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

JOURNAL OF THE SOCIETY OF COSMETIC CHEMISTS 807 not more than 5%, of dermatologic patients will be found to possess internal disturbances which are relevant to their skin diseases. Derma- tologists, of course, must be cognizant of the possibility that the patient may have a systemic disorder in which the skin is participating, or indeed, that the patient may ½oncomitantly have some unrelated in- ternal disorder whose detection, cardiac or pulmonary disease, for instance, might be even more important than the skin manifestations. I am, however, proposing that the extensive and expensive work-up more or less as a matter of routine when there is no clue to suggest the possibility of internal disease is an action that is calculated, perhaps unconsciously, to be more helpful to the doctor than the patient. Once the biopsy is taken the average hospital has little more to offer in the way of studies directed to the skin itself with the exception of such elementary procedures as patch testing for contact allergy, photosensi- tivity and the like. If one can't study the skin in depth, one can at least call on the resources of the internist and request an evaluation of the heart, lungs, kidney, pancreas, bone marrow, blood, adrenals--the diagnostic possibilities are impressive and are very helpful in quieting the physician's anxieties concerning his credentials as a real doctor. The pressing need is for a quantitative methodology which will portray and reveal the dynamic disturbances in the skin. It is not enough to classify and identify the disorder on the basis of its gross and microscopic attributes. We need to know a great deal more about functional derangements. The changes are often subtle and well below the level detectable by the eye. After a single modest ultraviolet ex- posure or even after so transient and trivial a reaction as a histamine wheal, the skin may remain abnormal for many months, though there's nothing to suggest this by appearance alone. Of course, one needs sensitive methods to appreciate these subtleties in the case of ultra- violet light, a suitable reflection meter to demonstrate the persistence of venous congestion revealed by an elevated amount of reduced hemo- globin after whealing, a means of measuring skin temperature with great accuracy to show that the affected site does not react in quite the normal way when it is again subjected to histamine whealing. The great French dermatologist, Gougerot, wrote a little volume, all but unknown in this country, dealing with the "invisible" or "silent" dermatoses relating to skin diseases which were hidden from view. He clearly appreciated that skin disease may involve more than meets the eye. Now I shall reveal the meaning of my cryptic title, "Blind Man Dermatology." I believe that the golden age of dermatology is still