Dermatology

DERMATOLOGY (from the Greek derma—skin and logos—word, science), the science of skin diseases. Skin diseases have been known since deep antiquity. Chinese medical literature, dating back more than 2,500 years before the Christian era, contains descriptions of favus, leprosy, ichthyosis, and scabies. The so-called Leipzig Egyptian Ebers Papyrus, from 1700 B.C., and the Berlin Brugsch Papyrus, from 1350 B.C., mention itching and scabies, as well as ointments, plasters, and lotions. The Book of Moses, from 1500 B.C. (Leviticus, ch. 13), contains a description of favus, loss of pigment, hair loss, and leprosy. In ancient Greece, Hippocrates described a large number of skin eruptions: favus (achor, kerion), loss of pigment (alphos), freckles (ephelis), and scabies (psora); he called tumors phymata, dry eruptions—scaling (pityriasis, lepra, lichen), and eruptions with vesicles and blisters—phlyktaina, pompholyx, and eruptions with a tendency toward 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 an eruption, in his opinion, could cause the disease to transfer to internal organs; conversely, various discharges and secretions, such as hemorrhoidal ones, could cure certain diseases. This is the so-called humoral theory, which held sway until the middle of the 19th century. It was subsequently displaced by cellular pathology, but nevertheless, it has survived in modified forms to our time. The outstanding physician of ancient Rome, Celsus, also described many skin diseases: furuncle, carbuncle, phlegmon, gangrene, acute condylomas, elephantiasis, vitiligo, sycosis, and callus. These names for diseases are used even at the present time. Circular hair loss still bears his name—area Celsi. Galen (2nd century A.D.) drew attention to the connection between skin diseases and arthritic conditions—a thought that received wide development in the French dermatological school of the 19th century. Arab scholars (9th, 10th, 11th, and 12th centuries A.D.) translated the medical works of Greek and Latin authors into Arabic and themselves quite accurately described smallpox, measles, leprosy, elephantiasis, favus, and scabies. Avenzoar (1162) even speaks of the scabies mite. In the 13th and 14th centuries, leprosy became very widespread on the European continent (weakening significantly by the 15th century), and at the end of the 15th century, a severe epidemic of syphilis developed; nevertheless, physicians were also interested in other skin diseases. Thus, Hieronymus Mercurialis compiled a textbook on skin diseases (De morbis cutaneis; 1572); the same was done in German literature by Hafenreifer (Hafenreiferus; 1660), in French by Riolan (1610), and in English by Willis (1682). Riolan already had the rudiments of a morphological classification of skin diseases; he divided all skin diseases into three classes: pustulae, difformitates, and tuberculi. The research of Malpighi, Morgagni, and Boerhaave on the finer anatomical structure of the skin dates to the end of the 17th and the beginning of the 18th century. In honor of Malpighi, a layer of the covering epithelium still bears his name to this day. Textbooks of the late 18th century by Plenck and Lorry (Plenck, Lorry) are already much superior to those mentioned. Plenck (1776) accurately distinguishes the morphological elements of an eruption: 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) excrescentiae, 10) ulcera cutanea, 11) vulnera cutanea, 12) insecta cutanea, 13) morbi unguium, 14) morbi pilorum. Lorry (1777) pays 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 emotional distress, sexual activity, air, and climate. He described skin diseases dependent on food (toxidermias) and gave clear indications of rheumatism as a cause of skin diseases—a thought already expressed by Galen. Lorry adhered to the humoral theory, first expressed by Hippocrates, and believed that skin glands secrete corrupted humors. Although many authors worked in the field of dermatology over many centuries, it still could not form 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) did the English physician Willan and his student Bateman widely disseminate the basic principles of diagnostics already indicated by Plenck. Willan reduced all the extraordinary, at first glance, variety of skin eruptions to just 9 initial changes of the skin: 1) macula, 2) exanthema, 3) papula, 4) vesicula, 5) bulla, 6) pustula, 7) squama, 8) tuberculum, 9) excrescentia. In accordance with this, all diseases were placed into 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 during its diseases. At the same time, the dermatologist Alibert emerged in France. He remained alien to Willan's classification and built his own 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 gain popularity. At the same time, Alibert paid great attention to the connection of skin diseases with diseases of internal organs and proposed the use of externally irritating agents for the therapy of skin diseases. Following Alibert was a large number of physicians from the Saint-Louis Hospital, who created the French dermatological school. Biett, a student of Alibert, became imbued with Willan's teaching and from 1820 taught a course in dermatology parallel to his teacher Alibert, but in a different direction. Lugol, a contemporary of Alibert and Biett, proposed the use of potassium iodide for scrofula; he also proposed the so-called Biett's mixture (see) for the treatment of syphilis. Cazenave (1795–1877), a student of Biett, attached great importance to temperaments, with the difference of which one and the same cause causes different diseases (thus, in persons with a nervous temperament, it causes a papular eruption—lichen, prurigo; in persons with a lymphatic temperament—a pustular eruption—impetigo; in persons with a sanguine temperament—a vesicular eruption—eczema, etc.). Cazenave described pemphigus foliaceus and lupus erythematosus. In Cazenave's lectures, published in 1853, skin diseases are divided into 8 classes; the basis of the division is not morphological, but 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 skin appendages. Gibert (1796–1866), another student of Biett, described the disease pityriasis rosea, which still bears his name. In the field of syphilidology, he proved the contagiousness of secondary manifestations of syphilis through inoculations on humans, in opposition to the opinion of his famous contemporary, the syphilidologist Ricord. Devergie (from 1841) is credited with the description of a severe skin lesion—pityriasis rubra pilaris Devergie. Rayer (1793–1867), also a student of Biett, compiled a textbook of skin diseases (1826–1827–1835), illustrated with an atlas, and gave an accurate description of the various stages of eczema, which were often mistaken for different diseases. He attached great importance to the study of the connection of skin suffering with diseases of the blood, the nervous system, and other internal organs. His classification is also based not on morphological, but on anatomical and physiological data (inflammations, changes in secretion, neuroses, etc.). Bazin also paid great attention to the connection between skin diseases and internal organs, trying to study the entire organism of the patient and clarify the full picture of all disorders in the organism, among which skin diseases constitute only a part of the whole. Bazin distributed all skin diseases depending on internal causes among four basic constitutional diseases: syphilis, scrofula, arthritism, and herpetism. 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 eruption, in the third—gummata, in the fourth—lesion of internal organs. In scrofula, in the first period—tumors of the lymph glands, mild forms of eczema, inflammation of mucous membranes (eyes, bronchi, vaginal entrance), in the second period—lupus, in the third—tumor albus, in the fourth—tuberculosis of internal organs. In arthritism, in the first period—bronchitis, mild and quickly passing eruptions, in the second—acute rheumatism of the joints and more persistent eruptions: psoriasis, eczema chronicum, in the third period the suffering of the joints continues, in the fourth—lesions of internal organs: heart (endocarditis) and brain (delirium, dementia, apoplexia).

In herpetism (which especially abounds in skin afflictions), in the first period there are widespread rashes: eczema universale, urticaria, zona, pemphigus; in the second period, persistent rashes: eczema chronicum of the popliteal fossae and cubital flexures, psoriasis, pityriasis, lichen, and various neuralgias; in the third period, metastases in internal organs: capillary bronchitis, asthma, dropsy; in the fourth period, a general severe lesion of the skin (herpetide exfoliatrice) and severe lesions of internal organs, including hemorrhage and softening of the brain. Hardy (1811–93) adhered to the doctrine of Bazin, calling the predisposition to skin diseases a dartrous diathesis (diathèse dartreuse), which combined Bazin's herpetism and arthritism. Among German physicians, Schönlein (1837) described the vegetable fungus of favus, Achorion Schönleini, and Eichstedt (1846) described another fungus, Microsporon furfur, in pityriasis versicolor. German physicians also held to the theory of corruption of the humors (dyscrasia). Thus, Schönlein and Fuchs speak of rheumatic, catarrhal, and erysipelatous dyscrasia. In skin diseases, they distinguished the periods of germination, development, flowering, maturity, fruiting, and withering of the rash. In Vienna, in a large hospital in the department of chest diseases, which was headed in 1841 by Skoda, there existed a large, neglected department of skin diseases, known by the name of the 'scabies ward.' Skoda suggested that the young physician Ferdinand Hebra take up skin diseases. Hebra soon transformed the 'scabies ward' into a world-famous dermatological clinic, and he himself became the founder of the Vienna Dermatological School. Under the influence of his teacher, the anatomist Rokitansky, he compiled a pathological-anatomical classification, dividing skin diseases into 12 groups: 1) hyperemias, 2) anemias, 3) anomalies of glandular activity, 4) exudative processes, 5) hemorrhages, 6) hypertrophies, 7) atrophies, 8) benign neoplasms, 9) malignant neoplasms, 10) skin ulcers, 11) neuroses of the skin, 12) parasitic diseases. Hebra compiled an excellent textbook, which to this day can serve as a handbook for the dermatologist. He described a number of rare forms of skin diseases: lichen ruber, lichen scrophulosorum, impetigo herpetiformis, pityriasis rubra, rhinoscleroma. Remarkable are his debates with the French dermatological school, which held to the humoral theory and considered the majority of skin diseases to be an expression of the corruption of the humors in the organism or a special dyscrasia, diathesis, or constitutional disease. From Hebra (1880) to our time, one can note the following outstanding facts from the field of dermatology: regarding the anatomy of the skin, the structure of connective tissue—its cells and fibers—has been studied (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, Dogiel, Smirnov, Timofeev, Leontovich, and others); the structure of the epithelial covering, the 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 the varnishing of the skin (Foucault, 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, Noishevsky); on the segmental innervation of the skin (Head, Blaschko); on the secretion of sebum and sweat and their composition (Arnozan, Leubuscher). In the clinical field, a tendency toward the comprehensive examination of skin patients using various methods of investigating the nervous system, blood, secretions, heart, respiratory organs, digestion, etc., has sharply emerged. Russian dermatologists played a prominent role in the development of this clinical direction. Such are the 'Dermatological Studies' from the clinic of Prof. Polotebnov (St. Petersburg, 1886–87). Among experimenters on animals, one can point to Max Joseph, Moskalev, and Ter-Gregoryants, who removed cervical intervertebral ganglia, which resulted in hair loss in the corresponding areas, and to Kozhevnikov, who proved, by injecting mercury and bismuth preparations into the arteries of animals, the dependence of deep gangrene in humans, upon injection of the named preparations, on their entry into an artery. In the pathological anatomy of the skin, enormous progress has been made thanks to the frequent excision of pieces of skin during life. Entire textbooks on histological changes of the skin have been compiled (Unna, Friboes, Kyrle, Lebedev). Pathological-anatomical autopsies established the dependence of herpes zoster (Baerensprung, Head, Campbell, and others) on diseases of the nervous system, and of Addison's disease on diseases of the adrenal glands. Bacteriology 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 was revealed, 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, Unna's gutta-percha gauzes, etc.), and then of physical methods of treatment (massage, electricity, heat, Bier'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 Viennese schools, having lost their sharp contradictions, although still remaining each with its own special coloring, widely developed their activity. In France, dermatologists are still concentrated at the Hôpital Saint-Louis, but alongside this school, schools of southern France have developed—in Lyon, Bordeaux, and recently in Strasbourg. The most prominent authors of French dermatology textbooks are Hardy (1886), Dubreuilh (1899), Brocq (1906–1921–1924), Darier (1909–1923), Sabouraud (1924). Especially valuable is the publication edited by Besnier, 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 Besnier with a mass of notes, almost equal to the text, clarifying the difference in views between the French and Viennese 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 proceedings (Bulletins de la Société française de dermatologie et de syphiligraphie). In the Vienna dermatological clinic, Hebra's successor 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, Kromayer, Scheske, and others). Since 1926, the multi-volume textbook Handbuch der Haut- und Geschlechtskrankheiten has been published in collaboration 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 provided with a multitude of valuable illustrations. The German Dermatological Society works fruitfully. In English, Italian, American, and Japanese literature, there are also their own manuals and journals. Dermatologists unite at world dermatological congresses. The World Congress of Dermatologists took place in Paris in 1889, one of the subsequent ones in 1897 in Moscow. The war of 1914–18 introduced a break in the work of the world congresses, the last of which was convened in 1912 in Rome. After an 18-year break, the next world congress is being convened in Copenhagen in 1930. In Russia, dermatology began to develop with the formation of dermatological departments, which were opened in 1869 in Moscow (at the Novo-Ekaterininskaya Hospital) and in Warsaw, and 2 years later, in 1871, at 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 striving to supplement clinical research with pathological-anatomical and bacteriological data. Prof. 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 was translated into German. Prof. of Kiev University M. I. Stukovenkov (1843–97) described a number of rare skin diseases (rhinoscleroma, Kaposi's pigment sarcoma, Pendinsky ulcer, atrophic striae of the skin, mycosis fungoides of Alibert). Prof. of Kazan University A. G. Ge left his successors a well-organized clinic. Prof. of Moscow University A. I.

A. I. Pospelov (1846–1916) made great contributions to dermatological science, assembled a large museum of artistically executed wax models, founded the Moscow Dermatological Society, and compiled the "Guide to the Study of Skin Diseases" (1905). Professor of Kharkiv University I. F. Zelenev (1860–1918), in addition to numerous works, published the "Russian Journal of Skin and Venereal Diseases" from 1900 to 1916. Professor of the Higher Women's Courses (now the 2nd Moscow State University) in Moscow A. I. Lyants (1856–1920) left a number of works on skin diseases. Professor of Tomsk University A. A. Lindstrem (1858–1920) left works on scleroderma and lichen planus. Professor of the Institute for the Advanced Training of Physicians in Leningrad O. V. Petersen (1849–1919) left more than 100 scientific works. The "Krutye Ruchyi" leprosarium in the Yamburg Uyezd of Leningrad Governorate owes its origin to him. Professor of Turkestan University A. I. Lebedev (1887–1923) compiled a guide to the study of histopathological changes in skin diseases and syphilis. Professor of the State Institute of Medical Knowledge in Leningrad G. F. Fridman left works on psoriasis and favus. Professor 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 directorship, many women graduated who dedicated themselves to the study of dermatology and syphilidology. Director of the State Venereological Institute S. L. Bogrov (1878–1923) discovered, together with E. I. Martsinovsky, the causative agent of cutaneous leishmaniasis (Pendinsky ulcer). The family of Russian dermatologists grew rapidly, and at the Pirogov congresses, from their very opening 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 on the fight against venereal diseases, the first of which took place in 1923 in Moscow, the second in 1925 in Kharkiv. The convocation of the III Congress is proposed for 1929 in Leningrad. At the present time, there are a number of dermatological societies: Moscow, Leningrad, Kiev, Odessa, Kharkiv, Don, Kuban, and others. Two dermatological journals are published: "Russian Bulletin of Dermatology" and "Venereology and Dermatology." The development of dermatology, 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 their skin and of all internal organs, including the endocrine system and metabolism, as well as the study of the patient's working and living conditions, which often have a considerable influence on the emergence and spread of various dermatoses. The special study of these occupational and domestic hazards has created an entire chapter in dermatology—"occupational dermatoses," which has attracted special attention in the West and in our country over the last decades. The teaching of dermatology should be primarily visual, using patients and well-executed wax models. In modern teaching of dermatology, great progress is noted. While in dermatological clinics in the pre-revolutionary period, the teaching of dermatology was reduced exclusively to a lecture system and the supervision of one patient, at the present time practical classes are conducted, and the study of all patients in the clinic is mandatory. Along with familiarization with the clinic of skin diseases, familiarization with laboratory methods of their investigation has been introduced as a rule (see also Venereology). The practical significance of dermatology is very great, because, in addition to rare diseases, it covers a number of social contagious diseases, such as: leprosy, Pendinsky ulcer, trichophytosis, which currently has an epidemic spread, scabies, which numbers more than 5,000,000 patients annually in the USSR, as well as occupational diseases (eczema, dermatitis, etc.). Likewise, dermatology has enormous significance for the diagnosis of syphilis. The development and teaching of dermatology in the USSR is conducted mainly in the dermatological clinics of universities and medical institutes, as well as in special dermatovenereological institutes.