hospitals in Leningrad. The peculiarities of the course of tuberculosis-like skin diseases have led to the creation of special therapeutic-laboratory institutions for these patients (so-called luposoria) in Moscow, Leningrad, and Sverdlovsk. To therapeutic-laboratory institutions of the colony type also belong leprosaria for patients with leprosy. Contagious fungal skin diseases, which are most common and easily transmitted among children, lead in places of their greatest prevalence to the organization of special outpatient clinics (favosis dispensary in Kiev) and school-type institutions for long-term hospitalization—so-called isolation wards (for example, the Dzerzhinsky Hospital in Moscow, the favosis house in Minsk). The dispensary care methods adopted for venereal disease patients in dispensary institutions are also applied, when necessary, to patients with skin diseases.

Moments of such care include, for example, periodic examinations in children's and school institutions to identify primarily contagious skin diseases among children and service personnel; detection of skin diseases during mass examinations conducted by dispensaries in industrial enterprises, and for the prevention of professional dermatoses, elimination of harmful effects on the skin of workers; systematic, carried out jointly with sanitary organizations, periodic examinations of the skin and mucous membranes of workers and employees who, by the nature of their work, may become a source of spread of skin diseases (for example, examinations of food handlers, conducted upon hiring and periodically, according to the 'Regulations on Medical Examinations of Workers in the Food Industry' - circulars of the People's Commissariat of Health and the People's Commissariat of Labor of February 2, 1925, and September 2, 1925, sanitary examinations of hairdressers, conducted according to mandatory resolutions of local administrative authorities, etc.); examinations conducted by venereal teams among the rural and outlying population to detect syphilis, during which the spread of skin diseases is also detected. For the popularization of preventive measures for skin diseases in the USSR, extensive accessible literature (leaflets, brochures) has been published about the most common skin diseases. Teaching hygiene in elementary schools and students' acquisition of necessary information on skin care also facilitate the tasks of mass prevention. N. Efron, S. Galperin. The problem of the general and local in the pathogenesis of skin diseases is particularly interesting from both a theoretical point of view and from the point of view of a practicing physician. For the latter, this question is especially important because, depending on the answer to what predominates in the pathogenesis of this or that skin disease - the skin itself or some other organs (for example, internal organs) - depends the nature of therapeutic intervention. This question is resolved differently for different groups of skin diseases. In this sense, it is necessary to distinguish between genotypic and paratypic skin diseases, and each of these groups can in turn be conventionally divided into primary and secondary. The first division does not need explanation (see Genetics, Genotype, Paratype, Phenotype). Under the second, however, the following is meant: 1) a paratypic primary disease should be considered one whose external agent was localized or manifested exclusively or mainly on the skin (for example, scabies, bruising from trauma); a similar skin disease can be considered secondary when the exogenous factor mainly or exclusively affected other organs (besides the skin), and the latter is affected only subsequently as a complication (for example, rash in sepsis); 2) a genotypic primary skin disease will be one when the corresponding gene phenotypically affected only the skin (for example ichthyosis) or in the order of pleiotropy (see) - simultaneously the skin and various other organs (for example, anhidrosis of the skin, hair, and teeth); a similar skin disease can be considered secondary in the case when the corresponding gene does not affect the skin as such and the latter is affected only subsequently as a complication. For example, this includes bruising in hemophilia (see); the latter is a genotypic disease, but the realization of the corresponding gene is not necessarily associated with skin bruising; on the other hand, the latter may occur in any other form of hemorrhagic diathesis (see). This probably also includes furunculosis in diabetes, etc.-Turning now to the question of the role of local and general in each of the listed forms, the following can be noted. Primary paratypic skin diseases should undoubtedly be considered local diseases of the skin as such, which, naturally, does not exclude but presupposes the participation of the entire organism both in the very fact of the origin of the corresponding disease in each individual case and in the individual characteristics of its course: not all people, for example, when coming into contact with some pathogen, get sick, and not all the sick have the same picture of the disease. The question is somewhat differently posed for secondary paratypic disease: being in its essence general (at any rate not a disease of the skin), it, partly depending on the properties of the skin, complicates it. The problem is solved quite differently in relation to genotypic skin diseases; they are sometimes incorrectly considered 'secondary', allegedly arising from damage to internal organs or the nervous system. For proper orientation in this issue, one should proceed from the indisputable position established by modern genetics and cytology that all cells of the organism have the same genotype and that they differ from each other only phenotypically due to the different manifestation of the corresponding gene or gene complexes in different parts of the body. Genes for eye color, for example, are equally present in all cells of the body, but the area of their manifestation is limited to the iris; the same can be said, for example, of ichthyosis: the corresponding gene is present in all cells of all tissues, but the area of its manifestation is the skin. Such a disease is therefore both general and local: general in the sense that the gene is spread uniformly throughout the body, local - due to the phenotypic localization of it in the skin. In another sense, such a disease is both general and local because both from the general properties of the entire organism and exogenous effects on it, and from the local peculiarities of the skin and external influences on it, depends, in the presence of the gene, both the fact of its phenotypic realization and the form of the latter. It should, however, be noted that the above position about the uniformity of the genotype of all cells of the organism needs correction in the sense that the possibility of somatic mutation (see) in any of the cells of the organism is not excluded, and the descendants of such a cell will have a genotype identical but different from all other cells that originated from non-mutated ones. Somatic mutations, resulting in the mosaic structure of the organism, have been studied in detail on Drosophila melanogaster and other objects of genetic research. It goes without saying that a trait arising as a result of somatic mutation is not inherited, although it is genotypic. Modern research methods do not yet allow to reliably prove the presence of somatic mutations in humans, although indirect data allow to speak of this (for example in relation to malignant tumors). Undoubtedly, they also occur on the skin (perhaps some forms of naevus belong here). In such a case, the problem of local and general is posed differently: somatic mutation gives a local disease, but from the organism as a whole depends the form of its manifestation. Finally, the above cases of secondary genotypic skin changes should be interpreted quite differently: for example, bruising in the skin in hemophilia occurs not because each skin cell has the gene of this disease, but due to random circumstances. Such bruising is therefore a local complication of a general disease. From what has been stated, it thus follows that the unity of the general and local takes place in each skin disease, but the specific forms of this unity are different in each individual case.

s. Levit.