JOURNAL OF THE SOCIETY OF COSMETIC CHEMISTS 505 Blind Man Dermatology A.M. KLIGMAN, M.D., Ph.D.* Presented at the Literature Award Luncheon, May 10, 1966, New York City The reader will not likely discern the intent of this little piece from the title. A sampling of my colleagues' guesses showed that I had succeeded in keeping them in the dark. Influenced by my past history in public speaking, they generally surmised that I was going to denounce dermatologists for being "blind," adding thereby a new dimension to the better known deficiencies of this sub-order of medical specialists. Neither I nor any other informed person can deny that dermatologists have keen eyes, though in some instances there is controversy concerning the adequacy of the connections between the retina and the brain. No, my sermon is not about sins on skin but secrets about skin. Dermatologists are fond of pointing out that the skin is the largest and most visible organ in the body. Every recess can be minutely examined, not only with the eyes but with the fingers as well. For those who enjoy looking and touching, the skin is a playground. Our concern is more serious. How much learning, even at the elementary level of description, is possible in a school based on looking and touching ? However accessible the skin, this seeming advantage has not elevated dermatology to a premier position in biologic science. Indeed, this high visibility is, in my view, not a munificence but in fact a misfortune of the first magnitude. The skin is too obvious and too familiar. Just as it is the forbidden which excites the greatest curiosity, it is the hidden, the concealed which stirs the mind. What is inaccessible is challenging easy seeing is sedating. Knowledge seems to be proportional to the barriers standing in the way of its acquisition. If size and accessibility were advantages, we should know little about those tiny tissues, the adrenal and pituitary, about which we probably know the most. Dermatologists are wont to utter other propagandistic pronounce- ments which have the sound of validity but which, like most clich•s, * Duhring Laboratories, University of Pennsylvania, Philadelphia, Pa.

506 JOURNAL OF THE SOCIETY OF COSMETIC CHEMISTS are not much more than noise. Novitiates are instructed that the skin is a window through which we may peer to obtain clues of systemic disease. This proposition is appealing to those externists who uncon- sciously wish to be internists or who feel obliged to explain that they are "real" doctors with far more than superficial interests. I personally find the crust as appetizing as the pie and do not need such rationaliza- tions. A parallel exaggeration, equally popular, is the concept of the skin as a mirror, which reflects internal happenings. Here again we perceive the dermatologists' yearning for depth. If we search in the medical literature for the consequences of viewing the skin as a mirror, we find precisely what might be expected. What the dermatologist sees when he looks into the "mirror" is of course his own image. Such re- flections confirm his own reality and importance. Instead of describing the skin, writers of this narcissistic bent mainly describe themselves. It does not avail much to think of skin as either a mirror or a window. The skin is not a powerful reflector moreover it is too turbid for the eye to penetrate its true depths. Besides, the eye is an organ more worthy of praise from the poets than scientists. In our more exuberant youthful days, Shelley and I wrote that the eye was "the supreme dermatologic instrument." Assertions of this kind confirm Montaigne's observation that it is easier to write luridly than accurately. The fact is, the limitations of the eye are prodigious. It enables us to perceive but a tiny fraction of the electromagnetic spectrum, from 4000 to 8000 A. Helmholtz, the renowned physicist, found numerous engineering faults in the construction of the human eye. Yet the eye is almost our exclusive means of obtaining diagnostic data whether we examine the skin grossly or microscopically. By way of contrast, think of the extra- ordinary array of exquisitely sensitive and complex testing procedures available to the internist, none of them dependent on the native sensing devices of the examining physician. In an up-to-date hospital one needs only to know how to write in order to place at his service the extraordinary technology of modern physics and chemistry. A mere listing of the routine diagnostic services available occupies a small vol- ume. The dermatologist, of course, is not disbarred from using these tests, and, indeed, this is one of his chief strategies in the work-up of hospitalized skin patients. He can, in this way, establish that he is not merely an externist (an outsider) but an interhist (an insider) as well. Although the "window" concept of dermatology is now fashionable, requiring that a profound search be made for evidences of internal involvement, I am of the opinion that only a small fraction, perhaps