PSORIASIS: 
ITS ETIOLOGY, RELATION TO RHEUMATIC 
DISEASE, 
AND THE 
RATIONALE OF A COGNATE TREATMENT. 
BY 
F. LE ROY SATTERLEE, M.D., Ph.D, 
Professor of Chemistry, Materia Medica anil Therapeutics in the N. Y. College of Dentistry; 
Lecturer on Chemistry in the N. Y. College of Veterinary Surgeons; Surgeon to the N. Y. 
Dispensary for Diseases of the Skin; Surgeon to the Northeastern Dispensary— 
Department of Skin, Fevers and Rheumatism; Fellow of the New York 
Academy of Medicine; Member of the N. Y.-County Medical 
Society, of the New York Dermatological Society, 
Reprinted from the Journal of Syphilography and Dermatology, July, 1873. 
NEW YORK: 
POOLE & MACLAUOHLAN, PRINTERS. 
205-213 East 12th St. 
1873. PSORIASIS: 
ITS ETIOLOGY, RELATION TO RHEUMATIC 
DISEASE, 
AND THE 
RATIONALE OF A COGNATE TREATMENT. 
BY 
F. LE ROY SATTERLEE, M.D., Ph.D, 
Professor of Chemistry, Materia Medica and Therapeutics in the N. Y. College of Dentistry; 
Lecturer on Chemistry in the N. Y. College of Veterinary Surgeons; Surgeon to the N. Y. 
Dispensary for Diseases of the Skin; Surgeon to the Northeastern Dispensary— 
Department of Skin, Fevers and Rheumatism; Fellow of the New York 
Academy of Medicine; Member of the N. Y. County Medical 
Society, of the New York Dermatological Society, 
etc., etc., etc. 
This Paper was read before the New York Dermatobgical Society, May 20th} 
1873. 
NEW YORK: 
POOLE & MACLAUCHLAN, PRINTERS. 
205-213 East 12tii St. 
1873. PSORIASIS: 
ITS ETIOLOGY, DELATION TO RHEUMATIC DIS- 
EASE, AND THE RATIONALE OF A 
COGNATE TREATMENT. 
To those of the profession who have battled with psoriasis, not 
only in severe exhibitions where major portions of the body are 
covered with this most obstinate eruption, but even where pre- 
sented in more insignificant proportions, a sense of disappoint- 
ment and impotency are not wanting in viewing the results of 
all treatment hitherto academically received and adopted. 
It is needless to ask whether topical treatment with tar, green 
soap, oil of cade, blistering, carbolic acid or the like, and with 
internal arsenical medication, meets with other than tempo- 
rarily suppressive or palliative results; thus seeming to evince 
that our treatment is at best an attack upon symptoms. 
In the search for cause suggested by this dissatisfaction, it 
has occurred to the.notice of Dr. Bence Jones, and been hinted 
by two or three other practitioners, that an identity or simi- 
larity of cause in psoriasis and in certain rheumatic affections 
was indicated, but nothing has been presented showing any ex- 
tended following up or testing of the suggestion. While pursu- 
ing with interest this affection of the skin in private practice 
and in the N. Y. Dispensary for Diseases of the Skin, it fell also 
to my lot to deal with many rheumatic cases, especially in that department of the Northeastern Dispensary of this city. The 
success of the latest and most logical treatment of rheumatism 
confirming the most scientific theory of its cause, and the con- 
tinued observation of psoriasis suggesting similar chemical 
actions, an inquiry of patients under the latter disease developed 
almost universally the precedence or concomitance of rheumatic 
exhibitions; or otherwise a rheumatic diathesis in the person 
or family, and the same characteristics in inheritance of ten- 
dency, persistency of continuance or recurrence in both diseases. 
It was with the satisfaction and encouragement in noting the 
confirmitory hints alluded to, of Bence Jones and others, that 
I commenced, some two years since, to test the similarity of 
physical conditions present in rheumatism and psoriasis, and 
to treat the latter disease on the theory of an identity of the 
materies morbi, and with results so uniform and permanent 
that I feel warranted in presenting the rationale and argument 
after citing a representative case, which fortunately gives 
necessary test conditions of long continuance, the fullest exhi- 
bition of severity and the prior treatment in the best colleges, 
dispensaries and asylums ; thus insuring the most thorough and 
discreet employment on several occasions of present accepted 
treatment. 
P. H., age 24, Irish ; by occupation a porter. The psoriasis 
eruption broke out eleven years ago, progressing rapidly until 
the wrhole body, except the head and hands, was covered. 
Spots the size of an English shilling; very close to each other, 
always dry and scaly; worse in cold and damp weather. After 
live years they appeared on the hands and face also. Family 
history : healthy on the mother’s side, as far as known ; mother 
died of some bladder disease (probably calculous). Does not 
know about the family on the father’s side ; father was killed ; 
several brothers and sisters had this eruption. Antecedent his- 
tory : always moderate in habits; wrorked hard; very active. 
General functions, digestion, circulatory and respiratory symp- 
toms normal; nervous temperament. Has had rheumatism, es- 
pecially within later years. Seven jmars ago received treatment 
in Manchester, Eng.; internal medication for several weeks, 
with no effect, after which took medicine and applied salve as recommended by friends, or on his own suggestion, with no 
effect; nearly killed himself by the excessive use of senna and 
salts. In this country, first tried the homoeopathic and hydro- 
pathic treatments, with no effect, except to wash off the scales 
by excessive bathing. After this he applied to the College of 
Physicians and Surgeons in this city, and was exhibited to the 
class as a typical case of psoriasis. Sent to the Strangers’ Hos- 
pital, where he received the orthodox treatment; alkaline baths, 
green soap, and Fowler’s solution, run up to very large doses per 
diem. After live weeks of this treatment, no improvement was 
noticed, as declared by the visiting physician. The same treat- 
ment more energetically tried, served only to slightly moderate 
the severity of the affection ; after four months of this treatment 
he was discharged from the hospital incurable. ITe went back to 
work covered with the eruption. (I lind at this time he suf- 
fered for two weeks with inflammatory rheumatism.) He then 
again tried the homoeopathic treatment for three weeks, with 
no good results. Was sent to the H. Y. Dispensary for Dis- 
eases of the Skin, and came under my charge. He was at 
that time, eight months ago, completely covered with the 
disease, excepting the face and hands; the legs and arms one 
mass of eruption. I directed my internal treatment on the 
theory of an excess of uric acid in the system, which must be oxi- 
dized up to the point of urea ; putting him on internal treatment, 
giving alkalies, and restricting the diet to vegetables and fruits 
and vegetable acids, forbidding meat, and using no external 
treatment except an occasional alkaline bath. Applied acetic 
acid externally to one or two inches of the eruption, merely as 
a placebo. The result manifested itself in three weeks, and 
from that time he gradually cleared off until in three months he 
was completely well, and had gained several pounds in weight 
during the treatment. 
To demonstrate fully the theoretical basis of identity of cause 
and treatment, I may be permitted to allude to the chemical 
argument of the etiology of rheumatic affections, continuing 
its application to the morbific cause of psoriasis, previously 
alluded to as the abnormal amount of uric acid and its non- 
oxidation to the point of urea formation. In doing this, I use as far as possible the form of statement of the investigators of 
this diathesis, whose labors give ns authority : u A vast class of 
diseases can be proved to be errors of chemical action—inter- 
ferences caused either by want of regulation, or by the intro- 
duction from without, or by the generation within the body of 
substances that increase, diminish, or change the oxidation 
which is necessary for the working of the body.” * 
“ The precise constitution of healthy blood is adjusted by the 
balance of the nutritive process for maintaining the several 
tissues, so that none of the materials appropriated for the main- 
tenance of any part may remain in excess in the blood. Thus 
each part is in relation of an excretory organ to all the rest. 
For example, if the muscles did not take material for their nu- 
trition, there might be an excess of fibrin and their other con- 
stituents in the blood ; if the bones did not do so, the salts of 
lime might be in excess, and so on.” f 
ISTow, this balance may be destroyed, and there are two con- 
ditions most likely to have been the cause; a given constituent 
of the food in too great an excess ; and conditions retarding the 
normal change of tissue, and thus preventing the appropriation 
of the new material to construct healthy blood. Accordingly 
experience shows that gout, rheumatism, and allied affections 
are met with in individuals addicted to an over-indulgence in 
nitrogenous diet and generous wines, combined with sedentary 
habits. These conditions are intimately associated with the 
presence of uric and oxalic acids in the blood, and their mani- 
festations. That there is an excess of fibrin in the blood in 
cases of rheumatism, has been shown by the analyses of Alder- 
son and others. It is apparent that in rheumatism fibrin is 
present in more than double the usual proportion. By still 
more recent investigation the difference is made even greater, 
as it has been ascertained the amount of fibrin in healthy blood 
is considerably less than 3 per cent. 
Given, therefore, excessive indulgence in nitrogenous diet, 
accounting for excess of fibrin in the blood, and conditions 
which retard the transformation of effete tissue, what is likely 
* Bence Jones. 
f Kirke’s Physiology. to result? First, fibrin in excess in the blood will render the 
normal supply of atmospheric air for its required purposes in 
the economy, insufficient; while a sedentary life, independent 
of the foregoing, retards metamorphosis. Under these circum- 
stances, it must follow, that if urea, carbonic acid, and ammonia 
represent the full oxidation of the proteids in the body, a com- 
promise may be the result, and the production of intermediate 
compounds. “Under ordinary circumstances, when uric acid 
is formed, as it is in all warm-blooded animals, it must be 
further oxidized, or else, by its insolubility, it is deposited or 
combines with alkaline bases, producing calculous diseases.”* 
Liebig observes that “ when uric acid is subjected to the ac- 
tion of oxygen, it is first resolved into alloxan and urea; a new 
supply of oxygen acting on the alloxan causes it to resolve itself 
into oxalic acid and urea, or into oxaluric and parabanic acids, 
or into carbonic acid and urea.”f The various excretions, as 
we know, are simply removed by the emunctories; and those 
excretions, it seems, must be in some required chemical condi- 
tion, or they are imperfectly removed and otherwise remain as 
abnormal disturbants. The varied phases of disturbance in the 
vital economies produced by these abnormal conditions we can 
only perceive by observations of results and existing states ; the 
molecular methods that determine the specific exhibitions of 
disease are as yet beyond our ken. What we do perceive is, 
that a certain state of oxidation is a prime necessity for elimina- 
tion. Urea represents the oxidation more or less complete, of 
effete material, or of superfluous protein matter in the circula- 
tion. 
If the oxidation of the proteids be not sufficiently complete, 
intermediate compounds are formed, and these constitute the 
materies morbi of certain diseases, such as rheumatism, etc. 
While uric acid may be a normal constituent of the urine, it 
should exist in but small quantity; hence the greater part of it 
is, in the system, raised, so to speak, by oxidation to urea. The 
kidneys do not, then, form, urea; they merely remove it from 
the blood where it has been created by chemical changes. 
* D. Campbell Black. 
f Liebig’s Animal Chemistry, p. 137. Urea, carbonic acid, water, ammonia, etc., are the results of the 
ultimate oxidation of effete tissue—not by direct oxidation, but 
through a serious of chemical evolutions. In gout and rheuma- 
tism, with an excess of fibrin and uric acid in the blood, and ex- 
cess of uric acid in the urine with sedentary and indulgent 
habits, we have affections of the white tissues, sheaths of mus- 
cles, aponeuroses, bursae, capsular ligaments, pericardium and 
endocardium, and deposition of urate of soda in the joints, and 
we look for a deficient oxidation of effete tissue as the immedi- 
ate cause of these affections. A theory corroborated by the op- 
posite conditions which occur in the pyrexiae, in which class of 
diseases there is excessive oxidation of tissue, as represented in 
excessive excretion of nitrogenous compounds from the body, 
and in the treatment of which we give such agents as counter- 
act oxidation, viz.: quinine, arsenic, alcohol, etc.* 
Another demonstration of these opposite states should, I 
think, be shown by the non-existence of rheumatism or psori- 
asis with consumption in the same subject, which my observa- 
tion *has so far indicated to me. Recapitulating our argument 
briefly, we have seen that certain habits of body tend to the 
undue accumulation of proteids in the blood; that they are 
absolutely in excess relatively to the wants of the system, and 
relatively to the amount of oxygen consumed ; that urea, car- 
bonic acid, and ammonia represent the full oxidation of pro- 
teids ; and that when this process is imperfect, the formation 
of intermediate products must result. And that the morbific 
cause of gout, rheumatism, etc., are the result of the imperfect 
oxidation of effete tissue, a theory borne out by the treatment 
most successfully employed. “In gout and rheumatism, then, 
it is inferred theoretically, on the best possible grounds, and 
practically on the evidence of our senses, that there is an ex- 
cess of uric acid circulating in the blood.” f With this view 
of the cause of rheumatism, borne out by the results of its 
treatment, it has occurred to several observers that in some 
manner psoriasis seems to occur with the same abnormal pliysi- 
cakconditions, and to be associated with the rheumatic diathesis, 
* D. Campbell Black. 
t D. Campbell Black. and being indicated as the result of a like cause, should be 
cured by similar treatment. Among those who have noticed 
this connection between rheumatism and psoriasis I would cite 
Dr. Begbie, who, after recounting the symptoms usually 
resulting from the uric acid diathesis, adds : “ And there is a 
tendency to certain cutaneous diseases, such as psoriasis, in 
these patients.” And Dr. W. R. Basham writes : “ Psoriasis 
and some other eruptions are in some measure connected with 
the defective metamorphosis of uric acid; and the inference is 
still further strengthened by the well-known favorable results 
of an alkaline plan of treatment.”* Speaking again of the 
theory of oxidation, he says: “The interpretation, moreover, 
is strictly in accordance with wdiat the ablest chemists have 
recently established, namely the conversion, both in and out of 
the body, of uric acid, by the agenc}T of oxidizing agents, into 
oxaluric acid, and ultimately into urea and oxalic acid 
The action of alkaline salts, then, appears to be to facilitate 
the metamorphosis of uric acid and hasten its conversion into 
oxaluric acid, which, as oxalurate of ammonia or potash, is ex- 
creted in the urine, and which, after passing from the bladder, 
is quickly split up into oxalic acid and urea.”f;{: If, then, we 
will regard psoriasis and rheumatism as produced by the same 
general cause or condition of the system—namely, the result of 
the metamorphosis of an excess of nitrogenous substances—our 
treatment is readily suggested. Decrease the amount of nitro- 
genous food taken into the body, by restricting the diet, and 
give such remedies as will promote oxidation, so that the excess 
of nitrogenous material may be oxidized up to the point where 
it is easily eliminated from the body. In a chemical point of 
view, the alkaline salts constitute the most important principles 
promoting oxidation; even vegetable acids are converted in the 
system into carbonates for this purpose. The alkalies do not 
neutralize the uric acid, as was at one time supposed; but 
* Dr. Basham in The Practitioner. Nov., 1870. 
f Dr. Basham. 
\ Oxaluric acid (C6 H3 N-. 0, + H0) contains two atoms of oxalic acid (2(C2 
0:i)), and one atom of urea (C2 H4 N2 02). they prevent its formation to the extent which constitutes a 
materies morbi, by oxidizing it up to urea. Lemon-juice, of 
which the chief constituent is citric acid, has likewise been 
shown to possess remarkable therapeutic properties in these, as 
well as other affections. Large draughts of pure water act 
by oxidizing, the water being decomposed, its hydrogen con- 
tributing to form ammonia, and its oxygen urea. ' In this treat- 
ment the good effects are but slowly manifested. Two or three 
weeks sometimes pass before a change is noticed; then the 
eruption begins to pale and to scale less; this is followed by an 
improved general condition. The patient says that- he feels 
better and stronger than-he has done since the first appearance 
of the disease. The eruption takes a natural mode , of sub 
sidence, the spots changing into rings, by the appearance of 
healthy skin in the centre of each spot. These rings gradually 
break up into segments of circles, and then disappear, leaving 
a faint pinkish stain on the skin, which in turn vanishes. The 
smaller spots (guttata) also disappear, some leaving transitory 
stains, and others none at all. When the patient is entirely well 
of the eruption his general health is improved ; he has often 
gained much in weight during the treatment; and I have yet 
to see a case where the disease has returned after the cessation 
of alkaline medicine, although I have maintained (but not so 
strictly as during the treatment) a general vegetable diet. 
Several times I have suspended the treatment, and allowed a 
return to a meat diet, with alcoholic stimulants, which was 
speedily followed by a retrogression in the cure. As psoriasis is 
essentially a chronic affection, coming on slowly and gradually, 
requiring sometimes many years to cover the body, we cannot, 
of course, expect to speedily eradicate the disease. By this 
treatment, from one to six months may often be necessary to 
produce the desired result.