Man's health, the functioning of the nervous, endocrine, cardiovascular and other systems of the body, the character

of the activity of separate internal organs, the activity and tendency of metabolism, and many other factors cause a direct or indirect effect on the condition and function of the skin. There is a direct dependence between the skin and the activity of the organism as a whole. Beginning the study of dermatology with the anatomy and physiology of the skin, it should therefore be emphasized that the skin is an integral organ closely related to all functions of the organism. SKIN ANATOMY AND HISTOLOGY Skin anatomy. The human skin (cutis) is the outer covering of the body and is continuous with the mucous membrane in the region of the mouth, nose, urogenital organs, and the anus- In an adult, the skin surface measures 1.5 to 2 m2 while the thickness of the skin (without the subcutaneous fat) varies from fractions of a millimetre (on the eyelids, the external acoustic meatus) to 4 mm (on the palms and soles). The thickness of the epidermis varies from 0.06-0.09 mm (on the eyelids) to 0.5-0.8 mm (on the palms and soles). The thickness of the subcutaneous fat varies considerably: some areas are devoid of fat while in others (on the abdomen and buttocks of obese persons) it is several centimetres thick., The mass of skin i an adult accounts for approximately 5 per cent while together with the subcutaneous fat for about 16 to 17.7 per cent of the total body mass. There are numerous furrows, folds and depressions on the skin surface which form a complicated pattern of triangular or rhomboid fields. The wrinkles on the face and the folds on the palms, soles and scrotum are the coarse furrows of the skin. The ridges and furrows running parallel to each other on the skin of the palms and the plantar surface of the fingers form diverse figures the pattern of which is very individual and is an authentic distinctive mark of a person (dactyloscopy). The skin has a mat tinge and a peculiar colour due to the colour of its component tissues, the thickness of the granular and horny layers, the blood vessels visible through the skin, and the presence of the pigment melanin. The colour of the skin may change because the amount of the pigment in it varies under the effect of external and internal factors. The skin surface is covered with hairs over a great area. The areas devoid of hairs are the lips (vermilion border), the palms and soles, the palmar surface of the fingers and the plantar surface of the toes, the glans penis, the inner surface of the prepuce, and the in-jier surface of the large and small pudendal lips. There are hardly noticeable pores on the skin surface which are openings of the sweat and sebaceous glands. In some diseases (e.g. seborrhoea) these pores are seen with the naked eye. The distal phalanges of the fingers and toes have nails on their dorsal surfaces. Skin histology. In ontogenesis the skin develops from two germinative zones: the ectoderm (the outermost embryonal layer) which is represented by the epidermis (the most superficial skin layer) and the mesoderm (the middle embryonal layer) represented by two-layers, namely the true skin, or dermis (the middle layer) and the subcutaneous fat, or hypoderm (the deepest skin layer). The boundary between the epidermis and dermis forms a wavy line because of the presence of skin papillae (special outgrowths on the surface of the true skin) the spaces between which are filled with epithelial processes. EPIDERMIS, THE OUTER SKIN LAYER The epidermis is stratified epithelium undergoing keratinization, it consists of the following layers: (1) germinative layer, or stratum basale, or stratum germinativum; (2) prickle-cell layer, or stratum spinosum; (3) granular layer, or stratum granulosum; (4) stratum lucidum; (5) horny layer, or stratum corneum. All these layers are pronounced well in the skin of the palms and soles; the stratum lucidum is not found on the face, chest or the flexor surface of the limbs, whereas the stratum granulosum in these areas is formed of a single, sometimes interrupted row of cells. There are many nerve endings in the epidermis but no blood vessels; the cells are supplied with nutrients by the lymph flowing in the intercellular slits. The germinative layer (stratum basale or stratum germinativum) is the innermost layer of the epidermis and borders directly upon the dermis, or true skin. It consists of a single layer of prismatic

(columnar) cells arranged like a palisade; between these cells there are slit-like spaces called intercellular bridges. Large round or val nuclei are seen mostly in the upper part of the cells. These nuclei are rich in chromatin and stain deeply with main nuclear dyes and because of that they seem darker than the nuclei of the cells of the overlying layers. In addition to the prismatic cells, the germinative layer contains a few peculiar branching (dendritic) cells with small dark nuclei a light protoplasm. The bodies of these cells lie on a level with prismatic cells while their numerous processes entwine the neighbowing cells and penetrate between the cells of the overlying layers. With regard to function, the cells of the germinative layer have two features. First, they re the main sprouting (cambium) elements of the epidermis, from which cells of all the overlying epidermal layers form. The columnar cells arranged perpendicular to the basement membrane divide by mitosis. Second, the protoplasm of the cells of the germinative layer contains a pigment, melanin, in the form of brown granules of various size. It is now believed that the function of pigment-formation is inherent only in the dendritic cells of the stratum basale which are the only true melanocytes. It is considered that there are 1155 melanocytes per 1 mm2, on the average, and it was established that the number of melanocytes in intensely pigmented skin (e.g. the skin of Africans) is not more than that in people with a light skin and that the amount of melanocytes at the site of freckles is 28.6 to 44.5 per cent that in the surrounding light skin. Because of this, it is now accepted that the degree of skin pigmentation is determined by the functional capacity of the melanocytes and not by their amount. Melanin forms in the melanocyte cytoplasm through polymerization of the products of tyrosine oxidation under the effect of the enzyme tyrosinase the activity of which depends on the presence of copper ions. The function of the endocrine, glands influences the formation of the pigment actively. Stimulation of the sympathetic nerve inhibits the production of the pigment, while ultraviolet rays, ionizing radiation, and some chemical substances stimulate it. Vitamins, vitamin G in particular, play an important role in melanin formation. The prickle-cell layer (stratum spinosum) overlies the germinative layer and consists of five to ten rows of cells which are cuboid in the deep parts of the layer but become flatter gradually as they approach the next layer, the granular layer. The cells of the prickle-cell layer like the cells of the germinative layer are separated from each other by intercellular bridges and come in contact by means of protoplasmic processes. The nuclei of these cells are spherical and large and contain one or two nucleoli. Special Langhan's cells are demonstrated (with the gold stain) in this layer. They have a poorly staining nucleus and numerous branching processes stretching between other cells. These cells are devoid of pigment and are always located above the germinative layer. The nature of Langhan's cells has not been disclosed. Some authors believe that these cells are of nerve origin, others refer them to migrating leucocytes, still others claim them to be of mesenchymal origin, while a fourth group identifies them with dendritic cells devoid of the pigment. The cells of the prickle-cell layer are marked by the presence of specific tonofibrils in their cytoplasm. The tonofibrils do not pass from cell to cell but terminate in the protoplasmic processes; in the cytoplasm of the prismatic cells of the germinative layer they are demonstrated less clearly. As we approach the next layer, the stratum granulosum, the cells of the stratum spinosum become flatter gradually and elongate parallel to the surface of the epidermis and blend with the overlying layer without forming a distinct boundary. The granular layer (stratum granulosum) contains one to two or four (on the palms and soles) rows of cells elongated parallel to the epidermis; the nuclei of these cells gradually grow smaller and numerous granules which take a deep stain with the main dyes appear in the protoplasm. Some authors believe these granules to be the products of nuclear degeneration, others think that they are the result of fragmentation of the tonofibrils. It was considered previously that they were formed of a special substance called keratohyalin; it proved, however, that this substance is neither keratin nor hyalin but is related to DNA in structure. The presence of the keratohyalin granules is the first visible stage, of the beginning of the process of keratinization of the epidermal cells. The epidermal germinative, prickle-cell, and granular layers are sometimes embraced under the name of Malpighian layer. The lucid layer (stratum lucidum) overlies the granular layer and is composed of elongated cells containing a special protein substance which refracts light strongly. This substance resembles drops of oil and is called eleidin (Gr. elaia olive tree). Besides its main component, eleidin, the stratum lucidum contains glycogen and fatty substances (lipoids, oleic acid). With the commonly used staining methods, the stratum lucidum of skin areas that have a thick epithelial layer (e.g. on the palms and soles) is seen as a colourless strip. It is also demonstrated well in some

pathological processes (ichthyosis, porokeratosis). A substantiated opinion has been advanced to the effect that impermeability of the epidermis to water and electrolytes is associated with the stratum lucidum and that it consists of two layers, the upper one has an acid and the lower an alkaline reaction. There fore, this stratum is a very complex epidermal layer. The horny layer (stratum corneum) is the outermost layer of the epidermis, it comes in direct contact with the external environment and is distinguished by resistance to a variety of external factors. It is composed of fine, anuclear keratinized elongated cells. They are firmly attached to one another and are filled with a horny substance (keratin) the chemical structure of which has still not been finally determined. It is believed that this is an albunoid substance poor in water and rich in sulphur and contains fats and polysaccharides. The outer part of stratum corneum is less compact and occasional lamina separate from the main bulk, i.e. the process of physiological desquamation occurs. The various areas of the skin differ in the thickness of the stratum corneum which is especially thick on the palms and soles and very thin on the eyelids and the external male genitals. DERMIS, THE TRUE SKIN The dermis, or true skin (derma, cutis, corium) is located between the epidermis and the subcutaneous fat. Two layers are distinguished in it, the papillary (stratum papillare), or the subepithelial layer and the reticular layer (stratum reticulare). The papillary layer is that part of the dermis which is found between the epidermis and the superficial network of blood vessels. The reticular layer merges with the subcutaneous fat and is not demarcated from it sharply. The epidermis is molded into the dermis in the form of rounded strands between which the papillae penetrate, which lends the boundary between the epidermis and the dermis the appearance of an uneven wavy line; this ensures close joining of the epidermis and the true skin. The height and shape of the papillae in the same layer but in different areas of the skin differ. On the palms and soles, for instance, the papillae may be very high, whereas on skin areas with a thin epidermis they form only a wavy line which can hardly be distinguished. The presence of the papillae probably improves the conditions for the nutrition of the epidermis because in this way the area of contact between it and the dermis is greatly increased as a result of which the supply of nutrients to the epidermis from the papillary capillaries is easier. The basement membrane situated between the epidermis and the dermis plays an important role in metabolic processes though its structure is still insufficiently known. Some researchers believe that the epidermal protrusions of the membrane cells and the dermal argyrophil fibrils form a common thick network which has the appearance of a membrane, others contend that there is a true homogeneous membrane containing small amounts of lipoids and mucopolysaccharides (mainly hyaluronic and chondroitin-sulphuric acids). The true skin is composed of a fibrous substance of collagen, elastic, and argyrophil (precollagenous) fibres, and an astructural amorphous interstitial substance found between the connective-tissue fibres. The dermal papillary layer consists of thin bundles of collagen fibres and many fine elastic and argyrophil fibres. In the reticular layer the collagen bundles are more compact and thick and intertwine into a thick network of loops. Here also numerous elastic fibres, thicker than those in the papillary layer, lie between the collagen bundles and form a thick reticulum. The structure of the reticular layer determines on the main the strength of the skin which differs with the skin area. The reticular and particularly the papillary layer of normal skin have a small number of various cell elements: fibroblasts, histiocytes, lymphocytes, mast and plasma cells, and peculiar pigment cells (melanophages). Hairs, glands (epithelial appendages of the skin), muscles, vessels, nerves and nerve endings are located in the dermis. THE DEEP PART OF THE SKIN (SUBCUTANEOUS FATTY TISSUE), THE HYPODERM The subcutaneous tissue, or hypoderm, consists of thick bundles of collagen and elastic fibres stretching from the reticular dermal layer and forming a wide-loop reticulum in which accumulations of large fat cells, lobules of fatty tissue, are lodged. The fat cells are almost completely formed of a large drop of fat which displaces the cell nucleus to the periphery, and a very small amount of protoplasm. The skin fascia which is a thick connective-tissue plate is also part of the hypoderm; it often fuses with the

underlying periosteum or the aponeurosis of the muscles to form a single structure. Bundles of connectivetissue fibres stretch from the superior surface of the fascia to the dermis and form a sort of a lattice called retinaculum cutis. The thickness and length of the elastic and collagen bundles determine the degree of mobility of the skin over the underlying tissues and organs. The thickness of the hypoderm is marked by considerable variability both in different persons and on different skin areas of the same person. It is usually about 2 mm thick over the skull, 5 to 10*mm thick on the back, while its thickness in the region of the abdojnen and buttocks may reach several centimetres. There is no subcutaneous fatty tissue on the eyelids, under the nails, on the prepuce, small pudendal lips, and scrotum, and there is very little of it on the nose, ears, and lips (the vermilion border). The subcutaneous fat protects the body from mechanical injuries and cooling. Vessels and nerves are found in its thickness and hair bulbs and coils of sweat glands may grow into its upper part. Muscles of the skin. Muscles stretching obliquely in relation to the hairs and raising them on contraction (mm. arrectores pilorum) and muscle fibres in the walls of vessels and sweat glands are the smooth voluntary muscles of the skin. When the arrectores pilorum muscle contracts, it raises the hair and squeezes out the secretion from the sebaceous gland. Smooth muscle fibres which are not connected to the hair follicles are present in the skin of the scalp, forehead, cheeks, and dorsal surfaces of the hands and feet. Considerable layers of these fibres are found in the papillary layer of the skin on the scrotum, the axillae, the nipple, and in the regionthe anus and the prepuce. The muscles which lend expression and mobility to the face are the striated muscles of the skin. BLOOD SYSTEM OF THE SKIN The blood system of the skin is formed of several networks of blood vessels. Large arterial vessels stretch from the fascia through the subcutaneous fat and give of! small branches to the fat lobules. On the boundary of the dermis and hypoderm, they divide into branches which stretch horizontally and anastomose with one another. A deep arterial plexus of the skin forms, which gives rise to branches supplying the coils of the sweat glands, the hair follicles, and the fat lobules. In addition, the deep arterial plexus gives off quite large arteries which reach the subpapillary layer and form here a superficial subpapillary arterial plexus. The small arterial branches originating from it supply the muscles, the sebaceous and the sweat glands, and the hair follicles. The subpapillary plexus also gives rise to small arteries which do not anastomose (and are therefore called end arteries) but pass parallel to the epidermis for some length. They give off capillaries which pass into the papillae and form loops in them. These loops are continuous with loops of venous capillaries which are wider than the arterial capillaries. The venous capillaries stretching from the papillae, the sebaceous glands, the draining ducts of the sweat glands, the hair follicles and muscles come together and form the first superficial subpapillary venous plexus. In the area up to the boundary with the subcutaneous fat, there are four venous plexuses. The veins arising from the fourth plexus pass through the hypoderm and drain into the subcutaneous veins. The epidermis is devoid of blood vessels. The most powerful network of blood vessels is located in the skin of the face, palms, soles, lips, genitals and in the skin around the anus. LYMPHATIC SYSTEM OF THE SKIN The lymphatic system of the skin forms a superficial and deep networks. The superficial lymphatic network arises in the papillary layer as blind rounded dilated capillaries between which there are numerous anastomoses. The second network of lymph vessels is in the lower part of the dermis and already has valves. This is a network of wide loops forming a lymphatic plexus which in deeper parts is continuous with lymph trunks. NEURO-RECEPTOR APPARATUS OF THE SKIN The skin is richly supplied with nerve fibres and special nerve end apparatus or nerve endings which form together a large receptor field of the skin as the result of which it can accomplish the function of a sense organ. Both the cerebrospinal and the vegetative (sympathetic) nerves contribute to the innervation of the skin. The main nerve plexus is in the deep parts of the subcutaneous fatty tissue. The skin nerves originating

from it ascend through the thickness of the true skin and give off along their length numerous small branches to the hair follicles, the sebaceous and sweat glands, and the vessels of the skin. A plexus of closely arranged nerve fibres is located in the subpapillary layer, from which separate nerve branches penetrate the papillae and epidermis. On approaching the epidermis, the fine nerve fibres lose their myelin sheath and penetrate the intercellular bridges of the germinative and prickle-cell layers as demyelinated axial cylinders. There are free (non-capsulated) and encapsulated nerve endings (receptors). The free nerve receptors are either dendriform or coil-shaped, sometimes with a button-like or funnel-like thickening on the end of a very fine fibre. Nerve endings (bodies, or corpuscles) are enclosed in a connective-tissue capsule. The sensory nerves of the skin and the special end apparatus make it possible to perceive the sensation of pain, warmth, cold, pressure, and touch. There are several varieties of the encapsulated nerve bodies, depending on the structure of the end branchings of the nerve (inner bulb) and the outer capsule. The following encapsulated end apparatus are distinguished in the human skin: laminated Vater-Pacini corpuscles, Golgi-Mazzoni bodies, Meissner's corpuscles, Krause's bulbs, and Ruffini's bodies. Some authors, however, claim that there are no Ruffini's bodies in the human skin. represents schematically some of the end nerve apparatus. Laminated Vater-Pacini corpuscles are the largest encapsulated receptors, which may measure 3 mm and more. They are usually located in the subcutaneous fatty tissue and are thought to be the receptors of the sense of deep pressure and proprioceptive sensations. They are found in especially large amounts on the palms, soles, and genitals. Fine, connective-tissue laminae, between which there is tissue fluid, form capsule of the laminated corpuscle. The capsule has a cylindric cavity in its centre (inner bulb). Blood and lymph capillaries are supplied to the capsule. The nerve fibre approaching the corpuscle loses its sheaths and enters the centre of the capsul as a demyelinated axial cylinder. It stretches along the entire cavity of the inner capsule, gives off fine lateral branches, and ends as a mace-like thickening. Golgi-Mazzoni bodies are now considered to be a variety of laminated corpuscles although they are much smaller than these corpuscles and are located not in the hypoderm but in the dermis almost directly under and in the papillae. Meissner's tactile corpuscles are situated in the papillae and have an elongated-oval shape. Their outer connective-tissue capsule is tnin and special 'tactile cells' are arranged inside it horizontally in relation to the long axis. The myelinated nerve fibre approaches the lower pole of the capsule, loses its sheaths, and as a naked axial cylinder penetrates the capsule in which it forms meniscus-like thickenings adjoining the tactile cells. Meissner's corpuscles are developed especially well in man, in whom the tactile function is very important in every day activity, in work in particular. The corpuscles are present in especially large numbers in the finger-tips, lips, and tongue mucosa. Krause's bulbs (the receptors for the sensation of cold) are situated in and under the papillae. They are composed of a fine connective-tissue capsule and are oval. The nerve fibre loses its sheaths, enters the capsule and forms a thick coil in it. Ruffinis bodies (receptors for the sensation of warmth) resemble Krause's bulbs in structure but are located much deeper, in the deep parts of the dermis and in the upper parts of the subcutaneous fat. GLANDULAR GLANDS APPARATUS OF THE SKIN. SEBACEOUS AND SWEAT

The glandular apparatus of the skin is varied and consists of the sebaceous and sweat glands of different structure and a diverse principle of functional activity. The sebaceous glands (glandulae sebaceae) are related to holocrine glands in the character of secretion, i.e. glands in which the formation of the secretions is associated with physiological degeneration and decomposition of the cells of the gland. This occurs as follows. The intensively dividing epithelial cells of the sebaceous gland are arranged in a single row on the periphery of the sac of the gland. They are gradually displaced from the wall of the gland to the centre and undergo physiological degeneration as a result of which many drops of a fat-like substance form in them while the nuclei of the cells shrink. The cells that had undergone fatty degeneration swell and rupture, and the secretion of the gland, sebum, together with the cell fragments enters the wide draining duct of the gland. The sebaceous glands are found in all skin areas with the exception of the skin of the palms and soles. In most cases they are connected to the hair follicles, one or more (up to six or eight) sebaceous glands

surrounding a follicle. Contraction of the mm. arrectores pilorum promotes the discharge of the secretions. In the skin of the vermilion border, glans penis, inner surface of the prepuce, small pudendal lips, nipples, and the eyelid margins the sebaceous glands open directly on its surface without any association with the hair follicles, of which these areas are devoid. Sebaceous glands of the inner surface of the prepuce are called Tyson's glands (they produce smegma), those on the margins of the eyelids are known as maibomian glands. The amount of sebaceous glands not connected with the hair follicles varies greatly in man. The size of these glands is also just as variable; they are largest on the skin of the nose, cheeks, in the region of the sternum, and above and between the shoulderblades. The composition of the sebum is complex. It includes free and bound lower and higher fatty acids, cholesterol and isocholesterol esters, lipoids, protein products, phosphates, chlorides and other extractive substances among which are those which have been insufficiently studied. In the atmosphere, the sebum turns into a thickening mass. The sweat glands (glandulae sudoriberae) are simple tubular glands which secrete sweat by reflex and play an important role in thermoregulation. In the human skin their number exceeds 3 million. According to the character of secretion, eccrine and apocrine sweat glands are distinguished. In the process of secretion, the cells of the eccrine glands are preserved while the apical part of the cells of the apocrine glands is destroyed and turns into the secretions. The sweat glands secrete 300 to 800 ml of sweat daily; in unfavourable conditions its amount reaches 1500 ml and more. The eccrine sweat glands are found in all skin areas with the exception of the vermilion border, the glans penis, the inner surface of the prepuce, and the outer surface of the lesser pudendal lips. They are present in particularly large numbers in the skin of the palms, and soles and there are many of them on the forehead, chest, abdomen and forearms. The eccrine gland is a long epithelial tube which has a coiled end (the body of the gland) located in the deep layers of the dermis, less frequently in the upper layers of the hypoderm, and a long draining duct. The wall of the body, or the secretory part, of the gland consists of glandular cuboidal or columnar epithelium, a basement membrane, and a connective-tissue capsule. At rest, the secretory cells have a columnar shape and contain many basophil inclusions in the form of granules of various size, drops of fat, and vacuoles; after the secretion is discharged they become flatter. There is a layer of longitudinally stretching muscle fibres between the epithelium and the basement membrane. They are called the myoepithelial cells and contract under the effect of nerve impulses and thus contribute to the secretion of sweat. The draining duct of the eccrine sweat gland stretched upward from the body of the gland almost perpendicular to the epidermis. In the dermis, the wall of the duct is formed of epithelial cuboidal cells, in the epidermis the duct has a twisted corkscrew shape and preserves its own walls, which was proved by G. Pinkus and K. Kalantaevskaya independently of each other. The apocrine sweat glands are located predominantly in the axillae(where they form a whole layer 0.5 to 4 mm thick) and there are very many of them around the anus, in the region of the nipples, the external female genitals, in the groin, on the pubis, and around the umbilicus. It was mentioned above that when these glands discharge their secretions part of the secretory cells die. The apocrine glands are larger than the eccrine glands, their draining ducts open into the hair follicles, while their body lies deep in the subcutaneous fat. The activity of the apocrine glands is linked with the activity of the sex glands and they therefore remain underdeveloped until the period of sexual maturation. In the elderly their function weakens. The body (coil) of the sweat glands is surrounded by many capillaries forming a thick network. Innervation is mainly accomplished by branches of the sympathetic nerve, which are located in the connective-tissue capsule. HAIR AND HAIR FOLLICLES Several types of hair are distinguished: long (on the head, beard, moustache, in the axillae, pubis, genitals); bristly (eyebrows, eyelashes, the hair in the nose and external acoustic meatus); downy (on the face, trunk, and limbs). The length, thickness of localization, rate of growth, and shedding of hair vary considerably in the different skin areas. There are 300 to 320 hairs per 1 cm 3 on the crown of the head, 200 to 240 on the back of the head, 44 on the chin, 24 on the dorsal surface of the forearm, and 18 per 1 cm2 on the dorsal

surface of the hand (Brunn). According to different authors, there are 30 000 to 150 000 hairs on the scalp. The rate of hair growth varies from 0.1 to 0.5 mm per 24 hours and increases or decreases depending on the general condition, the function of the nervous system and the endocrine glands, the value of nutrition, and many other factors which exert an effect on tissue trophies. The duration of the life of hairs varies from several months to four years and longer; under normal conditions, an adult loses 30 to 100 and more hairs daily. The hair consists of a shaft rising above the skin surface (the outer or free part of the hair) and a root buried in the dermis. The hair root enclosed in membranes and a connective-tissue capsule is called the hair follicle, or sacculus. The lower expanded part of the root is known as the hair bulb, this is the site from which the hair grows. The hair papilla conveying nerve fibres and blood vessels supplying nutrients to the hair protrudes into the bulb. The hair follicle is cylindrical in shape and terminates on the skin surface as a peculiar expansion called the infundibulum of the follicle, through which the hair shaft passes. The draining ducts of the sebaceous glands are connected with the follicle on the boundary between its upper and middle third. The wall of the hair follicle is lined with epithelium which preserves all its layers in the region of the infundibulum but is represented only by the cells of the stratum basale and stratum spinosum below it (the outer root sheath). As this sheath penetrates deeper and comes nearer to the bulb it thins out gradually and deep in the follicle it merges with the cells of the hair bulb. The hair bulb is formed of polygonal cells which multiply continuously and contain a great amount of pigment. The cells of the bulb give rise to the hair and to several rows of cells located between the hair root and the outer root sheath. They form the inner root sheath which almost reaches the site where the ducts of the sebaceous glands open. It consists of three layers: (1) the inner root-sheath cuticle formed of a single layer of keratotic cells lying close to the hair cuticle; they are poorly distinguished on sections; (2) Huxley's layer (one or two rows of polygonal cells, those located deep in the layers of the hair follicle, have a shrunken pyknotic nuclei while cells found in its upper parts are devoid of nuclei);Henle's layer, the outer layer of a single row of keratotic cells devoid of nuclei. At the site of the orifice of the sebaceous gland, the cells of Huxley's and Henle's layers become squamous, disintegrate, and mix with the sebum. Three layers are also distinguished in the hair root: (1) the central layer, called the medulla, consisting of keratotic polygonal cells; it is found only in long hair; (2) the bulk of the hair, the cortex, formed of spindle-shaped keratic elements containing a large amount of pigment; (3) the hair cuticle formed of keratic laminae devoid of pigment and arranged like tiles. The cuticles of the hair root and inner root sheath are connected to each other and ensure^ strong fixation of the hair to the walls of the hair follicle. The connective-tissue capsule of the hair follicle contains many fine elastic and argyrophil fibres which form the basement membrane on the boundary with the outer root sheath. Like the hair bulb, the hair follicles are surrounded by many nerve fibres. The hairs are supplied with smooth muscles (mentioned above) shaped like a band, one end of which is attached to the compact dermis layer and the other to the outer connective-tissue hair sheath slightly below the orifice of the sebaceous gland. On contracting, the muscle raises the hair which thus compresses the sebaceous gland and facilitates the excretion of the sebum. NAILS The nail (unguis) is a horny plate on the dorsal surface of the distal phalanx of the fingers and toes (nail bed). The proximal end and sides of the nail plate are covered with skin folds called the nail folds. The nail has a body (corpus unguis), a root (radix unguis) which is its proximal part, and a distal free margin (margo liber) that freely protrudes forward. The proximal nail fold covers the proximal part of the nail plate like an arch and forms a thin horny plate of the epidermis, the nail cuticle (eponychium). The area of the nail bed covered by the nail root is called the matrix (matrix unguis); this is where the nail grows. In the proximal part of the nail body (which corresponds to the distal part of the matrix) there is a whitish crescent area called the lynula; it is particularly noticeable on the thumb and big toe. The nail plate is formed of hard compact horny masses the outer surface of which is smooth, whereas the inner surface is rough because it has horny ridges which ensure close fitting of the nail plate to the nail bed. Large cells with a homogeneous light protoplasm, unclear outlines, and abnormal nuclei are found in the region of the matrix near to and under the root of the nail. They are called onychoblasts and are thought to

be concerned with nail formation. It is believed that in the region of the matrix the onychoblasts are responsible for growth of the nail plate in the direction of the free margin, whereas in the region of the nail bed they simply contribute to the thickening of the nail. The nail plate moves gradually along the nail bed and is completely renewed in 90 to 115 days. MAIN ANATOMICAL AND HISTOLOGICAL FEATURES OF CHILD'S SKIN Like the whole organism, the skin in children is in a state of organic and functional development from birth to puberty, which is reflected in the physiology and pathology of the skin in the different periods of early childhood (in the newborn, in infants, in young children) and at a more mature age. A marked effect is produced on skin physiology and pathological conditions in the different periods of childhood by hereditary and constitutional factors, allergic and immunological reactivity of the child's organism, the activity of the nervous and endocrine systems, and the metabolic processes in the growing organism. The social and life conditions, the care of the child, and the character and assimilability of the child's diet are factors which also influence the pathological processes in the skin. The skin begins to form from two embryonal buds in the first weeks of intrauterine life. The epidermis forms from the ectodermal germinative layer, ectoderm, and the dermis and subcutaneous fat from the mesoderm. By the end of the second month of uterine life, there are two layers of polygonal cells in the epidermis, the buds of elastic and collagen fibres form in the dermis, and the formation of the hair follicles and the sebaceous and sweat glands begins. By the end of the fourth and in the fifth month of intrauterine life, all the layers of the epidermis are clearly outlined, the formation of the elastic and collagen fibres is completed, and the formation of the nails, hair, and fat lobules in the hypoderm begins. The buds of the sweat glands are distinguished in the skin in the second month of intrauterine life, the buds of the apocrine glands between the second and third months, while the buds of the sebaceous glands are revealed much earlier, between the second and third weeks, and their formation is completed by the third or fourth month that is why the skin of the newborn is entirely and abundantly covered with an unctuous lubricant (vernix caseosa). The first hair buds appear in the region of the eyebrows on the second or third month of intrauterine life; the formation of hair buds over the whole skin surface is completed by the fourth or sixth month. This hair appearing first is unmodulated, atrophic and is rapidly lost. Formation of the nails begins in the third month of embryonal development. The nail grows very slowly and reaches the tip of the finger only at the end of pregnancy and the maturity of the newborn may therefore be judged by the length of the nails. Complete structural formation of all main anatomical skin components occurs in the second half of intrauterine life. Children grow and develop so intensively and with such significant differences in the structural functional features of the whole organism, and of its separate organs and systems, that from the didactic standpoint six main periods in the development of children are commonly distinguished: the first period (from birth to three or four weeks), the period of the newborn; the second period (from three or four weeks to 12 months), the period of breast-feeding, or the period of infancy; the third period (from one to three years), the period of early childhood, or nursery age; the fourth period (between the ages of three and seven,) the period of preschool age; the fifth period (between the ages of seven and twelve), the period of young school age; the sixth period (from twelve to eighteen), the period of older school age, or the period of adolescence, or the period of puberty. Underdevelopment of the central nervous system, lability, imperfect immunity, and variability of metabolism are especially revealed before the age of three years. These conditions together with the abundance of vessels in the child's skin, its looseness, a high content of water, increased permeability of vessels and tissues lead to a more frequent and more turbulent development of allergic reactions in children, particularly those of the first three or four age groups. The epidermis of the newborn is covered with a skin lubricant, the periderm, and only three layers (stratum basale, stratum spinosum, and stratum corneum) are found in the epidermis over a long distance. Stratum granulosum and stratum lucidum in this age group begin forming only on the palms and soles. At the same time, the epidermis on the palms and soles is much thinner in children than in adults, while the papillae and epidermal strands are still poorly developed. This explains the smooth velvety appearance and indistinct pattern of the child's skin. The rapid physiological change of the epidermal layers in children and the loose arrangement of the cells that are undergoing keratinization are attributed to intensive mitotic division occurring not only in the stratum basale, but also in the stratum

spinosum and stratum granulosum. The dennis in children, like the epidermis, has marked structural specific features which distinguish it from the dennis of an adult. In a child, for instance, there is a prevalence of cell elements while the elastic and collagen fibres are insufficiently developed. During the entire period of childhood, changes are revealed in the structure, compactness, and extent of the fibrous substances. The papillary layer is flattened out or is seen as a wavy line, except that on the palms, soles, the dorsal surface of the hands and feet, and the lips (vermilion border) where the papillae are well developed by the time of the infant's birth. All the fibres (elastic, collagen, and argyrophil) in a child are poorly developed, insufficiently differentiated, short, unclearly outlined, and abnormally thin or thick. For example, in the papillary layer the elastic fibres, which are prevalent here, have the structure of thin fibrils and are arranged perpendicular to the skin surface. In the reticular layer, the collagen fibres are scattered at random, they do not form the regular rhomboid-triangular network and have a fibrillar structure; there are many elastic argyrophil fibres among them. The argyrophil fibres in a child's skin are short and weakly convoluted, which is believed to be associated not with their coarsening but with the unclearness of their outlines because the process of their formation into fine thin fibres is still not completed. The collagen tissue in this period is also composed of very fine non-hyalinized fasciculi and only with the gradual growth of the organism do the collagen fibres become hyalinized and thickened (in the aged this process leads to clear collagenization of the whole dennis, its sclerosis, drastic thinning of the argyrophil fibres, and the formation of gross fasciculi of fibres in the elastic network with the conversion of elastin to elacin; it is possible that this process is linked with a shift of the acid-base equilibrium in the acid direction). The dermis in the period of the newborn and the nursery period is marked by the presence of a large number of various immature connective-tissue cells among which the most common are histiocytes, fibroblasts, reticulocytes, lymphocytes, melanophores, melanoblasts, and mastocytes. The last are also called Ehrlich's mast cells and play an important role in delayed allergic reactions; during the antigenantibody reaction they produce great amounts of histamine, heparin, hyaluronidase, protease, and other biologically active factors which are conducive to an increase in the permeability of the vascular walls and tissues and, therefore, to the frequent occurrence of delayed allergic reactions. In the subcutaneous fat of children, especially the newborns and infants of nursery age, there is an abundance of fatty lobules and, as a result, looseness of the pronounced hypoderm. The connective tissue alveoli separating the accumulations of fat cells are formed by processes of collagen fibres which are still immature and unclearly outlined. The fatty lobules are composed of small incompletely differentiated fat cells containing large nuclei. As compared to the fat cells of adults, those of children contain liquid oleic acid in a lesser proportion but larger amounts of high-melting denser acids such as stearic and palmitic acids, which determines a high turgor of the subcutaneous fat and rapidly developing thickening of the dermis and hypoderm in sclerema and scleroderma of the newborn. The characteristic features of the child's blood system are a single layer of endothelial cells forming the walls of most vessels and increased permeability of vessels which are visible through the thin epidermis. This, and the insufficiently developed dermis, are responsible for the 'physiological hyperaemia in the newborn and the peculiar pink-mother-of-pearl colour of the skin in older children. By the time of the child's birth the sweat (eccrine) glands are already formed but their functional activity is low because the cerebral centres controlling sweat production are still insufficiently differentiated and there is no physiological equilibrium between the cortical and subcortical structures. Sweating increases gradually in the first two years of the child's life. Insensible perspiration (perspiratio insensibilis) predominates in child-type perspiration; it is especially intensive in the first year of life. It is replaced by adult-type perspiration during puberty. The apocrine sweat glands develop completely within the first year of life, but they begin functioning only in puberty. The sebaceous glands of children are larger than those of adults and are found in large numbers on the face, scalp, back, and in the region of the anus and genitals. With the growth of the child, the intensity of the sebum-producing function of the glands decreases and some of them atrophy completely. By the time of the child's birth, secondary, or infantile, hair grows, while the lanugo which had appeared during intrauterine life is shed rapidly. Down hair (lanugo) covers almost the entire skin of the newborn, with the exception of the lips (vermilion border), palms, soles, lateral surfaces of the fingers and toes, the dorsal surfaces of the distal phalanges, nipples, the glans penis, the inner surfaces of the prepuce, clitoris, and the small pudendal lips. During the first year of life the downy hair is shed several times and new hair grows. Long hair grows on the baby's scalp. Bristly hair forms the eyebrows

and eyelashes. During puberty hair appears in the axillae and over the pubis; at this same time it begins to grow on the face of boys. The muscles of the skin are underdeveloped in children. For instance, the smooth-muscle fibres of the skin of the scrotum, around the anus, on the nipples and in the axillae are somewhat atrophied, thin, and loose. Their formation is completed only in the pubertal period. Because of the thin epidermis and the underdeveloped connective-tissue fibres of the dermis, irritability of the nerve receptors and special nerve terminal apparatus of the skin in children is increased. With the child's growth, the skin nerve apparatus becomes less accessible to the external stimuli and, in addition, the regulating and coordinating influence of the central nervous system is noticeably intensified, SKIN PHYSIOLOGY The skin and external mucous membranes separate the human organism from the environment and accomplish a variety of functions. Normal functioning of the skin and its appendages is of high significance for the organism's activity as a whole and has a positive influence on its general condition. The skin not only responds by its adaptative reactions to the different effects of the external (exogenic) environmental factors, but is also very sensitive to changes in the various body organs and systems and is often the first to signal the development of a pathological condition by different changes in its function. Consequently, though the skin is an independent organ, it at the same time is in a constant dynamic connection with the external environment and with all the organs and systems of an adult and child. The skin communicates with the organism by means of the nervous system, circulation and endocrine glands. The skin takes an active part in protein, carbohydrate, fat, water-mineral, and vitamin metabolism. PROTECTIVE (BARRIER) FUNCTION OF THE SKIN Many properties of the skin, subcutaneous fat, and skin appendages allow us to speak of the barrier function of the skin in a broad sense, a function which contributes to the protection of the underlying organs and tissues from the pathogenic effect of the diverse environmental factors. The skin is resistant to mechanical effects (blows, friction, compression, etc.) because of the tightness of its epithelial covering and the presence of a large amount of resilient elastic and collagen fibres and subcutaneous fat. The stratum corneum of the skin, being a poor conductor of heat, protects the underlying tissues from drying. The thicker the stratum corneum, the more is the skin capable of withstanding the effect of electric current. In moist skin, resistance to electric current is sharply reduced. The skin protects the organism from the damaging effect of sun rays because it contains the pigment melanin which absorbs ultraviolet rays. That is why brunettes, who have more pigment in the skin, tolerate solar insolation better than fair-haired individuals. The skin surface is covered with an acid (pH 5.0-6.0) water-lipid mantle, which attenuates or neutralizes the damaging effect of chemical substances and prevents penetration of micro-organisms into the skin. Chemicals occurring on damaged skin or those which are soluble in the epidermal lipoids penetrate the deeper skin layers and from there may be disseminated in the body by way of the blood and lymph vessels. The sterilizing properties of the skin are due to the bactericidal properties of sweat and sebum and the continuous desquamation of the upper layers of the stratum corneum. It is believed that the chemical composition of the sebum contributes greatly to the bactericidal properties of the skin and, therefore, degreasing of the skin with alcohol or ether as well as its cooling reduce its protective functions. Heating, in contrast, increases them. The definite role of the skin in the control of the entry of infections into the body is also a protective function. SKIN AS AN ORGAN OF SENSE The section dealing with the anatomy and histology of the skin describes the numerous nerve endings and terminal nerve apparatuses which make the skin an enormous receptor field which is directed towards the external environment and transmits to the central nervous system stimuli from various environmental factors.

Four types of skin sensitivity are distinguished: pain, tactile, heat, and cold. The last two types are embraced under the common name of temperature, or thermal sense. The sense of touch, pressure, and vibration are related to tactile sense. The various types of receptors responsible for this or that skin sensitivity surface are localized irregularly. It has been established that on 1 cm 8 of skin surface there are approximately 100 to 200 pain points, 25 tactile points, 12 or 13 cold points, and only one or two heat points. Temperature and tactile sensitivity are aroused by definite specific stimuli acting on the skin. The pain effect may be induced by various factors which, on reaching a definite stimulation threshold, are perceived as the sense of pain. The sensation of itching may also be considered a form of sensitivity. Pain is a specific sensation with a pronounced emotional colouring. It is perceived by free nerve endings in the epidermis and dermis. Because of the different emotional colouring of pain sensitivity, acute and dull, stabbing, cutting and aching, dragging, and other types of pain are distinguished. As the result of pain a reflex act occurs which is of a defensive, or protective, character and directed against the stimulus. Pain sensitivity may be greatly disturbed. Increased pain sensitivity is called hyperalgesia and hyperpathia; in hyperalgesia the sensation of pain is aroused even by a weak stimulus because the excitation threshold in such patients is decreased, whereas in hyperpathy the patient's sensitivity is increased and super-threshold stimuli are perceived as long-term very sharp pain. Diminished sensitivity to pain is called hypalgesia, while its loss is known as analgesia. Hyperalgesia of various skin areas is encountered very often in diseases of the viscera. In such cases increased skin sensitivity is encountered in only definite metameres which receive afferent fibres from the same spinal segment that contains the sensory fibres of the diseased organ (e.g. hyperalgesia of the skin on the neck, chest, upper part of the abdomen and back in diseases of the heart and lungs, hyperalgesia of the skin of the lower abdomen and in the region of the lower vertebrae in intestinal disease). These skin areas are called Zakharyin-Head's zones. Patients with skin diseases, like some patients suffering from neuroses, often complain of a sensation of itching which at times is so unbearable that the desire to scratch becomes irresistible. Both exogenous and endogenous factors induce the itch sensation; the itch is quite often of psychogenic origin. A sensation of itching on skin areas previously subjected to analgesia gives reason to assume that it is conducted by nerve fibres other than those concerned with the sense of pain. The tactile sensitivity of the skin is perceived by two types of receptor apparatuses: the nerve plexuses around the hair follicles (hair sensitivity) and Meissner's corpuscles (particularly in skin areas devoid of hair). The sense of touch is aroused when the skin comes in contact with objects and when it is slightly compressed. This type of sense makes it possible to judge the properties of the objects which the skin touches and orient oneself in the environment. The acuity of touch is determined by measuring the smallest distance between the legs of a pair of compasses (mm) at which twostimuli are still discriminate. The acuity of touch is most pronounced on the palmar surface of the fingertips, the tip of the tongue, and the vermilion border. Tactile stimuli may be distinguished not only according to the acuity of touch (with Weber's compasses) but also by the strength of the stimulus, for which purpose special ly designed instruments are used. The senses of touch and pres sure are sensations similar in quality but differing in force. The sen sation of deep pressure is perceived by the laminated corpuscles. Temperature sensitivity (the sensation of heat and cold) is very important in the life of man because it makes it possible to regu late body temperature by reflex. It is believed that Ruffini's bodies perceive heat stimuli and Krause's bulbs cold stimuli. It is mentioned above that there are much more cold points than heat points on the skin. The skin on the face is most sensitive to temperature, where as the skin on the limbs is least sensitive. It should be pointed out that the strength of the temperature sense is greater the larger the stimulated area (0.5 to 0.7 C is the minimum temperature fluc tuation appreciated by the skin). It is of interest that mechanical, chemical, and electric stimuli cause a sensation of warmth or cold when they act on the temperature points. Dissociation (or splitting) of sensitivity is encountered in clini cal practice, when one type of skin sensitivity is lost, while the others are preserved. The conduction pathways of the skin sensory systems in the cen tral nervous system are distinguished according to the functional sign. The central, or cerebral part of the skin

temperature or tac tile analyser, for instance, is the region of the postcentral gyrus. SKIN THERMOREGULATING FUNCTION Participation of the skin in the process of body thermoregula tion is one of its most important physiological functions. The body temperature in healthy man is usually maintained at a constant level irrespective of the environmental temperature, whether high or low. This is achieved by chemical and physical thermoregulation. The production of heat, which forms in the body as the result of metabolism and the consequent release of energy, belongs to chemi cal thermoregulation. This is heat production. An opposite process is heat emission which is related to physical thermoregulation and is accomplished by the skin through three mechanisms: heat radia tion (heat is radiated as radiant energy, namely infrared rays), heat conduction (heat is given off into the external environment because of the difference in temperature between the body and environment and because the environment conducts heat), and evaporation of water from the skin surface . The body gives off heat by radiation and conduction only when the environmental temperature is lower than the body temperature. Heat conduction occurs as the result of changes in circulation in the skin blood vessels: when the environ mental temperature is high, they dilate, the volume of blood flow ing in them increases, and the emission of heat intensifies. With the increased heat emission the activity of the sweat glands inten sifies greatly and, consequently, still more heat is emitted through the evaporation of sweat: in the period of intense sweating, up to 10 litres of sweat and even more may evaporate from the skin sur face within 24 hours. When the environmental temperature is low, the skin vessels are drastically constricted, circulation in them de creases (but increases in the viscera) and as a result heat emission reduces. Heat emission is regulated by reflex (on stimulation of the skin temperature receptors) and by direct stimulation of the thermoregu lation centres in the tuber cinereum and lateral wall of the third ventricle (hypothalamic region). The skin vascular reactions and the secretion of sweat, which are constituents of the process of heat emis sion, are controlled by sympathetic nerves and fibres arising from the sympathetic ganglia. SECRETORY AND EXCRETORY FUNCTIONS OF THE SKIN The sweat (eccrine and apocrine) and sebaceous glands are great and excretory functions of the skin.

ly responsible for the secretory

The eccrine sweat glands produce sweat which has a weak acid reaction, relative density of 1.004-1.008. It consists of 98-99 per cent of water and 1-2 per cent of inorganic compounds such as phosphates, sulphates, sodium and potassium chloride, calcium salts and organic substances (uric acid, urea, creatinine, creatine am monium, amino acids, carbohydrates) dissolved in it. The chemical composition of sweat may alter depending on its amount and the organism's general condition. In some diseases attended with met abolic disorders, substances may appear in the sweat which are usually not found. Diabetes mellitus in which sugar is detected in the sweat may serve as an example. Various drugs given to the patient (arsenic, mercury, quinine, iodine, bromine, and others) may also be excreted in the sweat. This is the excretory function ot the sweat glands. Under normal conditions, the excretion of wa ter by the sweat glands and its evaporation from the epidermal surtace is even and imperceptible; this is called insensible perspiration, m tne period of increased heat emission, perspiration is visible profuse, and continuous whereas under normal conditions sweat excretion is pulsatile. Increased perspiration leads at first to copious now of water from the tissues into the blood, after which the water from the plasma is excreted by the sweat glands. The oral mucosa becomes dry and there is a feeling of thirst. The apocrine sweat glands, whose function is linked with the endocrine, especially the sex, glands contain in their secretions, besides the common components of sweat, glycogen, cholesterol and its ethers, and iron. Their secretions have a neutral or weak alkaline reaction. The functional role of the apocrine glands is still not clear to a great measure. Evidently, they do not play an important role in thermoregulation but, like the sweat glands of the palms and soles, they increase their activity sharply during emotional reactions of the organism. The sebum, the secretion of the sebaceous glands, has a complex chemical composition. Its main components are free lower and higher fatty acids, neutral fats, nitrous and phosphorous compounds, carbohydrates, various stearins, steroid hormones, and cholesterol compounds. On the surface, sebum

mixes with the sweat and forms a fine film of water-fat emulsion. This film plays an important part in maintaining a normal physiological condition of the skin. The excretory function of the sebaceous glands consists in the excretion with the sebum, like with the sweat, of some drugs (iodine, bromine, salicylic acid, antipyrin, etc.) that had been given to the patients and some toxic substances which form, in particular, in the intestine. As it is pointed out above, the function of the eccrine glands is regulated by the sympathetic (cholinergic) nerves, whose centres are in the spinal cord, medulla oblongata, and the diencephalon (the higher centres). The cerebral cortex has a regulating effect on the activity of the sweat glands, that is why perspiration increases in fear, anger, fright, and other emotional experiences. The secretion of the sebaceous glands is regulated by the nervous system and the gonadal, pituitary, and adrenocortical hormones. The process of keratinization of the epidermis with gradual conversion of the cell protein substance to keratohyalin, eleidin, and keratin is now considered to be the secretory function of the epidermis. RESPIRATORY AND RESORPTION FUNCTIONS OF THE SKIN The skin takes little part in respiration, i.e. the absorption of oxygen and elimination of carbon dioxide; in children the diffusion of gases through the dilated skin capillaries is more pronounced. As compared to pulmonary exchange, the skin absorbs 1/180 of oxygen and eliminates 1/flo-1/8B of carbon dioxide. Besides, the skin discharges water vapours (up to 800 g daily, which is twice to three times the work performed in this respect by the lungs). Hardly any water or solids are resorbed through the healthy skin, but substances easily dissolved in fats and lipids (resorcinol, sulphur, salicylic and boric acids, lead oxide, ferric chloride, iodine, mercury, chloroform, pyrogallol, etc.) are readily resorbed by it. The degree of resorption on a skin area depends on the condition of the water-lipid mantle, the buffer capacity of the skin surface, and the presence of the sebaceous follicles. Therefore the skin of the palms and soles, for example, which is devoid of sebaceous glands, has low resorption capacity, the more so since there is a dense corneal layer. In some cases, however, resorption is intensified. Factors conducive to this are swelling of macerated epidermis, long-term rubbing into the skin of finely ground substances, application to the skin of solids dissolved in volatile fluids (e.g. salicylic acid in ether), hyperaemia of the skin. It should be borne in mind that in some dermatoses (eczema, psoriasis, dermatoses attended with the formation of vesicles and erosions) the resorption by the skin of resorcinol, tar, pyrogallol, chrysarobin, salicylic acid, and other substances increases sharply. In such cases, the prescription of these substances in high concentration is not advisable and, besides, the condition of the whole organism and of the kidneys must be continuously checked when tar, chrysarobin, pyrogallol, and salicylic acid are used. High doses of salicylic acid may cause sharp meningeal symptoms (headache, nausea, vomiting, loss of consciousness). PARTICIPATION OF SKIN IN METABOLISM Some biochemical processes take place only in the skin. They include the formation of keratin (the horny substance), melanin, and vitamin D. They are complex and have been insufficiently studied to date. The skin takes an active part in the metabolism of water, minerals (sodium, potassium, calcium, etc.), fat, proteins, and carbohydrates in the body. It is also concerned with the metabolism of hormones, enzymes, vitamins, and trace elements because, on the one hand, it is a spacious depot and, on the other, some of these substances are removed from the body with the secretions of the sebaceous and sweat glands. The water content in the body of an adult ranges from 60 to 65 per cent, whereas in the skin it may reach 71 per cent. The skin takes second place after the muscles as a large water depot. The water content in the subcutaneous fat is much less (up to 10 per cent). In some dermatoses (pemphigus, acute eczema, erythroderma, etc.) the amount of water in the skin increases. It is stored within and outside the cells because of the hydrophilia of the connective tissue cells, the elastic and collagen fibres, and the subcutaneous fat. The total amount of mineral substances in the skin may account for as much as 1 per cent of the

skin mass; the amount of these sub-stances in the hypoderm is about half that in the dermis. The amount of some of the minerals alters and interrelationship between them is disturbed in various disorders of mineral metabolism. In pemphigus and Duhring's dermatitis herpetiformis the content of sodium chloride (like the content of water) in the skin grows considerably. In tuberculosis of the skin, the amount of potassium increases in the foci of affection and in areas free of the lesions. Protein metabolism in the skin occurs at the expense of collagen (98.8 per cent of the total skin proteins), albumins, globulins, mucoid, elastin, keratin, and protein metabolites (amino acids, urea, creatine, uric acid, ammonia, purine bases, and pigments). Tests for non-protein nitrogen make it possible to judge the intensity of protein metabolism which grows in acute inflammation, burns, tuberculosis and other pathological processes of the skin. The content of sugar in healthy skin ranges from 50 to 75 per cent. In diabetes mellitus there is much more sugar in the skin than in blood. It is believed that disorders of carbohydrate metabolism (whether obvious or latent) lead to the development or persistence of some dermatoses (furunculosis, acne, rubromycosis, candidiasis, urticaria, eczema, etc.). A. I. Kartamyshev established that unpleasant emotions induced by hypnosis led to changes in the skin sugar content, and thus proved the effect of the nervous system on metabolic processes, carbohydrate metabolism in particular. Vitamin metabolism plays a very important part in the skin biochemical processes. Vitamin C, for instance, contributes to the production of melanin and the conversion of glucose to glycogen; vitamin A participates in the formation of the horny substance; vitamins A, E, and D activate protein metabolism in the epidermis and the assimilation of sulphur. Vitamins of the vitamin B complex, i.e. BL (thiamine), B2 (riboflavine), B5, B8, B12, and others participate in the oxidation-reduction processes. Vitamin PP (nicotinic acid) improves various functions of the liver and produces a vasodilative and photodesensitizing effects. Lack of vitamin A causes the development of phrynoderma, ichthyosis, xeroderma, acne vulgaris, and dystrophy of the nails. Pellagra, cheilitis, stomatitis, and glossitis are linked with lack of the B complex vitamins in the body. Reduced vitamin C content leads to the development of scurvy. INTERACTION OF THE CENTRAL NERVOUS SYSTEM AND THE SKIN Nobody doubts today that the central nervous system has an enormous effect on the skin and its appendages under normal conditions and in various pathological conditions. The nervous system is responsible for the interaction of the systems and organs of the whole human organism, the connection with the external environment, and the character of the organism's reactions to the effect of the numerous and diverse exogenic and endogenic factors. The reflex principle of reaction, expounded and substantiated in the works of Sechenov, Pavlov and Vvedensky and the scientific schools they founded, is of decisive importance for the vital activity of the whole organism. Research conducted by Petrova at Pavlov's laboratory proved to be of direct importance for dermatology; in dog experiments she demonstrated the role of nervous trauma ('collisions') of the cerebral hemispheres in the development of eczematous foci and trophic ulcers of various localization. Among the Russian and Soviet dermatologists Polotebnov, Pospelov, Nikolsky, Kartamyshev, and Zheltakov were the first to emphasize the effect of the cerebral centres and the sympathetic nervous system on the origination of some dermatoses. They showed in hypnotized persons the effect of the second signalling system on the biochemical processes in the skin, the state of the skin capillaries, the morphological composition of the skin, the regenerative processes in the epidermis and dermis, and on the character of allergic and inflammatory reactions of the skin to the administration of a stimulus into the body. By exerting an effect on the second signalling system (treatment by suggestion under hypnosis, electric-sleep therapy, treatment by indirect suggestion) it proves possible to treat patients suffering from lichen ruber planus, warts, and sometimes those with urticaria, to bring relief to patients with some form of eczema or neurodermitis, to alleviate some symptoms (e.g. itching) and mitigate an inflammatory skin reaction (Pototsky, Zheltakov, Skripkin, and others). At the same time, the condition of the skin, particularly in various pathological processes, has a direct effect on the activity of some of the nerve centres and the cerebral cortex. Persistent dermatoses, particularly if they are attended with severe and excruciating itching and various unpleasant sensations, may lead to diverse disturbances in the activity of the nervous system at its different levels and to the development of neurotic states and even psychotic reactions of definite severity. This may ultimately lead to the creation of a vicious circle. A break in the chain of this circle at any level

has a favourable effect on the course of the whole morbid process. MAIN SPECIFIC FEATURES OF SKIN FUNCTION IN CHILDREN The anatomical deficiency of the structural components of a child's skin (non-differentiated cells of the connective tissue, very rich vascularization and hydrophilia, etc.) results in marked imperfection of its protective components. Other contributing factors are the lowered bactericidal property of the secretions of the sebaceous and sweat glands and the neutral or weakly alkaline pH of the water-lipid mantle (in adults it has an acid reaction). Because of all this, the skin of children, especially in the very young, is very vulnerable and is marked by a tendency to the formation of cracks and abrasions, easier development of pathological processes, and rather frequent development of extensive pyoderma, sometimes with symptoms of general sepsis. In this respect one should not ignore the weakness of the pituitary-adrenal system, which is conducive to diminution of oxidation-reduction processes in the child's tissues, the immaturity of the cerebral cortical cells, and the non-differentiation of the vegetative nervous system in childhood. On the other hand, the rich vascularization of the child's skin, the high intensity of the metabolic processes, and the marked function of the thymus favour the activity of the regenerative (restorative) reactions, while the weak heat conductivity of the skin protects the child's organism from overcooling and overheating. The neonatal period and the period of infancy are also more favourable in respect of some infectious diseases because the level of natural immunity is directly dependent on the state of immunity of the mother and the immunobiological properties of her milk. The infectious disease incidence (dermatomycoses among others) increases at the ages between one and eight years because after the age of 12 months congenital immunity weakens while acquired immunity is still not adjusted. The secretory function of child's skin is marked by a higher than in adults production of cholesterol by the sebaceous glands and calcium and phosphorus compounds by the sweat glands. At the same time, vitamin D synthesis and keratinization of the epidermis are weaker in the newborn and infants, which lowers the protective properties of the skin, its bactericidal effect in particular. Because of the fine, thin horny layer of the epidermis, the dilated blood and lymphatic vessels and increased permeability of their walls, the excretion of water through the skin of children occurs mainly by means of insensible perspiration. Minerals are excreted in the water (in amounts several times those excreted through the lungs). This process must be continuously corrected by means of a rational regimen of feeding (including the intake of fluids) and bathing of the child. In febrile conditions or when the child is clothed too warmly, much more water is lost through profuse sweating, which often leads to the development of heat rash (miliaria crystallina), especially in infants of the first months of life. The same factors (the thin epidermal horny layer and the dilated vessels with increased permeability of their walls) are responsible for the fact that gas exchange through the skin of children accounts for 1 per cent of the total gas exchange of the body. Besides, the child's skin possesses high resorption capacity which grows still more during inflammatory processes. Metabolic processes are more active in child's than in adult's skin, and the fact that more water is contained in children's skin than in the skin of adults is important in this respect (all metabolic processes occur in the water phase). For instance, water constitutes three fourths of the body mass of infants and three fifths of the mass of adults. With age, the percentage content of water in the skin, like in the whole body, decreases. The water requirements per kilogramme of body mass vary accordingly. In a newborn infant they are 150-200 ml, in the first six months of life 100150 ml, by the age of 12 months 80-90 ml, under the age of five years 60-70 ml, under the age of ten 15-60 ml, and under 15 years of age 40-50 ml per kilogramme of body mass. Though the child's skin perceives cold and warmth and possesses tactile sensitivity, in infants the development of the nerve endings is not completed and the epidermis and dermis are underdeveloped. Because of the insufficient differentiation of the peripheral analysers and the centres in the brain, the nerve stimulation in children is not converted to a realized, clearly located sensation. Functional immaturity is therefore typical of the receptors, conduction pathways, and cortical cells. The insufficient differentiation of a large flow of skin stimulating impulses arriving from the external environment induces a state of protective inhibition in the child's central nervous

system, which is displayed by long periods of sleep, especially in infants. HISTOMORPHOLOGICAL CHANGES IN THE SKIN Many skin diseases are marked by an inflammatory character. According to the severity and duration of the reaction, acute, sub-acute, and chronic inflammation is distinguished which occurs in response to the effect of various external and internal stimuli. The type of the response of the organism and skin to the action of the stimulus is determined by many factors: the condition of the receptor apparatus, the character of higher nervous activity in the person, the organism's reactivity, and others. Allergic reactions play a very important part in the type of the response of the skin as a part of the entire organism to the effect of the stimulus. Though the combination of the stimulation and the response of the organism, the skin in particular, depending on numerous factors, may result in the development of an inflammatory reaction differing in severity and duration, various degrees of manifestation of alteration, exudation, and proliferation are distinguished in the microscopic picture of each inflammation. Alteration is the manifestation of tissue damage (dystrophy and necrosis of the tissue elements); exudation is the escape of fluid and formed elements from the vessels because of increased permeability of the vascular wall; proliferation is the multiplication of tissue elements. In acute inflammation, occurring within a short period of time, vascular-exudative phenomena prevail and the inflammatory process is characterized by great intensity. In chronic inflammation, which is marked by a prolonged course, proliferative phenomena prevail, the vascular-exudative component is much less manifest and the inflammatory process is not intense.. According to the intensity of the inflammatory reactions, subacute inflammation takes an intermediate place between acute and chronic inflammation. Because of the specific anatomical features of the epidermis, the pathological processes in it have a peculiar course. Three main types of inflammatory changes are distinguished in the epidermis. The first type of serous inflammation is marked by intracellular oedema, or vacuolar degeneration (alteration cavitaire), in which vacuoles forming in the protoplasm of the cells of the Malpighian layer are arranged in the vicinity of or around the nucleus and displace it to the periphery. In such cases the nucleus is distorted and often has all the signs of pyknosis. The oedematous fluid gradually dissolves the cell and causes its death. If the vacuoles occur within the nucleus, it swells and transforms into a spherical vesicle filled with fluid in which a nucleolus is sometimes preserved. The second type of serous inflammation is characterized by spongiosis, or intercellular oedema (status spongioides), in which the oedematous fluid separates the intercellular spaces of the Malpighian layer and ruptures the intercellular bridges, as a result of which the connections between the cells are lost, the cells themselves become oedematous, and epithelial vesicles begin to form. Spongiosis is typical of eczema and other dermatoses. The third type of inflammation of the epidermis is ballooning degeneration occurring in necrobiotic and degenerative changes in the cells of the Malpighian layer. Besides the deep changes in the epithelial cells, destruction of the intercellular bridges leads to the loss of the connections between the cells which swim freely in the serofibrinous contents of the vesicle and take a spherical shape. Such changes are found, for instance, in herpes. A combination of the first and second types of serous inflammation is usually encountered in skin diseases marked by an inflammatory process. Polymorphonuclear leucocytes (neutrophils, eosinophils) predominate in the infiltrate in acute inflammation. In chronic inflammation the infiltrate mostly contains lymphocytes which are scattered or arranged around the vessels. The infiltrates contain many histiocytes representing all transitional stages, from non-differentiatedround cells to fibroblasts. The reticular cells are the same histiocytes, but are larger in size. The plasma cells have a well developed basophil protoplasm and an eccentric nucleus and are larger than the lymphocytes. The epithelioid cells are elongated and have a large spherical or oval nucleus and abundant protoplasm. Large spherical or oval multinucleate cells with irregular contours are called giant cells. Besides serous inflammation, the following peculiar pathological changes may be found in the epidermis. Acantkosis is intensified proliferation of the prickle-cell layer in the form of projections into

the dermis to this or that depth. In acanthosis the number of mitoses in the basal layer is increased and the connective-tissue papillae of the dermis are elongated accordingly, the condition is known as papillomatosis. Acanthosis is encountered in psoriasis and eczema. Acantholysis is melting of intercellular epithelial bridges, the impairment of firm connections between epithelial cells with the result that cells are easily separated and form more or less large layers of the desquamating epidermis. Such a process is observed in pemphigus. Dyskeratosis is abnormal cornification of the cells of the epidermis; it may occur as hyperkeratosis, i.e. thickening of the horny layer without changes in the structure of the cells, or parakeratosis, i.e. the presence in the horny layer of the epidermis of cells with stained rod-shaped nuclei (the granular and clear layers are absent in such cases). Granulosis is thickening of the granular layer of the epidermis. MAIN INFORMATION ON THE AETIOLOGY AND PATHOGENESIS OF SKIN DISEASES Aetiology is the science of the cause of the disease; pathogenesis is the mechanism of the origin and development of the disease and the routes by which the morbid process spreads; sanogenesis are the mechanisms protecting the organism from disease. There are many causes of the development of various skin diseases. Sometimes these causes (factors) may be related to unconditioned stimuli because their action always and in all individuals evokes a definite reaction of the skin and is a local response of the whole organism to the damaging effect of the stimulus. Examples of such stimuli are concentrated acid and alkaline solutions, which produce chemical burns, large doses of radiant energy, e.g. X-rays, which cause specific skin lesions, the action of high temperatures on a limited skin area (thermal burns) or the effect of low temperatures (frostbite), etc. In most cases, however, a combination of several factors inducing the pathological process is necessary for a skin disease to develop. For instance, it is general knowledge that microbial associations, staphylococci among others, are always present on the skin. In some cases the staphylococcal strains are highly virulent, but despite this, additional factors are needed for the development of pyoderma. Among such factors, for example, are disturbance in the defence properties of the skin (changes in the water-lipid mantle of the skin, microtraumas) or in the organism's reactivity because of hypovitaminosis, diabetes, and other endogenous factors. The separation of the aetiolbgical factors of skin diseases into exogenous and endogenous would therefore be conditional to a certain extent in such cases. Exposure to the effect of exogenous factors usually gives rise to a morbid process when endogenous factors weaken the organism's physiological defence mechanisms and in this manner create a background, as it were ('predisposition') against which skin diseases develop. It should be borne in mind that the condition of the human organism depends greatly on the conditions of life and work. A disease may, therefore, be considered a social phenomenon. The exogenous aetiological factors of skin diseases include physical, chemical, and bacterial stimuli and plant and animal parasites. 1. Mechanical stimuli, thermal injury, and the effect of radiant energy are distinguished among the exogenous physical aetiological factors. Long-term pressure, friction, contusion, and other mechanical effects may cause an inflammatory process of various intensity and haemorrhage and may promote the development of corns and callosity. The thermal factors are the action exerted on the skin by low or high temperatures as a consequence of which chilblain, frostbite, burns, etc. may develop. Exposure of the skin to radiant energy (in particular ultraviolet rays, Xrays, ionizing radiation, etc.) may lead not only to the development of dermatitides of various severity but also to severe dystrophic changes with necrosis of skin areas which heal poorly. 2. Chemical factors capable of producing dermatosis are very diverse. They may be of an occupational character (occupational chemical irritants) or may be encountered in every-day life or as various medicinal agents. The pathological changes induced in the skin by chemical factors are also diverse. The degree of sensitization of the organism, its allergic condition plays an important role in the pathogenesis of dermatoses caused by these agents, as a result of which it is sometimes difficult to

interpret the pathogenesis in a concrete case. 3.Bacterial factors, pathogenic microbes, are the cause of pyoderma, tuberculosis of the skin, lepra; protozoa cause leishmaniasis and other diseases; filtrable viruses induce lichen planus pernphigoides, herpes zoster, warts, pointed condylomata, molluscum contagiosum. 4. Plant parasites (pathogenic fungi) cause trichophytosis, microsporosis, favus, and other dermatomycoses. 5. Animal parasites (the scabies mite, the gadfly larvae) may penetrate the skin and develop in it or induce itching by their bites (fleas, lice, bedbugs, mosquitoes, ticks), which is conducive to the development of scratches and pyoderma. The endogenous aetiological factors are still more diverse than the exogenous factors, although all the various types of the effect of the former have still not been fully understood on the current level of knowledge. Abnormally functioning viscera may have an effect on the skin in various ways. In some cases this is a reflex process, in others the effect is accomplished by the humoral route (in disturbed metabolic processes, dysfunction of the endocrine glands, etc.), in still others neurohumoral mechanism of the pathological effect on the skin is noted. Some skin diseases develop as the result of transfer of live tissue elements into the skin by the haematogenous or lymphogenous route, which is called metastasis and may be encountered in malignant tumours. Finally, the pathological process may spread to the skin by extension (per continuitatem), which is encountered in tuberculosis of the lymph nodes. Clinicians have noted long ago that some skin diseases (eczema, neurodermitis, lichen ruber planus, and others) occur under the influence of psychic and emotional disturbances, i.e. as the result of dysfunction of the central nervous system. Data on the fact that functional changes in the nervous system are sometimes the principal aetiological factor in pathological skin processes were verified in the experiments of physiologists, particularly in the works of I. P. Pavlov's pupil M. K. Petrova, which are mentioned above. Organic diseases of the central and peripheral nervous systems may also lead to various skin diseases. Perforating ulcers, for example, may develop in syringomyelia, tabes dorsalis, alcoholic neuritis, etc., trophic ulcers in injury to the sciatic and other nerves. Various disorders of endocrine function are a frequent aetiolbgical factor in the origin of diverse pathological processes of the skin. For instance, disturbed secretion by the pituitary and sexual glands during puberty may be the cause of seborrhoea and acne; myxoedema (a peculiar mucoid swelling of the skin) is encountered in thyroid insufficiency, Addison's disease with a bronze colour of the skin in disturbed adrenal function, etc. In these cases the endocrine disorders are the main aetiological factor of the skin disease, more frequently, however, together with neurotic disorders (neuroendocrine dysfunction) they form the predisposing background against which chronic allergodermatoses (neurodermatoses, eczema) develop. Disorders of water, mineral, carbohydrate, lipoid and other forms of metabolism are factors predisposing to the development of various dermatoses (e.g. candidiasis or furunculosis in diabetes mellitus). Dermatoses in the development of which metabolic disorders play the principal aetiological role are less frequent (e.g. the development of xanthoma in disturbed cholesterol metabolism). Hypovitaminosis may be the cause of some skin diseases. In lack of vitamin G in the body, for instance, scurvy with peculiar skin manifestations develops (scurvy haemorrhages); pellagra occurs in lack of vitamin PP. Vitamin A deficiency is the cause of abnormal keratinization (phrynoderma). Besides, impaired vitamin balance in the body often predisposes to the development of dermatoses of other aetiology. There are skin diseases which are inherited by the dominant or recessive type. A group of skin diseases also exist which are related to congenital diseases because they arise due to intrauterine damage to the foetus (infection, toxicosis in pregnancy); such diseases are usually not inherited by the next generations. The skin may be involved in a pathological process with the development of systemic diseases (collagenoses, reticulosis, etc.). Disturbed blood and lymph circulation may be the cause of acrocyanosis, elephantiasis, symptoms of asphyxia, a disease of the vascular walls (e.g. endarteritis obliterans) may lead to skin gangrene and ulcers of the lower limbs. Diseases of the liver, stomach, intestine, and other viscera often cause the development of

eczema, neurodermitis, urticaria; together with other factors (e.g. endocrine dysfunction, disturbed activity of the nervous system) they promote the development of chronic allergodermatoses. Invasion by helminths may be responsible for a prolonged course of some dermatoses. In the course of their development various general acute (scarlet fever, measles, etc.) and chronic (tuberculosis, syphilis, etc.) infectious diseases are marked by various inflammatory manifestations on the skin, which often allow the diagnosis of the disease to be made. Special significance in the development of some dermatoses is now attached to the presence of foci of 'localized' infection (chronic tonsillitis, chronic appendicitis, dental granuloma, etc.), which sensitize the organism and by means of complex pathogenic mechanisms are capable of giving rise to diverse pathological processes on the skin, up to severe inflammatory-degenerative changes. An important role in the pathogenesis of many dermatoses is attributed to the organism's allergic reactivity which leads to hypersensitivity as the result of repeated contact with the allergen (stimulus) or increased congenital susceptibility to the given stimulus (idiosyncrasy). New immunoallergic methods provide the possibility for studying the immunological mechanisms of allergic diseases on a qualitatively new level. GENERAL SYMPTOMATOLOGY OF SKIN DISEASES A person suffering from a skin disease usually applies for medical advice because he discovers objective changes on the skin or visible mucous membranes, which are sometimes attended by subjective disorders. The clinical picture of skin diseases, however, is a complex of symptoms composed in most cases of manifestations differing in character and often not noticed by the patient. All symptoms of a disease are divided into subjective and objective. Subjective symptoms are those felt by the patient, objective symptoms are changes found on the skin or visible mucous membranes by the physician during inspection or palpation. However, in view of the fact that many skin changes are manifestations of a disease of the whole organism, the eruption is usually attended with general symptoms, namely, indisposition, a jaded condition, general weakness, elevated body temperature, etc. All this is also understandable because many skin diseases are associated with diseases of the nervous system, gastro-intestinal tract, endocrine glands, haematopoietic organs, etc. SUBJECTIVE SYMPTOMS Dermatological patients may complain of an itch (which is a particularly frequent occurrence in dermatoses), a sensation of burning or stinging, pain, etc. It should, be borne in mind, however, that the subjective signs depend not only on the severity of the disease but also, and to a greater measure, on the individual features of the patient, the reactivity of his nervous system (the type of higher nervous activity according to I. P. Pavlov). Therefore some patients react very painfully to mild manifestations of the disease, while others show restraint and have very little complaints in severe pathological conditions of the skin. This applies particularly to the sensation of itching (pruritus) the pronounced character of which is determined not only by the type of dermatosis but sometimes to a greater measure by the patient's reactivity. The objective signs of an itch are multiple excoriations, traces of scratches, grounded off free edges of the fingernails, and polished nail plates. The presence or absence of an itch is of definite diagnostic importance. Some dermatoses are always attended by itching (scabies, urticaria, various forms of prurigo, neurodermitis, lichen planus, almost all forms of eczema), in others there is no itching or it is very mild (psoriasis, pityriasis rosea, pyoderma, acne vulgaris, acne rosacea, etc.). In some dermatoses the itching is usually attended with scratches (scabies, pediculosis, prurigo, etc.); in others there are no scratches despite the severe itching (urticaria, lichen planus, etc.). Besides, in patients with pruritic dermatoses the itching usually intensifies or occurs in the night when the skin is warm under the blanket; this is particularly so in patients with scabies. OBJECTIVE SYMPTOMS To define properly the pathological skin process, which is manifested by morphological lesions composing the skin affection, the dermatologist must appraise the condition of the skin over the whole

body of the patient, its colour, turgor, moistness, lustre, local temperature, etc. The objective findings are judged on the basis of visual impression and touch. The ability to distinguish the lesions of the skin rash makes it possible to define the pathological process correctly and approach the diagnosis of the dermatosis. In many cases the clinical picture 'drawn on the skin' by the erupted lesions and the character of their arrangement allow the diagnosis to be made and treatment begun; in certain cases additional methods of examination (including laboratory tests) have to be resorted to in making the diagnosis. These data are discussed in the special part of the textbook dealing with the separate nosological forms of dermatoses. Eruptions on the skin may be inflammatory or non-inflammatory. Most rashes in skin diseases are of an inflammatory character. Pigmented spots, tumours, atrophy, hyperkeratosis, etc. are the noninflammatory manifestations. All lesions of skin eruptions are subdivided into primary and secondary. Primary inflammatory morphological lesions appear on a seemingly healthy skin as the first, direct reaction to an exogenous or endogenous stimulus. Secondary morphological lesions form as the result of spontaneous evolution of the primary lesions or as a consequence of applied treatment. The primary morphological lesions are subdivided into infiltrative and exudative. PRIMARY MORPHOLOGICAL LESIONS The inflammatory process has five classical symptoms: redness (ruber), swelling (tumor), pain (dolor), elevated temperature, or heat (color), and impaired function (runctio laesa). The severity of these symptoms, however, may vary depending on the degree of the inflammatory reaction which may be acute or non-acute. In an acute inflammatory reaction, some of the classical signs of inflammation are clearly expressed: redness, or hyperaemia, is intensive and succulent, the swelling of the foci of affection has unclear boundaries because of a marked exudative reaction which often leads to the formation of cavities (serous or purulent). The itching or burning and elevation of local temperature are very evident, and pain is sometimes felt. All this may result in disturbance of function. In a non-inflammatory, or chronic reaction, the symptoms of inflammation are less marked, congestive hues (cyanosis, lividness, and a brownish tinge) of the foci of affection prevail and the foci are clearly demarcated; the infiltrative component of the inflammation with proliferation of cell elements predominates. Such patients have no sensation of pain or burning, but itching is very severe sometimes. In accordance with the histomorphological difference between acute and non-acute inflammation, the primary lesions are subdivided into exudative and infiltrative. A spot (macula), papule, tubercle, and a nodule are infiltrative lesions; a vesicle, bulla, pustule, and wheat are exudative lesions.

Infiltrative Primary Morphological Lesions

A spot (macula) is a circumscribed alteration in the colour of the skin or mucous membrane. In most cases it is not raised above the surface of the skin and does not differ from it in consistency. According to the cause of their formation, vascular, including haemorrhagic, and the less frequent pigmentation maculae are distinguished. Vascular maculae are clinically manifested by a circumscribed redness of the skin as the result of dilation of the vessels of the superficial vascular network. They are subdivided into inflammatory and non-inflammatory. An inflammatory vascular macula is a circumscribed area of skin redness of various size caused by external or internal stimuli. Depending on the degree of filling of the blood vessels the maculae differ in colour; they may be red, rose-coloured or bluish (cyanotic or congestive). A macula formed as the result of dilatation of the skin vessels disappears when it is pressed but reappears in the same form when the pressure is removed. Small inflammatory rose-coloured spots which may reach the size of the nail of the little finger form a rash called roseola. This rash occurs in secondary syphilis, measles, scarlet fever, typhoid fever, drug rash, etc. The spot may be of an acute inflammatory character, with a bright rose colour, unclear contours and a tendency to coalesce and desquamate, and is often attended with swelling and

itching. There are also non-inflammatory spots which are pale-rose with a brownish tinge, their contours are clearly seen, there is no itching, and the spots do not coalesce as a rule. Rose-coloured spots of an acute inflammatory character appear as a primary lesion in patients with the above-listed children's infections, in eczema, dermatitis, pityriasis rosea; those of a non-inflammatory character form in patients with secondary (rarely tertian) syphilis, erythrasma, pityriasis versicolor. Large vascular spots (the size of a child's palm and larger) are called erythema. They may be swollen, have irregular contours and a bright red colour; they are attended with an itch and are consequent, as a rule, upon acute inflammatory dilatation of vessels in patients with eczema, dermatitis, 1st degree burn, erysipelatous inflammation, and erythema exudativum multiforme. In emotional excitation and neurotic reactions, large confluent non-inflammatory spots appear (short-lived dilatation of the vessels of the superficial vascular network) without itching or desquamation. These spots are called erythema fugax (erythema of confusion, anger or bashfullness). Maculae caused by stable non-inflammatory dilatation of the superficial skin vessels (capillaries) are called telangiectasias. They also disappear temporarily on pressure and reappear when it is removed. Telangiectasias are acquired spots which may occur independently or be a component of the clinical picture of acne rosacea, cicatrizing erythematosis, and some other diseases. Non-inflammatory vascular birthmarks (naevi) are congenital maculae. Effusion of blood into the skin may occur in increased permeability of the vascular walls, as a result of which haemorrhagic maculae form, which do not disappear when they are pressed. Depending on the period of time after the effusion, these maculae are red, bluish-red, purple, green or yellow (their colour changes with the gradual conversion of haemoglobin to haemosiderin and haematoidin). They are distinguished according to size: pinpoint haemorrhages are called petechiae, small round and usually multiple haemorrhages are known as purpura, large linear haemorrhages uibex, effusion of blood over a large area with irregular contours is called ecchymosis; massive haemorrhage with swelling of the skin which is raised above the surface of the surrounding areas is known as a haematoma. Haemorrhagic maculae occur in allergic vasculitis of the skin, scurvy (hypo-vitaminosis C) and some infectious diseases (typhuses, rubella, scarlet fever, and others). Pigmentation spots form on areas with an increased or decreased content of the pigment melanin in the skin. They may be patches of hyperpigmentation or depigmentation. Pigmentation spots may be congenital (birthmarks, lentigo, albinism) or acquired (freckles, chloasma, vitiligo). Spots of hyperpigmentation include freckles (small areas of light-brown or brown colour which form on exposure to ultraviolet irradiation of increased intensity), lentigo (foci of hyperpigmentation with hyperkeratosis), chloasma (large areas of hyperpigmentation forming in Addison's disease, hyperthyroidism, and other morbid conditions). Small patches of depigmentation are called leucoderma. True leucoderma occurs in patients with secondary recurrent syphilis when these spots of depigmentation form against a hyperpigmented background. False, or secondary, leucoderma (pseudoleucoderma) is encountered in places of former morphological lesions (usually maculo-desquamative), and in some dermatoses (pityriasis versi-color, psoriasis, etc.), when the surrounding healthy skin areas had been exposed to ultraviolet irradiation (sunburn). Vitiligo is marked hv areas of various size devoid of pigment, which is attributed to neuroendocrine disorders and enzymatic dysfunction. Congenital absence of pigment in the skin with insufficient coloration of the eyebrows, eyelashes, and hair on the scalp is called albinism. A papule is a solid, more or less hard lesion, elevated above the skin surface. It resolves leaving neither a scar nor cicatricial atrophy, though a non-persisting trace, pigmentation or depigmentation, may remain. Papules which mainly occur in the epidermis are called epidermal (e.g. a flat wart), those found in the dermis are called dermal (e.g. in secondary syphilis). Papules most commonly have epidermo-dermal localization (e.g. in lichen planus, psoriasis, neu-rodermitis). Inflammatory and non-inflammatory papules are distinguished. The former are much more frequent occurrences (in psoriasis, eczema, secondary syphilis, lichen planus, lichen rubra acuminatus, neuro-dermitis, and other diseases). They are marked by inflammatory infiltration in the papillary layer of the dermis, dilatation of vessels, and a circumscribed swelling. When pressed, the papule turns pale but does not lose its colour completely. In non-inflammatory papules there is proliferation of the epidermis (a wart), or deposit of abnormal metabolites in the dermis (xanthoma), or proliferation of dermal tissue (papilloma). Some dermatologists distinguish a papule of acute inflammatory

character (exudative papules in patients with eczema or dermatitis) which forms as the result of accumulation of exudate in the papillary dermal layer, in acute dilatation and increased permeability of vessels of the superficial capillary network. Papules vary in size, from that of a pin head to that of a coin or may be larger. Papules of the size of a millet seed or the head of a pin are palled miliary (those in lichen planus or lichen scrofulosorum), of the size of a lentil or pea, lenticular (in psoriasis, secondary syphilis, etc.), those of the size of a coin are called num-mular. Large (hypertrophied) papules are mainly encountered in secondary recurrent syphilis (condyloma latum). Confluent papules form plaques (to the size of a child's palm). Papules are usually strictly circumscribed but they vary in shape (they may be spherical, oval, flat, polygonal, pointed, navel-like, dome-shaped) and their surface is smooth or rough. The consistency of papules may also vary (they may be soft, dough-like, firm-elastic, firm, hard) just as their colour (the colour of normal skin, yellow, pink, red, purple, livid, brown, etc.). The surface of papules growing on adjacent skin surfaces may undergo erosion as a result of friction, the surface of those growing on mucous membranes may also erode because of the irritating effect of saliva, secretions, food, etc. (these are erosive papules), while the papules themselves grow larger, undergo hypertrophy. Papules with a villous surface are called papillomas. In papules, the histological picture in the epidermis is marked by hyperkeratosis, granulosis, acanthosis, parakeratosis; deposits of various infiltrates are found in the papillary layer of the dermis. A tubercle is an infiltrative solid skin elevation of a non-acute inflammatory character. It often ulcerates and terminates by cicatrization or cicatricial atrophy. It is difficult to distinguish it from a nodule in its morphological appearance, especially in the initial developmental stage. A tubercle and nodule may be similar in size, shape, surface, colour, and consistency. The inflammatory cellular infiltration in tubercles spreads not only in the papillary but mainly in the reticular layers of the dermis and histologically is an infectious granuloma which either ulcerates with the eventual formation of a scar, or resorbs leaving cicatricial atrophy. This is the main clinical distinction between a tubercle and a nodule, which makes it possible to determine retrospectively many years after the process had terminated whether the patient had had, for instance, lesions of tertian syphilis or those of lupus vulgaris (nor only the presence of scars or atrophy is taken into account, but the character of their arrangement, e.g. the mosaic pattern of the scar in syphilis, the presence of bridges in lupus vulgaris, and other symptoms). In some cases the tubercles have a rather characteristic colour: reddish-brown in tertian syphilis, reddish-yellow in lupus vulgaris, rusty-brown in leprosy. In different diseases the tubercles have distinguishing features in their histological structure. A tubercle in tuberculosis of the skin, for instance, consists mainly of epithelial cells and various numbers of Langhans' giant cells (Mycobacterium tuberculosis is rarely found in the centre, lymphocytes are usually present along the periphery); the tubercle in syphilis consists of plasma cells, lymphocytes, epithelioid cells, and fibroblasts (treponemas are not detected in the tubercle, but there may be a few giant cells). Tubercles occur on restricted areas of the skin as a rule, either in groups or they coalesce forming a compact infiltration, much less frequently they are scattered, disseminated. A nodule is a primary infiltrative morphological lesion without acute inflammation. It is large (the size of a pea to that of a walnut or larger) and is situated in the subcutaneous fat. The nodule may at first be not raised above the skin surface (in which case it is detected by palpation), but with growth it gradually becomes elevated (often considerably). The nodules ulcerate and eventually cicatrize. Their consistency varies from soft (in tuberculosis colliquativa) to firm-elastic (in leprosy and tertian syphilis). The specific features of the nodules in some diseases (appearance, colour, shape, surface, consistency, the character of secretions) permit designating them specially: scrofuloderma in tuberculosis colliquativa, gumma in tertian syphilis, leproma in leprosy. Benign and malignant new growths may occur in the form of nodules.

Exudative Primary Morphological Lesions

A vesicle is a primary morphological lesion of an exudative character; it has a fluid-containing cavity and is slightly elevated. A cavity with serous, less frequently serosanguineous contents, a covering, and floor are distinguished in a vesicle. The vesicles may be situated under the horny layer,

in the middle of the epidermis, and between the epidermis and dermis; they may be unicamerate or sometimes multicamerate (in which case one gets the impression that the patient has a bulla, but the last has no septa). The size of a vesicle ranges from that of a pin head to the size of a lentil. The contents of the vesicle may be clear, serous, less frequently sanguineous, and often turn cloudy and purulent, which occurs when the vesicle transforms into a pustule. The fluid discharged from the vesicle dries to form a crust or the covering of the vesicle ruptures, an erosion forms and weeping occurs. Such is the case in eczema in the stage of exacerbation. The vesicles may occur on normal skin but usually they have an inflammatory erythematous base. On the oral mucosa and rubbing skin surfaces the vesicles rupture rapidly, leaving erosive surfaces; in places with a thicker skin (e.g. on the palms in dyshidrosis) they remain longer. A vesicle either disappears without a trace or leaves a temporary pigmentation as is the case, for instance, in Duhring's herpetiform dermatitis. In vesicle formation the histological picture is marked by spon-giosis (eczema, dermatitis), ballooning degeneration (lichen planus pemphigoides, herpes zoster, chickenpox), and intracellular vacuo-lation (dyshidrotic eczema, epidermophytosis). A bulla is an exudative cavitary lesion the size of a hazel nut to that of a hen's egg and larger. Like the vesicle, it consists of a covering, a cavity with serous contents, and a floor. A bulla under the horny layer is called subcorneal, one in the thickness of the prickle-cell layer intraepidermal, and bulla found between the epidermis and dermis is called subepidermal. The bullae are spherical, semispherical or oval, and their contents are clear, yellowish, less frequently cloudy or sanguineous. Various amounts of leucocytes, eosinophils, and epithelial cells are found in the fluid. Cytological examination of impression smears or scrapings from the floor of the bulla is sometimes of practical importance in the diagnosis of dermatoses because the cell composition in some of them has specific features. Bullae occurring on rubbing skin surfaces and on the mucous membranes rupture rapidly and leave erosions with a border of scraps of the covering of the bullae. Bullae occur in pemphigus vulgaris, pemphigus congenitalis, acute epidermatic pemphigus neonatorum, erythema multiforme exu-dativum, burns, drug dermatitis (e.g. in sulphanilamide erythema), and some other skin diseases. A bulla usually forms against the background of an erythema-tous macula, though it may also be found on apparently healthy skin (in patients with pemphigus vulgaris). With exogenous penetration of the skin by microbes, bullae may form as a consequence of damage inflicted to the epidermis by the infectious agents (e.g. streptococci) or their toxins. In burns, the serous exudate raises the necrotized epidermal area. Various endogenous factors often promote the development of intraepidermal bullae; breakage of the intercellular connections (acantholysis) and degenerative changes in the epidermal cells are encountered in such cases. In disturbed structure of the basement membrane, the tran-sudate or exudate from the vessels loosens epidermis (epidermolysis) and subepidermal bullae form, e.g. in erythema multiforme exudativum. Pemphigus is characterized by intraepidermal localization of the bullae (in the prickle-cell layer) and the presence of acan-tholytic cells which are found either as occasional cells or in clusters. A pustule is an exudative cavitary lesion containing pus. There is a considerable number of leucocytes in the purulent exudate which is also rich in albumins and globulins. Under the effect of the products of vital activity of microbes (mainly staphylococci and streptococci) the epithelial cells undergo necrosis as a result of which the cavity of the pustule forms in the epidermis. Pustules located in the thickness of the epidermis and marked by a tendency to form a crust are known as impetigo. After the crusts drop of! a temporary pigmentation of the affected area remains. A condition in which pustules form around the hair follicles is called folliculitis. When pus penetrates the orifice of the hair infundibulum, the centre of the pustule pierces the hair and ostial folliculitis develops. Folliculitis may be superficial, in which case the lesions do not leave any traces, or deep (the part of the follicle lying deep in the dermis is involved in the process) with the formation of a scar. Staphylo-coccus is the most common causative agent of folliculitis. Eruption of deep nonfollicular pustules which form in the dermis is called ecthyma. After it resolves an ulcer forms which heals leaving a scar. Ecthyma is caused by streptococcus. Superficial streptococcal pustule (flaccid, flat) is called phlyctena. Pustules are always surrounded by a rose-coloured nimbus of inflamed tissue. They are sometimes secondary in character, developing from vesicles and bullae in concomitant pyococcic

infection. A wheat is an exudative non-cavitary lesion which forms as a result of circumscribed acuteinflammatory oedema of the papillary skin layer. It is a rather hard cushion-like elevation, spherical, or less frequently oval in shape, which is attended with strong itching. A wheal is an ephemeral lesion, i.e. it usually disappears rapidly (from several scores of minutes to a few hours) leaving no trace. It may be the size of a pea to that of a palm and larger. It is pale-pink because dilatation of the vessels occurs simultaneously with the oedema of the papillae. In drastic oedema the vessels are compressed and the wheals take a porcelain-like colour. Wheals may form at the sites of mosquito, midge, or other insect bites, after exposure to cold, on contact with stinging nettle (external factors), in severe emotions, toxicosis and sensitization of the organism (internal factors). Wheals appear on the skin in drug, food and bacterial allergy (urticaria, angioneurotic oedema, serum sickness) and may be induced by mechanical irritation of affected skin areas, for instance in urticaria pigmentosa. Large persisting wheals form in such cases after mechanical irritation of the skin (urticaria factitia, or dermatographia). Though the development of wheals is attended with severe itching, no scratches are usually found on the patient's skin. SECONDARY MORPHOLOGICAL LESIONS Secondary morphological lesions develop in the process of evolution of primary morphological lesions. They include pigmentation maculae, scales, crusts, superficial and deep fissures, excoriations, ulcers, scars, lichenification, and vegetations. Pigmentation. Primary pigmentations (e.g. freckles, chloasma, pigmentation birthmarks, etc.) are mentioned above. Here we shall deal with hyperpigmentation consequent upon increased deposit of the pigment melanin after the resolution of primary (papules, tubercles, vesicles, bullae, pustules) and secondary (erosions, ulcers) skin lesions and deposit of the blood pigment haemosiderih in haemosiderosis of the skin. Secondary hypopigmentation is associated with a diminished content of melanin in separate skin areas and is known as secondary leucoderma. Secondary pigmentation maculae take the shape and contours of the lesions which they replace. Scales (squamae) are detached horny laminae. Unnoticeable physiological shedding of the laminae of the horny layer occurs continuously ander normal conditions. These laminae are removed by washing and rubbing of the clothes against the skin. In some pathological conditions the formed scales are seen with the naked eye. They characterize the process of abnormal desquamation. Small and fine scales resembling flour or bran are called branny and the shedding of such scales is termed furfuraceous desquamation; it is encountered, for instance, in pityriasis versicolor. Larger scales are termed lamellae and their shedding is called lamellar desquamation; it is encountered in psoriasis. In some skin diseases, e.g. erythroderma and scarlatiniform dermatitis, the horny layer is shed in large plates. Scales are among the constant objective symptoms of some dermatoses, for instance ichthyosis. The colour of the scales may be white, grey, yellowish or brownish. Abnormal scaling usually occurs as a consequence of parakera-tosis (disturbed cornification), when there is no granular layer in the epidermis and remnants of nuclei are found in the horny laminae. Desquamation is less frequently the result of hyperkeratosis, i.e. abnormally intensive development of the ordinary horny cells, or keratosis (the layering of hard, dry horny masses as, for example, in corns). Knowledge of the form of desquamation and the type of scales helps in making the diagnosis of some dermatoses. Silvery-white scales, for instance, are encountered in psoriasis, dark scales in some forms of ichthyosis, yellow in seborrhoea oleosa, loose easily removable scales in psoriasis; in cicatrizing erythematosis (discoid lupus erythematosis) the scales are tightly attached and their removal is sometimes painful, because the under surface of the scales has horny projections penetrating the follicular orifices of the skin. Pityriasis rosea is characterized by crimped and imbricated scales, syphilitic papules by collette-like arrangement of the scales (Biett's band, or collar), parapsoriasis by 'wafer-like' scales (central exfoliation), some fungus diseases are marked by peripheral desquamation, etc. Crusts (crustae) form when a serous exudate, pus or blood, sometimes with an admixture of the drugs applied, dries on the skin. There fore serous, purulent, seropurulent, sanguinopurulent, and other kinds of crusts are distinguished. They result from the drying of vesicles, bullae and pustules, the ulceration of tubercles, and nodules, in necrosis and purulent melting of deep pustules. Laminated massive oyster-like crusts are called rupia; the upper part of the crust in such case is oldest but, at the same time, the smallest.

The colour of the crusts is determined by the character of the secretions from which they formed; they are transparent or yellowish in a serous secretion, yellow or greenish-yellow in a purulent secretion, red or brownish in a sanguineous secretion, etc. When the secretions are of a mixed character, the colour of the crusts changes accordingly and takes various tinges. Crusts often form on the lips (in pemphigus, erythema exudativum multiforme, lichen planus pemphigoides, in various types of cheilitis, etc.). Crusts appear on the skin in scabies, mycoses, pyoderma, eczema, neurodermitis, in various syphilids, and in other diseases. Mixed stratifications on the skin of scales and crusts are called crusts-scales; they are encountered in seborrhoea and in some cases of psoriasis exudativa, A superficial fissure (fissirra) does not penetrate beyond the epidermis and heals without a trace. A deep fissure (rhagas) forms in the epidermis and the dermis, sometimes with involvement of the deeper tissues, and leaves a scar after healing. Linear fissures (defects in the skin) appear when the skin loses its elasticity due to inflammatory infiltration on skin areas that are subject to stretching (e.g. at angles of the mouth, in the folds between the fingers or toes, on the skin overlying the joints, in the region of the anus, etc.). They also form in chronic eczema, intertriginous epidermophytosis of the feet, pyodermal or fungal lesions at angles of the mouth (perleche), intertrigo, etc. and also from stretching of skin with a dry horny layer. Deep fissures may be encountered in early congenital syphilis. They form around the natural orifices and bleed easily. Depending on the depth of the fissures, serous or serosanguineous secretions appear which dry and form crusts corresponding to the fissures in shape. An excoriation is a skin defect resulting from scratches or some other traumatic damage. Scratching may injure not only the epidermis but also the papillary layer of the dermis; no scars form in such cases. A deeper penetrating excoriation leaves a scar, pigmentation or depigmentation. Excoriations are objective signs of excruciating itching. The localization and shape of the excoriations sometimes help in making the diagnosis (e.g. in scabies). Erosion is a superficial skin defect within the epidermis. Erosions appear after rupture of vesicles, bullae and pustules and are of the same shape and size as the primary morphological cavitary lesions in whose place they had formed. They are usually pink or red and have a moist, weeping surface. Large eroded skin and mucosal surfaces are observed in pemphigus. Small erosions form in rupture of vesicles in patients with eczema, lichen pemphigoides, herpes zoster, dyshidrosis, and dyshidrotic epidermophytosis of the feet. Eroded syphilitic papules are often found in the mouth and on the rubbing skin surfaces; hard chancre may also form as an erosion. Erosions heal without leaving scars. An ulcer (ulcus) is a skin defect with involvement of the epidermis, dermis, and sometimes the deeper lying tissues. Ulcers develop from tubercles, nodules, and after rupture of deep pustules. Trophic ulcers alone form as the result of primary necrosis of seemingly healthy tissue because of its disturbed trophies. Ulcers may be spherical, oval or of an irregular shape. The surface of ulcers varies in colour from bright-red to cyanotic congestive. The floor may be even or uneven and covered with a serous, purulent, or sanguineous secretions, and with scanty or rich granulations. The edges may be regular, undermined and eroded, flat or raised, hard or soft. In a purulent inflammatory process the edges of the ulcer are oedematous and soft, and there are abundant purulent discharge and diffuse hyperaemia around the ulcer. In disintegration of infectious granulomas (e.g. a gumma in syphilis), hard circumscribed infiltration forms around the ulcer with congestive hyperaemia on the periphery. A hard infiltration around the ulcer with no inflammatory phenomena suggests a new growth. An ulcer heals always leaving a scar from the character of which the previous pathological process may be judged. A scar (cicatrix) forms in place of deep defects in the skin which had been replaced by coarse, fibrous connective tissue (collagen fibres). The skin papillae are smoothed out in such cases and the interpapillary epithelial processes disappear, with the result that the boundary between the epidermis and dermis is seen as a straight horizontal line. The scar has neither the skin pattern nor the openings of the follicles or sweat ducts. Gicatricial tissue also contains no hair, sebaceous or sweat glands, vessels or elastic fibres. A scar forms at the site of deep burns, cuts, ulcerated tubercles, nodules or deep pustules or it may form in the 'dry manner' without preceding ulceration, e.g. in papulonecrotic tuberculosis of the skin or in some cases of tertiary tubercular syphilis. Fresh scars are red or pink, older scars are hyperpigmented or depigmented. Scars may be smooth

or rough. Hypertrophic scars raised above the skin surface form as the result of excessive amount of hard fibrous tissue; they are called keloidal scars. Cicatricial atrophy is a condition in which finer connective tissue forms and in a lesser amount than in a scar. In such cases the skin in the affected area is very thin, devoid of the normal pattern for the most part, and is often depressed, i.e. is below the level of the surrounding skin. Atrophy develops without preceding ulceration of the lesion as a rule, i.e. in the 'dry manner' (e.g. in erythematosis and scleroderma). When pressed between the fingers such a skin gathers in fine folds like cigarette paper. The localization, shape, number, size and colour of the scars often help in making the diagnosis of a pathological process suffered earlier by a person. A syphilitic gumma, for instance, leaves a deep retracted stellate scar; colliquative tuberculosis of the skin leaves retracted uneven, irregular in shape bridge-like scars in the region of the lymph nodes. Similar scars on other skin areas may be caused not only by tuberculosis but by chronic deep pyoderma. Papulonecrotic tuberculosis of the skin leaves clearly demarcated, as if stamped, superficial scars, whereas tubercular syphilid of the tertiary syphilis leaves motley tesselated scars with scalloped contours; smooth lustre atrophy of the skin develops in place of the lesions in lupus vulgaris. Lichenization, or lichenification is thickening and hardening of the skin marked by exaggeration of its normal pattern, hyperpigmentation, dryness, roughness, and shagreen-like appearance. Lichenification may be primary, developing as a consequence of longterm irritation of the skin by scratching (e.g. in patients with neurodermitis) or secondary in confluence of papular lesions (e.g. in psoriasis, lichen planus, chronic eczema, neurodermitisdiffuse papular infiltration). In lichenification the prickle-cell layer of the epidermis is hypertrophied and the interpapillary epithelial processes are considerably enlarged and penetrate deep into the dermis (acanthosis) and the upper parts of the dermis are involved in chronic inflammatory infiltration and the papillae are elongated. Vegetations form in the region of a persistent inflammatory process as the result of intensified proliferation of the epidermal prickle-cell layer. They have the appearance of villi, dermal papillae which lend them an uneven nodular character resembling a cock's comb. Vegetations whose surface is covered with a thickened horny layer are hard, dry and grey. Eroded vegetations, which are a frequent finding when the lesion occurs on rubbing surfaces, are soft, succulent, pinkish-red or red; they bleed easily and discharge a serous or serosanguineous secretion. With the development of a secondary infection, tenderness, a band of hyperaemia on the periphery, and a seropurulent discharge appear. In skin and venereal diseases the eruption may be monomorphic, consisting of a single type of primary morphological lesions (e.g. papules in psoriasis and syphilis, roseolas in syphilis, warts, etc.). In view of this, monomorphic dermatoses are distinguished, among which are psoriasis, lichen planus, urticaria, pemphigus vulgaris, furunculosis, hidradenitis, pemphigus epidermicus neonatorum, etc. If there are several types of primary morphological lesions, the condition is called true polymorphism. The group of dermatoses in which true polymorphism is encountered includes eczema, leprosy, Duhring's dermatitis herpetiformis, polymorphic exudative erythema, secondary period of syphilis, etc. These are cases of polymorphic diseases. False polymorphism is also encountered, in which primary and a few secondary morphological lesions are found at the same time. For instance, rapidly rupturing bullae form in patients suffering from epidermolysis bullosa. Eroded surfaces with an exudate drying to crusts are exposed in such cases; pigmentation spots remain when the crusts drop off. It seems as if there is a diversity of clinical signs. This is what gives the idea of the polymorphism of the eruption, that is why it is called false polymorphism. Correct recognition of a monomorphic or polymorphic eruption or false polymorphism makes the diagnosis easier.