THE 
Relations of the Urine 
TO 
DISEASES OF THE SKIN 
BY J 
L. DUNCAN BULKLEY, .A.M. M.D. / 
Physician to the Skin Department, Demilt Dispensary, New York ; 
Fellow of the New York Academy of Medicine ; Member of 
the New York County Medical and Dermatological 
Societies, etc. 
Reprinted from the Archives of Dermatology, October, 1875. 
NEW YORK 
G. P. PUTNAM’S SONS 
4th Ave. & 23d St. 
1875 THE 
RELATIONS OF THE URINE 
TO 
DISEASES OF THE SKIN 
“ We want a critical investigation of skin diseases in their relation with dis- 
eases of other organs. Are diseases of the kidney or of the liver frequently 
productive of them ? and if so, what are the peculiarities of such. Which are in 
special relation with the nervous system ? Are diseases of the intestinal or 
pulmonary mucous membranes frequently associated with those of the skin ? 
* * * * We earnestly beg of our specialists in this department that they will 
abandon all useless controversy as to nomenclature, orthography, and classifica- 
tion, and betake themselves to the earnest study of the causes of the maladies 
which come under their care.”—British Medical Journal, Jan. 22, 1870. 
FEW fields of scientific research in practical medicine present 
greater attractions, and yet at first sight greater difficulties, 
than that of chemical physiology and pathology, and but few lines 
of investigation and applied science have been more neglected by 
the profession, both in the teachings of the schools and in practice at 
the bedside. That this is unnecessary, and that exact chemical 
science can be applied to the study and treatment of disease, the 
names of Prout, Bird, Bence Jones, Thudicum, Garrod, Murchison 
and others, in the English school alone, well testify. 
The aim of the present paper is to contribute somewhat to this 
branch of study as far as relates to the changes observed in the 
urine in diseases of the skin, and to endeavor to draw therefrom 
some practical considerations and therapeutical suggestions. 
As is well known, many of the diseases of the skin are sup- 
* Read before the New York Academy of Medicine, April 15, 1875. 4 
Z. DUNCAN BULKLEY; 
posed to be entirely local in their origin, as the parasitic affections, 
lupus, epithelioma, etc. ; others, again, to be purely nervous, as 
herpes zoster, and perhaps others; still others to be due to 
dyscrasiae, as syphilis and leprosy. How far all these are depen- 
dent upon deranged blood-states such as appear to be measur- 
ably demonstrated in other affections, it is at present impossible to 
determine, but it is highly probable that such derangements not 
only favor the inception and development of all skin diseases, 
but, during their continuance, greatly retard their cure and ag- 
gravate their symptoms. While therefore my studies and my re- 
marks apply more particularly to such diseases as eczema, acne, 
psoriasis, urticaria, and the like, I consider that the condition of 
the urine is one well worthy of investigation in reference to all 
maladies affecting the integument, for we can never know how much 
a systemic disorder has to do with the local manifestations of the 
syphilitic or other poison, or in preparing the way even for parasitic 
diseases. 
It will be understood, of course, when I speak of the changes 
in the urine I take them only as indications of the blood state and 
of assimilation and nutrition as influenced in various ways, the 
urine being the secretion of all others which indicates most quickly 
and surely a disordered blood-current. The presence of sugar in 
the urine after a hearty meal of sugar or starch, the appearance of 
albumen after certain other ingesta, as also the quick and ready 
recognition of iodide of potassium and other drugs in the urine, all 
point to it as a valuable sign of the condition of the all-nourishing 
blood. The further fact of the urine being discharged, as a rule, 
very soon after its secretion, added to the ease of its collection and 
examination, renders it a valuable aid to the physician in studying 
disease. 
I am well aware that the constitutional origin and nature of 
skin diseases of the kind to which more especial attention is 
directed, in the present paper, is not a new matter ; it has, indeed, 
occupied very largely the attention of many for a long time. To 
the French school chiefly do we owe the literature relating to the 
arthritic diathesis, and to their writers would I give full credit for the 
persistency with which they have adhered to and promulgated their 
views on the subject, although continually slighted or ridiculed by 
others having ample opportunities of observation and practice. In 
the present paper, while vindicating in a measure, the diathetic 
origin of many skin diseases, I would not be understood by any 
means as supporting in toto the arthritic, herpetic or dartrous 
diatheses, which, I think, certain dermatologists, notably the 
French, have insisted upon further even than many of their own 
scholars are willing to accept and follow; I desire however, to 
direct very serious attention to the existence of a morbid blood 
state as a predisposing cause of many of the ailments affecting the 
skin, my studies and analyses convincing me that assimilative errors, 
as indicated very frequently and largely by the state of the urine, 
are at the base of a considerable share of cutaneous affections. RELATIONS OF URINE TO SKIN DISEASES. 
5 
I cannot better enter on my subject than by recalling certain 
experiments of Gigot-Suard,* illustrative of the effect to the circu- 
lation in the blood of some of the excrementitious elements from 
the urine, although I can hardly accede to the verity of some of his 
deductions. 
He administered 2.3 grains of uric acid to a medium sized dog, 
morning and evening, for two months : great itching ensued in about 
eight days, also scaliness. Its two pups exhibited eczema, the 
mother also showed some vesicles. Another dog, of three years, 
medium size, took 3 grains of uric acid daily for two months, with 
the effect of calling out a pruriginous eruption of papules and 
vesicles which remained after the administration of the acid was 
stopped, and six months later the animal presented, as Gigot-Suard 
says, a veritable psoriasis, in the scales of which he found on 
chemical and microscopic examination very numerous crystals of 
urate of soda and some of oxalate of lime. He likewise gave uric 
acid internally to some patients, with similar results, which I will 
not here detail. He further administered 4.5 grains of oxalic acid 
daily for a month to certain patients, with the effect of provoking 
rheumatic pains, severe pruritus, and, in one case, erythema and 
urticaria. Hippuric acid, in doses of 4.6 grains morning and 
night, caused itching, with the subsequent development of papules, 
an erythematous redness and many groups of vesicles resembling 
zona, about the waist of a woman aged 45, who had never had 
any cutaneous affection previously. Urea, given to the amount 
of 7.7 grains daily for 15 days to a boy n years old, produced 
coryza and a vesicular eruption at the external nares and on the 
lips. A man, aged 30, after taking 154 grains of urea, in ten days, 
had a coryza, then an angina and bronchitis, and a slight 
erythematous condition about the nostrils. He had also inter- 
costal pains and a pruritus of various parts of the body, but no 
eruption. 
Now we know well of the presence of uric acid in the blood in 
gout, as Garrod f has demonstrated, and that uric acid may be 
found in the fluid contained in blisters produced on gouty subjects. 
Gigot-Suard t discovered it also in the contents of the vesicles of a 
case of eczema of the hands in a man 45 years of age, who had, 
however, gouty pains and deposits as well. The same observer 
likewise found urate of soda, uric acid, phosphate of soda and 
phosphate of lime crystallized from the fluid of some pemphigoid 
bullae occurring in a patient with psoriasis. He further analyzed 
the scales from a patient who had had psoriasis 15 years, and 
who never had rheumatism, and found uric acid in one experiment, 
in another he developed the murexide, and in the third, crystals of 
urate of soda and some of urate of ammonia. He states that he 
has repeated these researches, and has frequently found uric acid 
in the pathological products of the skin. Dr. Beale § examined the 
* L’Herpetisme; pathogenie, manifestations, etc. Paris, 1870—pp. 21-38. 
and pp. 447-459 
t Reynolds’ system of of Medicine, Vol. I, p. 825. 
J L’ Herpetisme, etc. Paris 1870, p. 15. 
§ Archives of Medicine Vol. I, p. 316. 6 
L. DUNCAN BULK LEY; 
scales from two psoriatic patients and found sulphate and phosphate 
of lime, but did not appear to have searched for urea or uric acid. 
Again, urea exists to a very small degree as a constituent of the 
normal perspiration, and may be increased very largely in certain 
pathological conditions, and when there is deficient elimination by 
the kidneys.* Garrod f mentions the case of a patient suffering 
from a very decided attack of gout, who went into a Turkish bath 
and made preparations which enabled him to save a considerable 
amount of perspiration. This, on proper analysis, yielded a notable 
amount or urea but no uric acid. A remarkable case has recently 
been given by Dr. Taylor t where urea was largely secreted by the 
skin. The patient died with symptoms of uraemic intoxication, fol- 
lowing granular degeneration of the kidneys. Two days before 
death her face appeared as if sprinkled with flour, and the deposit, 
which was moderately adherent to the skin, was found to be com- 
posed of urea; somewhat the same appeared on the hands. Other 
similar cases have been recorded. 
The relations of the kidney secretion to the skin may be further 
illustrated by the experiments which have been made as to the 
urinary changes occurring under the use of baths. I will mention 
but a few of the more recent investigations. Kirejeff § submitted 
two healthy soldiers to the action of daily baths, at a fixed time, and 
concludes, that while the total daily quantity and the reaction of the 
urine is unaltered thereby, its specific gravity and daily quantity of 
solids are increased. Urea and uric acid are both excreted in 
large quantity, the ash of the urine in one instance exceeded the nor- 
mal by one-half. Much the same results were obtained from the 
daily use of cold sitz-baths, and he believes that exchange of material 
and metamorphosis of tissue are promoted by both cold and warm 
sitz-baths. Dr. Clemens || found that, during the first 15 minutes 
of a bath, the quantity of compared to that of the preceding 
15 minutes, was doubled, chloride of sodium and urea were slightly 
increased and the phosphates and other non-volatile saline matters 
were quadrupled. This effect gradually diminished during the next 
30 minutes, but on the addition of a decoction of spruce it was 
renewed in a higher degree than before, especially as to the 
phosphates, the excess of which was now nearly 5 times that before 
the bath. The addition of saline solutions to the bath, instead of 
the decoction of spruce, gave the same results. Clemens also 
found that all baths diminish the specific gravity of the urine 
passed during or just after the bath, and that the urine passed for 
several hours after is rich in phosphates and poor in uric acid 
and water.IT 
* Flint’s Physiology, Vol. III. p. 142. t Reynolds, Vol. I. p. 825. 
{Guy’s Hosp. Rep., Vol. XIX, 1874. Am. Jour. Med. Sci.Jan., 1875,p. 
209. 
§ Virchow, Vol. XXII. p. 496. Syd. Soc. Year Book, 1862, p. 422. 
|| Med. Centr. Ztg. Vol. XXX., Nos. 53 & 59. Syd. Year Book, 1862, p. 
424. 
IT Froriep’s Notiz. i860, Vol. II., No. 2. Syd. Year Book, 1861, p. 102. DELATIONS OF URINE TO SKIN DISEASES. 
7 
Muller * as the result of experiments on animals, determined 
that ice-cold packing and ice-cold showers increased very notably 
the rate of urinary secretion, while similar use of hot water markedly 
diminished the rate of secretion of the urine, the greatest increase 
being from 30 drops per minute to 41, and the greatest diminution 
from 26 to 5 drops per minute. The wonderfully intimate rela- 
tions between these two great secreting organs is thus shown, the 
relief to the kidneys by free action of the skin being here exhibited 
to its fullest extent. The same is shown where the skin takes on 
unnaturally free action as in a curious case of general sweating re- 
corded by Dr. Gibb.f A man, aged 25 years, had had profuse 
and very general hyperidrosis for 4 years. The urine was of a full 
amber color, clear on passing, and feebly acid, with a specific gravity 
of 1.028. In a few hours it turned opaque and muddy from a 
considerable deposit of pink urate of soda, readily dissolved by 
heat. The usual salts were present, also a large amount of chlorides. 
There was no albumen, no sugar, no hippuric acid. Oxalate of 
lime and cystine were found microscopically. 
In this same line of thought and argument, I may allude to the 
effects of arresting completely the perspiration, and its effect upon 
the kidneys. Socoloff found albumen in the urine of animals very 
soon after varnishing the skin, and in every case in which the ex- 
periment was tried a parenchymatous inflammation of the kidneys 
resulted. Lang found, an hour or two after death by varnishing 
the surface, crystals of triple phosphate in various parts of the 
body which he regarded as resulting from the decomposition of 
the urea; he thought the deaths resulted from uraemia.j 
Remembering, then, the physiological connections of the skin 
and kidneys, and bearing also in mind the pathological relations 
constantly exhibited in daily practice, such as the dry harsh skin in 
chronic kidney disease, and conversely the occasional occurrence 
of kidney congestion and urinary derangement from a chilling of 
the cutaneous surface, and considering further what has been pre- 
mised as to the effect of retained and circulating excreta, as urea, uric 
acid, etc.,we might well expect in diseases of the integument to find 
some alterations in the secretion of the kidneys. 
The urinary changes in diseases of the skin have been but little 
studied hitherto, and the observations bearing on the point are few 
and scattered, most of the standard works on cutaneous medicine 
ignoring the matter almost entirely. My experience, however, 
though limited as yet, has taught me the very close and important 
relations existing between the kidney secretion, on the one hand, 
and the state of the skin on the other, and that much may be 
learned of the latter by a careful attention to the former, and much 
done to relieve the skin by rectifying the disorders found in the 
urine. 
*Archiv fur Exper. Pathol.; Phil. Med. Times, 1874; Am. Jour. Syph. & 
Derm., July, 1874. 
t Beale’s Archives of Medicine, Vol. II., p. 280. 
$ Am. Jour. Med. Sciences, April, 1873, P- 527• 8 
L. DUNCAN BULKLEY; 
My recorded urinary examinations date back to January, 1867, 
since which time I have notes of 605 examinations, all made by 
myself, except those during the past year and a half, which 
were observed and recorded by my assistants, Dr. Lewis and Dr. 
Robert Campbell, under my immediate supervision. These 605 
examinations relate to 191 patients, but, as many of the earlier ones 
were from the practice of the late Dr. H. D. Bulkley, only about one 
half pertain to patients affected with diseases of the skin, and 
these latter alone I shall speak of and analyze on the present oc- 
casion. My personal observations, therefore, in the relations of 
urinary derangements to diseases of the skin are based on 323 
recorded examinations, relating to 109 patients, further verified by 
numerous recorded statements of patients and also of physicians 
with whom I have been in consultation, as to former disorders 
of this kind, and confirmed also by clinical observations on the 
action of remedies and measures calculated to affect the kidney 
secretion. 
These examinations, which have been confined almost ex- 
clusively to patients in private practice, and made solely in the 
ordinary run of business to assist in treatment, relate to 46 patients 
with eczema, mostly chronic, 22 patients with acne, 14 with 
psoriasis, 6 with pruritus, 5 with erythema, and 16 with miscella- 
neous cutaneous affections. 
For completeness I shall first make brief mention of the 
observations of others as to the urinary changes observed dur- 
ing the febrile affections of the skin, although I would by no 
means attach the same importance to the state of the urine in 
those that I do in the chronic diseases of the skin. I am well 
aware that the question arises, whether these alterations are not 
altogether independent of the cutaneous lesion and due solely 
to the febrile state, for we know that the urine is disordered in 
other fevers where the skin is not at all affected. The question 
cannot yet be answered, for our knowledge of the pathology of 
fever is far too small to assert that the blood derangement and 
consequent urinary alterations are certainly secondary and have 
nothing to do with the skin lesions, nor do we know how many of 
the phenomena of all febrile diseases are due to deficient cutaneous 
action. The same urinary changes occur also in states where there 
is no fever whatever, as in lithaemia from indigestion, and in func- 
tional derangements of the liver, as also in certain “structural 
diseases of the liver, and particularly in those which are charac- 
terized by an increased amount of blood in the organ, such as 
inflammation, cirrhosis, cancer and simple hyperaemia, whether 
mechanical or active.’’ * If, however, further research should 
establish certain differences between the urines passed during the 
different exanthemata the presumption would be strong in favor 
of a relation between the state of the kidney secretion and that of 
* Murchison, on Functional Derangements of the Liver.—New York, 1875, 
p. 65. RELATIONS OF URINE TO SKIN DISEASES. 
9 
the skin ; the number of recorded observations is as yet too few to 
prove this, but in the light of the above arguments I feel warranted 
in including, in our present consideration, the changes of the 
urine occuring during the febrile diseases of the skin. 
I. Erysipelas.—Schonlein * states that in Erysipelas the urine 
is frequently loaded with bile pigment, and is of a reddish brown 
or red color. At the urinary crisis fawn-colored precipitates occur, 
and the urine becomes clear. Becquerel f made two quantitative 
analyses of the urine of a man, 39 years of age, with erysipelas of 
the face. The first specimen passed on the fourth day was of a 
deep yellowish-red color, and clear, specific gravity, 1.021. The 
second specimen from the 6th day, appeared almost black, threw 
down a reddish sediment of uric acid, and had a specific gravity of 
1.023. The analyses are as follows, Becquerel’s analysis of 
healthy urine being placed for comparison in a third column :— 
ANAL. I. 
ANAL. II. 
HEALTH. J 
Ounces of urine in 24 hours.. 
.. 27.0 .. 
O 
00 
.. 45.O 
Specific gravity 
1.021.. 
.. 1.023.. 
I.OI7 
Water 
..965.5 .. 
..961.9 .. 
..972.0 
Solid constituents 
• • 345 • • 
.. 38.1 .. 
. . 28.0 
Urea 
.. 12.5 .. 
.. 12.7 .. 
.. 12.1 
Uric acid 
1.2 
.. i .3 .. 
. . O.4 
Fixed salts 
.. 8.2 .. 
. . 6.9 
Extractive matter... 
.. 15.9 .. 
.. 8.6 
In a woman, aged 45, with erysipelas of the head, Simon 
found the urine very scanty, of a dark brown color, strongly acid, 
specific gravity 1.023. and depositing a yellow sediment. It con- 
tained 
Water 9617 
Solid constituents 38.3 
Urea 11.7 
Uric acid 1.3 
Fixed salts 9.2 
Extractive matter 15.7 
Reynolds § states that albumen appears in the urine in many 
cases; it may make its appearance from the 4th to the 8th day, 
or even later in relapse ; also that the quantity of urea is in- 
creased, while that of the chlorides is diminished. Parkes || says 
that the excretion of chloride of sodium by the urine in erysipelas 
is so far diminished, that even when taken in 2 drachm doses it 
does not pass off by the urine in two days, showing most decided 
retention. 
In the only case of erysipelas in which I have examined the 
* Simon’s Animal Chemistry, Syd. Transl., Vol. II., p. 278. tlb. 
I This differs somewhat from that given by Flint (Physiology, Vol. III., p. 
193), but is here quoted in full because those in disease are by the same writer. 
§ A System of Medicine, Vol. I., p. 684. 
|| The composition of the urine, London, i860. 10 
L. DUNCAN BULK LEY; 
urine, I found the specific gravity of the morning and night 
specimens to be both 1.020, the reaction acid, the color of a red- 
dish yellow, and absolutely nothing microscopically, even after 
standing 24 and 36 hours. 
II. Measles.—During the eruptive period, the urine is dark 
red, rich in uric acid and urates, * followed by abundant diuresis 
when this stage is passed, f Albumen is extremely common in 
some epidemics, and appears simultaneously with the eruption : 
blood in small quantities is also common. In the Leith epidemic 
of 1854, the recoveries were most speedy when the albuminuria 
was the greatest.! 
III. Scarlet Fever.—Dr. Gee, § aftercareful study, states of the 
urine in this disease, that: 1. The water is diminished in quantity; 
2, the quantity of urea excreted is not necessarily increased dur- 
ing the pyrexia; 3, chloride of sodium is more or less diminished, 
sometimes very greatly, sometimes very little ; 4, phosphoric acid 
is diminished for several days after the first five days of the erup- 
tion ; 5, uric acid, in one case, was almost entirely suppressed on 
the second and third days, normal on the fourth, in great excess on 
the fifth and last day of the pyrexia, and normal thereafter. Sedi- 
ments of uric acid and urates he states to be common. Simon || 
examined the urine of a boy, aged 5 years, at the acme of septic 
scarlatina. The urine was of a dark yellow color, had an alkaline 
reaction, a very disagreeable ammoniacal odor, and deposited 
earthy phosphates and urates of ammonia and soda. The specific 
gravity was 1.022, and about 16 ounces were discharged in 24 
hours. There were contained in 1000 parts— 
Water 943.60 
Solid constituents 5640 
Urea.. 19.35 
Uric acid 1.69 
The urine was afterwards examined again and possessed similar 
characters ; the sediment being more copious. 
The occurrence of albuminaria in scarlet fever, and the attend- 
ant kidney changes are familiar to all, and need not occupy us here, 
except in a general way, as indicating the connection between the 
kidneys and the skin, for it is during the desquamative stage, when 
the skin as a secreting organ is especially damaged that this 
serious complication generally appears. 
IV. Small pox.—In the beginning of this disease, according to 
Simon, IF the urine is decreased in quantity and increased in 
specific gravity; its color is deep and red, it is frequently turbid 
and often contains a small amount of albumen. In the eruptive 
* Vogel, Diseases of Children, 2d. Edit., New York, 1871, p. 486. 
t Steiner, Diseases of Children, New York, 1875, P- 346- 
t Aitken, Science & Practice of Med., Phila., 1866, Vol. I., p. 297. 
§ Reynolds’ System of Medicine, Vol. I., p. 339. 
|| Animal Chemistry, Syd. Transl., Vol. II., p. 269 IT lb. p. 282. RELATIONS OF URINE TO SKIN DISEASES, 
11 
stage, as ascertained by Becquerel, in five cases in which the 
symptoms were severe, the urinary secretion was diminished and 
amounted on the average to only 23.5 ounces in 24 hours. The 
specific gravity had not, however, increased as much as might have 
been expected, being only 1.020,6. It frequently threw down uric 
acid precipitates, either spontaneously or on the addition of nitric 
acid, and in one case albumen was observed. Curschman * states 
that the chlorides are usually diminished, sometimes to a minimum. 
We may now pass to some of the diseases more commonly 
reckoned as affections of the skin, and will tp.ke first those nearly 
allied to the exanthemata, namely urticaria and erythema. 
V. Urticaria.—Dr. Gravest was one of the first to mention 
the occurrence of urticaria supervening upon an acute jaundice in 
rheumatic subjects, and established very clearly the connection be- 
tween those states. And I may here, for the present purpose, 
consider the jaundice itself as a skin disease quite as much as the 
urticaria, for with the discoloration of the skin we have often an 
intolerable itching, lasting generally till the cause is removed. 
Now the gross characters of icteric urine are familiar to all; an 
analysis of it is given by Simon, t who found the urea much be- 
low the normal average, and the uric acid much increased, the 
fixed salts also diminished, except the phosphates, which were 
also increased. He also gives an analysis by Scherer of the urine 
in urticaria tuberculosa, the patient being a young man who like- 
wise suffered from rheumatism. The urine was discharged in very 
small quantity, often not more than five or six ounces in 48 hours. 
It was clear, of a brownish red color, very acid and with a specific 
gravity of 1.028. The urea appears to be in great excess and the 
uric acid somewhat more abundant than in health. The difference 
between this and the preceding and following analyses is perhaps 
explained by the great concentration of the urine, or possibly by the 
co-existence of disturbing elements. In a case of urticaria where 
the urine was analyzed by Dr. Maclagan of Edinburgh, § its com- 
position was found to be as follows, in one thousand parts : 
Water and organic matter 981.01 
Urea 6.91 
Uric acid 0.05 
Inorganic matter 12.03 
The urine was distinctly acid, specific gravity 1.010, of a pale straw color 
and clear, with no deposit. 
The chief peculiarity was a deficiency in the ordinary character- 
istic ingredients of the urine, the urea and uric acid. This could 
not arise from mere excess of water, first, because the urine was 
not excessive in quantity ; second, because the inorganic salts were 
above the normal standard, whereas had the water been in excess 
* Ziemssen, Cyclopcedia of the Practice of Med., Vol. II., p. 348. 
t Clinical Lectures, Second Amer. Edit., Phil., 1842, p. 122. 
I Animal Chemistry, Syd. Transl., Vol. II., p. 314. 
§ London Lancet (Amer. reprint), Oct. 1846, p. 366. 12 
Z. DUNCAN BULK LEY; 
they ought to have indicated a diluted condition of the urine. Dr. 
Maclagan ventured, therefore, to propose as a pathological view of 
the case that the defect was merely a deficiency in urea and uric 
acid, in short, a want of what modern chemists call the products of 
the transformation of the tissues, and that the retention thus in the 
system of matters which ought to be eliminated, might be the 
cause of the cutaneous irritation, especially, occurring as it did 
after meals. The patient was given colchicum, and the specific 
gravity of the urine was found to have risen to 1.029, and the urea 
to have decidedly increased in quantity, an analysis yielding : 
Water and organic matter . 966.42 
Urea 20.36 
Uric acid 0.50 
Inorganic salts 12.72 
The urea was thus tripled in amount and raised above its normal standard, 
and the uric acid augmented ten-fold ; the urticaria improved and finally disap- 
peared under the use of the colchicum. 
His conclusions were, 1. That urticaria is intimately connected 
with a deficiency of the organic salts of the urine, and their pro- 
bable retention in the system ; 2. That colchicum has an action 
capable of restoring the deficient salts and thus curing the disease ; 
3. Rheumatism and urticaria, and purpura and urticaria are 
frequently found together. 
Dr. Murchison * mentions the case of a boy, aged 9, with 
urticaria tuberosa and purpura urticans complicated with hemor- 
rhages from the bowels, kidneys and urinary passage, and with the 
discharge of much lithic acid in the urine. Dr. Tilbury Fox t 
recognizes deficient urinary secretion as a cause of urticaria. Dr. 
Wilson Fox t alludes to urticaria and herpes as complications of 
acute gastric catarrh, when the urine is usually scanty, high colored 
and loaded with lithates; and Scudamore § refers to erythema 
and urticaria shortly preceding a paroxysm of gout, when, as we 
know the urinary secretion presents changes similar to those cited. 
Dr. Murchison || also records a curious case of a gentleman, aged 
42, who suffered from several symptoms of liver derangement until 
he had a severe attack of urticaria, when they ceased, and he had 
thereafter only occasional attacks of gout. 
I may, finally, mention that urticaria sometimes occurs during 
or just following other diseases, in which we know the urinary 
secretion to be deranged, as in scarlatina, of which I have lately 
seen a striking case. 
In one case of urticaria in which I examined the urine four 
times, I found it rather high colored and very acid, the specific 
gravity of the four specimens averaged 1.027J, the lowest being 
* Functional derangements of the liver, New York, 1875, P- J42- 
t Skin Diseases, 3d Edit. London, 1873, PP- I2°> 126. 
t Diseases of the Stomach, 3d Edit., London, 1872 p. 105. 
§ A treatise on the nature of Gout and Rheumatism, 1st Amer. Edit., 
Phil., 1819, pp. 51, 226. 
|| Loc. Cit., pp. 129, 130. RELATIONS OF URINE TO SKIN DISEASES. 
13 
1.024, when under treatment, the highest being 1.030, passed the 
previous night. Microscopically there were amorphous urates and 
oxalate of lime. 
VI. Erythema.—I have incidentally mentioned this disease 
as occuring in the same state as urticaria. The connection of ery- 
thema with rheumatism is now well established, especially those 
forms known as erythema nodosum and erythema papulatum, and 
in these cases we would expect to find urinary derangements. 
Wilson* mentions a case of erythema tuberosum where the 
patient, a young woman aged 22, had copious deposits in her urine, 
with dysuria. 
In a very annoying and rebellious case of erythema, of which 
I have six observations on the urine, it was strongly and persist- 
ently acid, except when under strictest regimen and severe alkaline 
treatment. The specific gravity was not above normal, it varying 
between 1.012 and 1.022, with an average of 1.018. Every speci- 
men contained abnormal crystalline deposits, sometimes the urates, 
sometimes oxalate of lime ; occasionally both. In another equally 
distressing case of erythema of the face, the urine stood at 1.030 
with an abundant pinkish deposit of amorphous urates with oxalate 
of lime. I also have record of the examination of the urine from 
a case of erythema urticatum, in which both morning and night 
specimens were very acid, of a specific gravity of 1.015 and 1.020 re- 
spectively, and both contained oxalate of lime. The urine from a pa- 
tient with erythema papulatum gave almost exactly the same results. 
Gintrac f says, “ In erythema nodosum the urine is more or 
less colored.” 
VII. Eczema.—Passing now to the protean disease eczema, 
we find that the recorded observations all show derangement of the 
important excretion, the urine. 
Bence Jones t gives the following case : W. S., aged 64, dyspep- 
tic, has, for 12 years, had dry and moist eczema. For the past two 
years has had at times frequent calls to urinate, but the quantity 
of urine often varied much from day to day. Thus: 
On Feb. 13, he passed 
oz. 
At 2 A. M. .4 
“ 3-3° “ • • 5 
“ 7.30 “ . . 6 
“ 8.30 “ . . 6 
“ 10 Breakfast 
“ 12 noon . . 7 
“ 2 p. M. . . 4 
“ 4-iS • • 4 
“ 6 Dinner . 
“8 p. M. .4 
“ 12 night . 4 
440Z. Sp.gr. 1.015 
On Feb. 14, he passed 
oz. 
At 7 A. M. . .8 
“ 8 “ Breakfast 
“10 “ . '. 2 
“ 2 P.M. .4 
“ Dinner 
“ 5.3O P. M. 4 
“8 “ . 2^ 
“ 12 “. . 2 yz 
23 oz. Sp. gr. 1.026 
* Diseases of the skin. London, 1871, p. 239. 
t Cours th6or. et clin. de Path. int. Vol. V. p. 112. 
t Lectures on Pathology and Therapeutics. Lond. 1867* p. 98. 14 
L. D UNCAN B ULKLE1 / 
Oxalate of lime existed in the first specimen, free uric acid and 
the urates in the second. 
Dr. Hillier* saved the urine of a patient aged 19, for six days 
while an eczema was at its worst, and found the urea and uric acid 
both below the normal standard. In another case of general 
eczema of 30 years’ standing, the urine was found to deposit lithates 
and lithic acid very abundantly, also some oxalate of lime. 
Dr. Win. Frank Smith f watched the urine of a large number 
of cases of inveterate eczema, and in 9 out of 10 he found indican 
present in pathological quantities. The patient was a robust man, 
aged 47, convalescent from eczema of both legs under alkaline 
lotions, taking no medicine, having full meat diet, with exercise, and 
one pint of beer daily. The mean of ten observations, gave, for 
24 hours : 
Quantity 1200 C. c. 
Specific gravity 1.018 
Urea 22 grammes. 
Chloride of sodium 4 “ 
Phosphoric acid. . 4 “ 
Sulphuric acid 4 “ 
The mean also of three analyses from another patient, having 
eczema of arms and hands, living in his ordinary manner at home 
and taking no medicine, gave as follows : 
Quantity • 1000 C. c. 
Specific gravity 1.015 
Urea 15 grammes. 
Chloride of sodium 1.5 “ 
Sulphuric acid 2.0 “ 
Phosphoric acid 2.5 “ 
A third case, aged 27, with eczema of face and neck, gave : 
Quantity 1200 C. c 
Specific gravity 1.020 
Urea 22.8 grammes. 
Chloride of sodium 4.2 “ 
These analyses indicate an abnormally low excretion of urea, 
and the chlorides. He regards the urine as furnishing the key to 
the question as to'the cause of the obstinacy of eczema. 
Dr. A. T. Thompson t gives a case of eczema where the state 
of the urine was noted at times for the period of nearly five 
months, during most of which time it was scanty, high-colored and 
deposited lithates, its character being somewhat improved occa- 
sionally under treatment. 
Dr. H. D. Bulkley § gives cases where the same condition of 
urine was observed with a specific gravity of 1.030 and 1.035 : this 
* Skin Diseases, 2d Edit. Phila. 1870, pp. 120, 121. 
t Journal of Cutaneous Medicine, Vol. I., p. 54. 
J Diseases of the Skin. Lond. 1850, p. 275. 
§ New York Medical Times, Vol. III., 1854, pp. 273, 273, 431. RELATIONS OF URINE TO SKI A DISEASES. 
15 
state of the brine was recognized in the treatment followed. Dr. 
Edward Ballard * details the case of a female child, 4J4 years old 
with eczema capitis, in whom there was persistent oxaluria, with a 
high specific gravity and a deposit, oftimes, of lithates and phos- 
phates. The oxaluria “ plainly fluctated with the progress of the 
eczema, the quantity of oxalates becoming increased whenever the 
formation of new vesicles was proceeding, and lessening or disap- 
pearing altogether as they died away, or were converted into crusts.” 
An interesting case of eczema, under the care of Dr. Robt. B. 
Todd, is given quite fully with analyses by Beale, f The patient, 
a laboring man of forty, had the whole body affected with a red scal- 
ing eczema of six months’ duration. He had had two attacks pre- 
viously. He was apparently healthy, and no cause of the eruption 
was discovered, except that he had lived almost exclusively on 
pigs’ meat and potatoes. His urine during a month ranged from a 
density of 1.038 to 1.015, in quantity from 3 pints to 22 ounces, and in 
appearance from a high colored and turbid fluid, even dark brown, 
with abundant deposit, to a clear pale color and no deposit. 
When the urine stood at 1.038, very acid and the quantity 24 
ounces in the day, it was analyzed by Dr. Beale, with the follow- 
ing results : 
Water 
926.1 
In 100 parts of 
Solid Matter 
73-9 
solid matter. 
Urea 
24.030 
32-3T 
Extractive matter 
27.210 
36.82 
Vesical mucus and lithic acid . . 
.460 
.62 
Earthy phoshates 
.970 
I-3I 
Chloride of sodium 
4.060 
549 
Other salts soluble in water . . 
1.170 
1.58 
Sulphate of potash 
6.828 
9.24 
“ “ soda 
6.169 
8.34 
Phosphate of soda 
3.290 . 
445 
The high specific gravity was due to the sulphates ; this great 
excretion of the sulphates, independently of muscular exertion, 
formed an interesting feature in the case. The quantity of urine 
was below the average amount found in health. 
In another case mentioned by Dr. Todd, a boy of 18, with 
eczema of the legs, scrotum and penis, there were abundant de- 
posits of lithates and oxalates, and an analysis is given which 
does not possess any great interest. 
Dr. Naylor* recognizes the scanty and loaded state of the urine, 
with crystals of urate of soda in acute and general eczema, and 
very wisely remarks, “ This latter condition is too often overlooked, 
and yet no truer guide can be taken, denoting a progressive im- 
provement, or the reverse,” which corresponds exactly to what ex- 
perience has taught me, as will be mentioned later. 
* Provin. Med. Jour., Sept. 8, 1847, p. 49°- 
t Lond. Med. Times & Gaz. 1852, Vol. II., pp. S90, 559. 
J Diseases of the Skin, 2nd Edit. Lond. 1874, p. 122 16 
L. DUNCAN BULK LEY; 
Dr. Parkes * gives quite fully the elaborate analyses of Beneke 
in a case of acute impetiginous eczema, covering almost the entire 
body. I will not quote it in full, but merely state that oxalate of 
lime was found miscroscopically, and that the urea was in some 
excess during the period of severe disease, and that the uric acid ex- 
ceeded the normal amount during convalescence. The specific 
gravity was low, 1.014,3 when taking no medicine, but the daily 
quantity was large, 2023 grammes (80 oz.) These results differ 
in some respects from others quoted, and from my own, but the 
discrepancy is explained by the fact that a large share of the 
secreting surface of the skin was impaired by disease, and when 
this is the case there must be increased secretion both of urea and 
water. Thus, Dr. Golding Bird t says, “ As a general rule, 
whenever the functions of the skin are impaired, where a due 
amount of excretion is not exhaled from the surface, an excess of 
nitrogen is retained in the blood and ultimately separated by the 
kidney in the form of urate of ammonia, or perhaps urea or 
creatine. A person in apparently good health experiences from 
exposure to a current of cold air a slight check to perspiration, and 
the next time he empties his bladder he voids urine of a deeper 
color than is usual with him, and on cooling it becomes turbid 
from the precipitation of urate of ammonia. The explanation of 
this phenomenon, with which every one is familiar, is found in the 
kidneys assuming temporarily a kind of compensating function of 
the skin.” 
Dr. Garrodt recognizes the frequent connection of eczema 
with the gouty habit. Dr. Murchison § states that his experience 
fully bears out the correctness of the observations of the connec- 
tion of eczema with the gouty diathesis, but very conclusively 
and correctly ascribes the disordered blood-state, or lithaemia to 
functional derangement of the liver. Dr. Golding Bird || says, “ I 
have two or three times been consulted in cases of patients lying 
bed-ridden from rheumatic gout, one or both legs being covered 
with an eczematous eruption, and the parts on which the exuda- 
tion had dried, have been actually frosted over with microscopic 
crystals of urate of soda. Dr. Tilbury Fox If writes, “ All dis- 
orders which are connected with the retention of excreta in the 
system, and their circulation throughout the blood-current, may 
furnish the exciting cause of eczema. This is a clinical fact of 
very great importance. Given the tendency to eczema, then the 
transmission of uric acid through the capillaries of the skin will 
so far derange as to aggravate certainly, and now and again excite 
an eczematous eruption. This is what is meant by gouty eczema ; 
and by securing the absence of the uric acid from the circulation, 
* The Composition of the Urine. Lond. i860, p. 298. 
t Urinary Deposits, 2d Amer. Edit. Phila. 1851, p. 116. 
J Reynolds’ System of Medicine, Vol. I., p. 824. 
§ Functional Derangements of the Liver, New York, 1875, p. 140. 
|| Urinary Deposits, 2d Amer. Edit., Phil., 1851, p. 117. 
IT Skin Diseases. 3d Edit., Lond., 1873, p. 175. RELATIONS OF URINE TO SKIN DISEASES. 
17 
the eczema will often disappear, and always be more amenable 
to treatment. * * * In some of these cases of eczema there 
is, and has been for some time a dificient kidney secretion, and if 
careful analysis of the urine be made a deficiency in exertion will 
be observed.” 
Gigot-Suard * gives the results of the administration of silicate 
of soda administered to an eczematous patient for 23 days, in 
quantities increasing from 30 to 80 centigrammes daily. The 
specific gravity of the urine was diminished, the quantity increased 
and the deposit of urates and uric acid ceased. 
Dr. Mapother f makes an interesting contribution to the 
urinary relations of eczema. Patrick M , aged 50, had had 
eczema on front of both arms and forearms and thighs for seven 
weeks ; for years he had been subject to acid eructations, and 
had drunk freely of porter. The urine of each twenty-four hours 
gave the following record : 
DATE. 
OUNCES. 
SPEC. GR. 
REMARKS. 
TREATMENT. 
Jan. 16 
26M 
1.028 
Very add—urates j 
No treatment. 
“ 17 
24^ 
I.O3O 
ao ( 
“ 18 
22^ 
1.031 
1 . do • • •• I 
Fifteen drops of Wine of Col- 
“ 19 
24 
I-°3i 
do .... 
chicum, thrice daily. 
“ 20 
26 
E030 
Thirty drops of Wine of Col- 
“ 21 
40 
1.020 
chicum, thrice daily; pro- 
“ 22 
37 
1.023 
ducing three or four small 
“ 2 3 
20 
1.026 
evacuations from the bowels 
“ 24 
34 
1.030 
daily. 
“ 25 
49 
1.018 
Neutral 
Five grains of citrate of lithia 
“ 26 
38 
1.028 
do 
with twenty grains of citrate 
“ 27 
39 
1.029 
do 
of potassa, thrice daily. 
“ 28 
42 
1.025 
do 
But little improvement took place in the eczema until the ad- 
ministration of the lithia and potash on the 24th, but, in four days 
afterward the disease was largely removed. 
My own observations in eczema accord very completely with 
what has been quoted. Of the 46 patients, of whose urine I have 
records, it may safely be stated that not in a single instance did that 
secretion represent a state of perfect health. In one patient it was 
examined 26 times, in another 9, in another 8, in another 6, and 4 
times each in 9 other patients, with almost uniform results, except 
when under the direct influence of medication. The total number 
of my recorded urinary observations in eczema amounts to 147. 
The changes I have noted in the urine of eczema may be 
divided into two classes : First, those indicating an acid dyspepsia, 
shown by the presence of oxalate of lime, and occasionally urates, 
or even uric acid, with an oftimes greatly varying quantity and 
specific gravity, as in the case cited above from Bence Jones, 
* L’LIerpetisme, etc., Paris, 1874, p. 396. 
t Lectures on Skin Diseases. 2d edit. 1875, p. 78. 18 
Z. DUNCAN BULKLEY; 
where on one day 45 ounces, with a specific gravity of 1.015, was 
discharged, and on the next but 23 ounces, indicating 1.026. I 
have also noted this variety, with the urine of a pale yellow or 
straw color, with a specific gravity as low as 1.010, in the morning 
specimen, passed on rising, * when that passed by the same patient 
on retiring stood at 1.028 ; the extremes I have noted were 1.005 
and 1.030 : or, there also may be in this dyspeptic variety a per- 
sistent abnormal acidity and high specific gravity, as in one case 
of eczema of the anus, where oxaluria was very obstinate, and 
the average of 26 examinations gave a specific gravity of over 
the lowest being 1.020, when under diluents and alka- 
lies, and the highest 1.030; Second,, where the uric or lithic acid 
diathesis, or better, perhaps, chronic lithaemia exists, where the 
urine is also unnaturally acid at almost, if not quite, all times, and 
deposits a moderate amount of urates or free uric acid. The 
specific gravity of the urine in this second class of patients does 
not vary so much, but generally remains rather above the normal, 
1.020 to 1.026. The average specific gravity of the urine from 
patients with various forms of eczema, a few acute, mostly chronic, 
gave x.022; in the 46 cases it was not recorded as having an 
alkaline reaction on passing, or soon after, in a single instance, 
while many specimens are recorded as “ very acid.” Two or three 
specimens it is true, are noted as neutral or alkaline, but I find 
that the test was made two or more days after the urine was voided, 
so that the alkaline fermentation had probably set in, and these 
instances may safely be excluded. 
The amorphous urates were not infrequently met with, being 
noted as found in 26 of the 46, cases; oxalate of lime appeared in 
25, and free uric acid was seen in 10. Albumen is rarely found in 
the urine of eczema, in but two of the cases was it noticed that 
there was “ a trace,” the other specimens from these same patients 
being free, as also all the others. It must be looked upon as a 
coincident phenomenon ; although, conversely, the presence of urea 
in the blood in chronic albuminuria may sometimes be the excit- 
ing cause of a very intractable eczema. 
VIII. Psoriasis.—Even more than eczema, has this disease 
been looked upon as a cutaneous manifestation of a gouty state. 
Sir Henry Holland t says, “ I cannot doubt from my own obser- 
vation that certain of these (skin) disorders occur as effects of the 
habit in question (gout). I have so often seen psoriasis, for example, 
occurring in gouty families—sometimes alternating with acute at- 
tacks of that disease, sometimes suspended by them, sometimes 
seeming to prevent them in individuals thus disposed — that it is 
difficult not to assign the same morbid cause to these results.” 
Dr. Garrod I believes that psoriasis is, perhaps, the most frequent 
* It will be remembered that normal urine “first discharged in the morning 
is usually dense, highly colored, of a strong acid reaction, and a high specific 
gravity.” Dalton, Physiology, Phil. 1866, p. 351. 
t Medical Notes and Reflections. Phil. 1837, p. 212. 
J Reynolds’ System of Medicine. Phil. 1868, Vol. I. p. 824. RELATIONS OF URINE TO SKIN DISEASES. 
19 
form in which the cutaneous (gouty) disease manifests itself, and 
that there are records of many cases in which the skin and joint- 
affection are alternated. Sir Thomas Watson,* speaking of psori- 
asis and lepra says, “ I believe that they sometimes depend upon 
the presence, or the generation, of an excess of acid in the system ; 
and that they are often cured by alkaline remedies, I am sure.” 
Proutf mentions the alternation of leprous and scaly skin diseases 
with deposits of phosphate of lime in the urine, in patients who have 
been subject to gout and rheumatism, the urinary affection be- 
coming better as the cutaneous affection has become worse, and 
vice versa. In these cases the urine has had a low specific gravity. 
With reference, however, to direct examination of the urine in 
psoriasis, I can find but three statements, one by Golding Bird,! 
to the effect that in cases of lepra, psoriasis and ichthyosis, where 
the excreting functions of the skin have been much impaired, the 
urine has been much richer in urea than was consistent with 
health,”; another by Nayler §, who remarks that in cases of 
psoriasis where the irritation of the skin is excessive it will be well 
to examine the urine, which will often be found to be high colored, 
and loaded with the urates; and third, an analysis by Beale.|| 
This latter observer examined the urine from a very severe case 
of psoriasis in a girl aged 20, which had recurred for many years, 
in the spring of the year. About 40 oz. were passed in the 24 
hours, with a specific gravity of 1.021. The analysis gave: 
Water 957-5° 
Soluble matter 42.50 
Urea . * . . 15-00 
Other organic matter . .6.20 
Fixed salts .... 21.30 
Chlorides .... 13.00 
Seven and a half months afterwards the urine was again examined, 
and the total of 24 hours gave a specific gravity of 1.007, was 
neutral in reaction and yielded the following analysis :— 
Water 985.40 
Solid matter 14.60 
Urea . . . . 5.90 
Uric acid 45 
Extract and ammoniacal salts .65 
Fixed alkaline salts . . 7.31 
Earthy phosphates . . .29 
Chlorides .... 5.00 
Sulphates 45 
Dr. Beale thinks the large amount of the fixed salts to be the most 
interesting point in these analyses, about double the normal amount 
of saline matter was found ; he also regards that the large amount 
* Practice of Physic. Phil. 1858, p. 1205. 
t Stomach and Renal diseases Phil. 1843, P- 221. 
$ Urinary deposits. 2d Am. Edit. Phil. 1851, p. 117. 
§ Diseases of the Skin. 2d Edit. London 1874, p. 40. 
I] Beale’s Archives of Med., Vol. I., p. 316. 20 
L. DUNCAN BVLKLEY; 
of organic matter thrown off by the disease in the scales had caused 
a diminution of the organic constituents of the urine. 
Three weeks later, the patient being much improved, analysis gave : 
Water 971.3 
Solid matter 28.7 
Urea .... 10.5 
Extraction . . . 3.6 
Salts .... 14.6 
Chlorides . . . 7.0 
My observations of the urine in psoriasis have been compar- 
atively few in number, 36 relating to 14 patients, but they are suf- 
ficient to support the view of the assimilative error which either 
underlies or at least manifests itself during many of the diseases of 
the skin of constitutional origin. Most of the examinations I have 
made in psoriatic patients show a hyper-acidity, with crystalline 
deposits, uric acid, urates and oxalate of lime and in one instance 
the stellar phosphate of lime ; their absence being rather an ex- 
ception. The specific gravity of psoriatic urine is not necessarily 
high, but may vary greatly at times. Nor is there any uniformity 
as to the time of the high or low specific gravity; in one patient 
six examinations at intervals of about a week between each couple, 
gave the following:—night, 1.026; morning 1.014; night 1.010; 
morning, 1.008 ; night, 1.026 ; morning, 1.008 ; in another patient the 
average of four examinations was almost 1.025. 
IX. Acne.—I have not been able to find any allusions to 
the urine in patients affected with acne, except a single line by Dr. 
A. T. Thomson,* who says of acne simplex, “ The urine deposits 
a yellowish or whitish sediment, indicative of indigestion ” ; and can 
therefore give only my own observations. Garrod,* however, states 
that “ acne of the face and other parts is sometimes found to be 
closely dependent on the gouty diathesis, and,” he says, “ I have 
known one case in which the patient could predict the advent of a 
gouty paroxysm from the appearance of these spots.” 
Urinary derangement is very common indeed in patients with 
acne simplex, indurata and rosacea, also in the simpler forms of 
acne sebacea, or seborrhoea and acne punctata or comedo. Al- 
though my recorded examinations are relatively few, I feel confi- 
dent in asserting that a very large share of the cases of acne, which 
are of any duration, will be found thus associated. In but two out 
of 61 examinations, relating to 22 patients with acne, was the urine 
recorded as other than acid, and in one of these it was neutral in 
the night specimen and acid in the morning, in the other case in 
which it was recorded neutral in one instance, the urine passed three 
hours afterwards was acid, as also all the other specimens. Very 
many of the reactions are stated as very acid. The specific grav- 
ity of the urines ranged from 1.014 to 1.040,with the average of 
over 1.023. 
* Diseases of the Skin. 2d Edit. London, 1850, p. 404. 
t Reynolds’ System of Medicine. Phil. 1868, Vol. I, p. 824. RELATIONS OF URINE TO SKIN DISEASES. 
21 
The urinary changes in acne are more commonly those of dys- 
pepsia, oxalate of lime being not an infrequent microscopic deposit, 
one case presented it very abundantly and persistently ; also uric 
acid and the urates. Another element of the urine of a proportion 
of acne patients is the presence of an abnormal amount of the phos- 
phates, discovered either by boiling, which causes a pale whitish 
precipitate, soluble at once by nitric acid, or found microscopically 
soon after voiding, that is, before the decomposition has taken 
place which produces the triple phosphates, which latter form may 
occur in almost any urine. 
These recorded examinations, however, form but a portion of 
my evidence of the urinary derangements in acne. On looking over 
my many and complete notes of cases I find very abundant testi- 
mony from the statements of patients, of changes which they them- 
selves have detected, such as persistent high color at times, with 
much lateritious deposit, staining the vessel, burning on passing, 
frequent calls at night to pass water, and great variations in the 
quantity and color, which they have noticed, from an abundant flow 
of pale, limpid, straw-colored urine to a scanty, irritating, red or 
muddy fluid. 
I mentioned above that urinary derangements would be found in 
cases of acne of long duration ; this statement should be modified, 
for when the eruption is provoked or kept up by a reflex uterine 
disturbance, or by local causes as cosmetics, heat, cold, etc., the 
kidney secretion may or may not present these changes; but I 
would here throw out the caution, not to imagine because a patient 
has uterine difficulty that therefore the acne must be dependent on 
that, for I have had opportunities of removing acne by a careful 
attention to the digestive functions, with a small amount of medi- 
cation, internal and external, long before the uterine disorder which 
existed had been rectified by the physician having it in charge. 
X. Pruritus.—In a few cases of pruritus in which I examined 
the urine I found it to be loaded with urates and of a high specific 
gravity and of much greater acidity than normal; in some cases 
oxalate of lime was found. In one case of pruritus of the vulva 
repeated examinations failed to detect any sugar in the urine, un- 
less it were a trace on one examination, the urine ranging in specific 
gravity from 1.014 to 1.038, the average of eight examinations 
giving After a month or so, my friend Dr. Oscar Simon, 
of Berlin, to whom I referred the case during her stay in Europe, 
reported quite an appreciable quantity of sugar, and her pruritic 
difficulty was very greatly relieved after a visit to one of the min- 
eral springs of Germany and the adoption of an anti-diabetic 
regimen. In this case there were boils and carbuncles, and 
I expected to find the glycosuric state, but looked for it in 
vain. The patient was an elderly lady, and recalls the remark 
of Trousseau* that “eczema of the genitals in elderly women will 
very frequently be found to depend on glycosuria.” The same 
* Trousseau, Syd. Soc. Edit., Vol. III., p 503. 22 
L. DUNCAN BULKLEY; 
statement is made in substance by Dickinson,* who also speaks of 
the boils and carbuncles accompanying diabetes mellitus, though 
he does not subscribe to Prout’s affirmation that diabetes always 
accompanies carbuncles and malignant boils, or abscesses allied to 
carbuncles. 
In this connection I may allude to a curious statement of Prout, 
which is important if verified. Speaking of the causation of diabetes 
mellitus he says ;t “ Another class of causes, or rather concurrent 
diseases, are various affections of the cutaneous and cellular tissues. 
I have seen several instances referable to this class; and were I 
permitted to draw a general inference from my experience, I 
should say that diabetes usually follows cutaneous affections, and 
accompanies (perhaps precedes') the affections of the cellular tissues. 
Thus, I have several times had patients observe, that they were 
formerly subject to eruptions in various parts of the body, but that 
such eruptions disappeared after the diabetic complaint became 
established ; nor do I remember more than two instances in 
wffiich diabetes actually accompanied a severe cutaneous affec- 
tion.” 
To return to pruritus. In another case of pruritus of the 
vulva I found in both morning and night specimens the specific 
gravity of the urine high, an acid reaction, and an abundant deposit 
of urates and some uric acid. In a most obstinate and distress- 
ing case of general pruritus, from no recognizable cause, which 
had lasted three or four years in a lady aged 23, the urine, which 
had never before been examined, was found to vary in density from 
1.030 to 1.008, and from a milky opacity, soon after passing, to a 
pale straw color, without a particle of deposit. The first two ex- 
aminations, morning and night, were each 1.030, very acid, and 
with very abundant deposits of urates and uric acid in large 
crystals ; after taking acetate of potassa for two weeks the night 
urine presented much the same appearance, very acid, specific 
gravity 1.024, the morning specimens being faintly acid, limpid, of 
a pale straw color and a density of 1.008. 
Dr. Purdon $ quotes Dr. Day in a statement “ that pruritus is 
often accompanied (if not preceded) by a diminished secretion of 
urine,” adding that “ this may furnish us a hint in reference to 
treatment.” Dr. A. T. Thompson § gives a case of pruritus in a 
man aged 74, where the urine was scanty and high colored, and 
after being broken down by the long continued irritation, boils ap- 
peared on various parts of the body. The urine became copious 
under treatment, and, when examined, was found to contain no 
trace of saccharine matter. Soon after the boils appeared the 
itching greatly abated, but after a lapse of three years was not 
yet completely removed. Dr. Murchison || attributes much of the 
* Diseases of the kidney, &c. Part I., Diabetes, London, 1875, p. 92. 
I Stomach and Renal diseases. Philadelphia, 1843, P- 51- 
t Cutaneous Medicine. London, 1875, p. 145. 
§ Diseases of the skin. London, 1850. p. 216.. 
|| Functional Derangements of the Liver. New York, 1875, P I44- RELATIONS OF URINE TO SKIN DISEASES. 
23 
pruritus to hepatic derangement in which we know the urine is 
often abnormal. 
XI. Herpes Zoster.—Simon * gives the analyses of urine by 
Heller in cases of herpes zoster. From them he concludes that 
“ in herpes zoster the chief peculiarities are : 
“ i. A marked increase of the chlorides and phosphates, and 
a corresponding diminution of the sulphates. 2. An excess of 
hydro-chlorate of ammonia. 3. A large amount of fat. 4. A 
diminution in the amount of uric acid. An increase only occurs 
when the disease is accompanied with fever. 5. The presence of 
oxalate of lime may always be suspected in these cases.” 
I have the record of the examination of the urine of a lady 
some time previous to an attack of herpes zoster of the forehead. 
She was a very dyspeptic subject, the urine was very scanty, acid, 
specific gravity 1.028, had an abundant rather thick flocculent de- 
posit, which showed oxalate of lime in considerable quantity, and 
triple phosphate 15 hours after passing, the urine having been kept 
cool. 
XII. Pemphigus.—The urine in a case of pemphigus has also 
been analyzed by Heller f. The patient was a woman aged 40 
years. The attack was very severe and proved fatal. The urine 
deposited a light cloudy sediment, consisting principally of mucus, 
but also containing fat molecules, urate of ammonia, and a few 
epithelium scales. It was acid, and its specific gravity was 
It contained in 1000 parts: 
Water 955.80 
Solid constituent 44.20 
Urea 24-63 
Uric acid 0.58 
Extractive matter 11.79 
Fixed salts 7.20 
Of the fixed salts the earthy phosphates were normal, the sulphates 
much increased, and the chloride of sodium proportionately dimin- 
ished. The urea was considerably above the normal average. 
“ In the case of a little boy affected with acute pemphigus, Dr. 
Harris Wilson found the quantity of urine passed in 24 hours 
much below the average, namely, about 12 ounces, its specific 
gravity high, namely, 1.033, and its reaction powerfully acid. It 
was of a light color, depositing on standing a light flocculent 
cloud, containing minute crystals of oxalate of lime, and was 
loaded with urea. In 1000 parts the quantity of solid constitu- 
ents was 78.89. Bamberger found the urine in pemphigus scanty, 
acid, of high specific gravity, rich in urea, uric acid, and the 
earthy phosphates, poor in phosphoric and sulphuric acids, but 
abundant in ammonia. He also found ammonia in the blood and 
in the fluid of the bullae, the blood being poor in solids, especially 
albumen. Hence he suggests as a proper treatment the use of an 
* Animal Chemistry, Syd. Edit., 1846, Vol. II., p. 320. 
t Simon’s Animal Chemistry, Syd. Edit., 1846, Vol. II. p. 322. 24 
L. DUNCAN BULK LEY; 
easily assimilable albuminous diet and hydrochloric acid.”* It 
may be here stated, in connection with the great amount of urea 
in the urine in this disease, that Simon f failed to find any trace of 
urea in the fluid from the blisters of pemphigus, examined in two 
attacks at an interval of five years. 
XIII. Purpura.—In a case of purpura in a girl 20 years old, 
Simon $ found the urine for a fortnight of a dark brown color, of 
a disagreeable ammoniacal odor, and with alkaline reaction. “ It 
deposited a viscid sediment of earthy phosphates, urate of am- 
monia, and mucus. The addition of nitric acid indicated the 
presence of a small quantity of bile-pigment. During her recovery 
the urine returned to its original state. Heller gives the analyses 
of urine from two cases, in a girl aged 19, aijd a boy of 16 years. 
The specific gravity ranged from 1.012 to 1.021, the reaction was 
faintly acid, and traces of albumen could always be detected in the 
urine of the boy till convalescence appeared. Heller observes 
that the augmentation of the ammonia (in the form of hydro- 
chlorate) and of the uric acid, together with the diminution of 
the chloride of sodium—characters seemingly associated with this 
disease—indicate that the blood must be in a state of dissolution. 
In a case observed by Martin, the secretion was very scanty, about 
one or two ounces being passed at a time, and the daily amount 
being from 12-20 ounces. Its reaction was faintly acid, three 
analyses at intervals of 12 and 22 days, gave a specific gravity of 
1.013.40, 1.021.26, and 1.010.31 respectively. 
In its physical characters it resembled the urine of Heller’s cases, 
namely, of an intensely yellowish-brown color, rather turbid and 
depositing flocks of mucus. The odor, at first ordinary, rapidly 
became ammoniacal.” A. T. Thompson § gives a case of pem- 
phigus with supervening purpura, where the urine deposited sedi- 
ment consisting of lithates, had a specific gravity of 1.026 and con- 
tained a large excess of urea, phenomena which, as we have just seen, 
belong rather to the pemphigus than to purpura. Wilson || men- 
tions a case of bullous purpura in a rheumatic and dyspeptic man, 
aged 42, in whom the urine was scanty, and high colored, with red 
sediment. The urine in purpura sometimes contains blood, at 
other times casts of the renal tubes. IT 
In the only case of purpura of which I have made the examination, 
I found the urine acid, with a specific gravity of 1.025 morning and 
night, color light, with large crystals of uric acid in the morning 
urine, 12 hours after passing, and amorphous urates deposited 
very abundantly in the night specimen, after standing three days. 
XIV. Melano-Sarcoma.—In a remarkable case of melano- 
* Wilson. Diseases of the Skin. London, 1867, p. 305. 
See also—Lafaurie, Pemphigus-Diagnose. Wirzburg, 1856, p. 37. 
t Animal Chemistry, Syd. Edit., London, 1846, Vol. II., p. 488. 
t Loc. cit, p. 259. 
§ Skin Diseases. London, 1850, p. 182. 
|| Diseases of the Skin. London, 1867, p. 350. 
Tf Ilillier. Reynolds’ Syst. of Med. Phil., 1868. Vol. I., p. 759 RELATIONS OF URINE TO SKIN DISEASES. 
25 
sarcoma of the skin I found the urine very acid, with a specific 
gravity of 1.020, urates quite abundant and with a moderate 
amount of oxalate of lime. The color varied from time to time, 
occasionally being as dark as rather black, clear coffee, then again 
nearly the color of sherry wine. Sometimes it was quite muddy 
from the urates, again it would remain clear for a long time. The 
sediment, which at times was quite abundant, was, besides 
the urates and oxalates, made up of irregular pigment masses and 
particles, largely amorphous, but many of them were apparently 
within epithelial cells, the size of those from the pelvis of the kid- 
ney, and many resembling the pigment celloids of Roberts .* 
Toward the end of the patient’s life, the urine diminished greatly 
in quantity. 
XV. Elephantiasis Graecorum—The urine of leprosy, or ele- 
phantiasis graecorum, has been analyzed by several,t and found to 
possess certain pathological interest, but the disease being very rare 
in this country, I need not dwell on it. I will state, however, that 
albumen is commonly found in it, and a very decided diminution 
in the quantity of urea, a state akin to Bright’s disease, with the 
with exception of the renal casts. 
XVI. Addison’s Disease.—Supra-renal melasma. Certain 
changes have been observed in the urine passed by patients with 
the bronzed skin disease, the main features being a diminished 
quantity, generally low specific gravity, and a deficiency in solid 
constituents: albumen has been found. $ 
XVII. Ichthyosis.—I will close this lengthy and perhaps tedi- 
ous recital of facts by quoting from Mr. Nayler,§ who furnishes us 
with some very interesting details in regard to the urinary changes 
in ichthyosis. Says he : “ The total arrest of all sensible perspiration 
in general ichthyosis, and its partial secretion only in some of the 
modified forms of the complaint offer an interesting subject for 
investigation, with respect to the state of the urine.” He carefully 
determined the urine passed in 24 hours, for several days in suc- 
cession, by two patients with this disease, and found that the 
quantity was very great, the specific gravity low, the color of 
the palest yellow, and the reaction but slightly acid. In a third 
case, a boy 11 years old, height 52 inches, weight 57 lbs., in which 
the scales were numerous and entirely enveloped the trunk, he 
made very careful analytical investigations, and compared the 
results with those obtained from three children of nearly the same 
* Urinary and Renal Diseases. Phil., 1866, p. 96. 
t Milton—Diseases of the Skin : Lond. 1872, pp. 305-313. Also, Journal 
of Cutaneous Medicine, etc., Lond. 1870, Vol. IV., p. 178. Also, Moralli- 
Schmidt’s Jahrb., 83, p. 9. Also, Parkes—The Composition of the Urine : i860, 
p. 334. Also, Duckworth—St. Barth. Hosp. Rep.: 1874. Also, Renault—The 
Doctor : May, 1874, p. 95. 
} Greenhow—Lancet, March 6th, 1865, p. 328. 
Also, West—Roy. Med. and Chir. Soc., Nov. 10th, I874. 
Also, Rosenstirn—Virchow’s Archiv. Bd. LVI: Reprint, Wurzburg Inaug. 
Abh. Berlin, 1872 pp. 13. 
§ Diseases of the Skin : London. 1874, pp. 74-78. 26 
L. DUNCAN BULKLEY; 
age, etc. He comes to the following conclusions : 1. Notwithstand- 
ing the small rate per cent, of urea, the absolute amount in 24 
hours is little altered in ichthyosis ; and this is somewhat remark- 
able when we consider that the skin, as a secreting organ, is 
reduced to the lowest possible limits in this disease. 2. The quantity 
of sulphuric and phosphoric acids, is hardly, if at all, affected in 
ichthyosis. 3. No hippuric acid crystals were detected by examina- 
tion with the microscope. Sdilossberger is said to have demon- 
strated hippuric acid in the scales of. ichthyosis. (Neubauer on 
the Urine, p. 34.) None, however, could be detected in the above 
case, after a most careful analysis by Dr. Marcet.” 
In contrast with the large quantity of urine in ichthyosis reported 
by Nayler, Dr. A. T. Thompson* mentions a case of ichthyosis 
covering a large portion of the body, in a boy 15 years old, in 
whom, when first seen, the urine measured but 3 ounces in 12 
hours ; it had a specific gravity of 1.030, and was turbid from 
urates. After four days’ treatment he passed 12 ounces in 24 
hours, with a specific gravity of 1.016, with further improvement 
later. 
XVIII. Xeroderma.—In two cases of Xeroderma, a mild form of 
ichthyosis, in which I observed the urine, I found it as follows : in 
one case a specimen passed at 11 A.M., and examined 12 hours 
afterward, was alkaline. There was an abundant deposit, which, 
when shaken, rendered the fluid milky white, but which dissolved 
completely on adding nitric acid, and consisted wholly of amorphous 
phosphates. The urine passed the same night was very acid, spe- 
cific gravity 1.010, of a yellow color, clear, no sediment, and 
microscopically a moderate amount of oxalate of lime was found. 
The specimen passed on rising the next morning was also very 
acid, specific gravity, 1.018, of a lemon color, with a very slight 
mucous deposit, and having also an abundance of large crystals of 
oxalate of lime. In the other case, the night and morning urine 
had a specific gravity of 1.027 and 1.016 respectively, were of a 
yellow and pale lemon color, with moderately acid reactions, a 
normal flocculent deposit in both, and an abundance of small 
crystals of oxalate of lime in the specimen passed on retiring. 
It will not be possible, within the limits of this paper, to ana- 
lyze perfectly the mass of material which I have here presented, 
but the urinary alterations which have been recorded are given 
thus in full, in order to make indelible the impression that the urine 
is a most important element to consider in the study and practice of 
Dermatology. In not one of the more than 16 diseases mentioned, 
where the skin is affected, was the urine found normal, and in 
many instances the pathological changes are clear and well marked, 
involving important prognostic and therapeutic considerations. 
I may, however, briefly recapitulate the main points in what has 
preceded, as follows : 
1. The urine represents the state of the blood, as well as the 
* London Med. Gaz., July 3, 1846, p. 35. RELATIONS OF URINE TO SKIN DISEASES. 
27 
integrity of the kidneys, and conversely the state of the secretion 
from the skin, and is therefore of very great importance in the 
study and treatment of diseases of the skin. 
2. The circulation in the blood of excrementitious substances, 
uric, hippuric and oxalic acids and urea, given experimentally, has 
been followed by eruptions on the skin. 
3. Uric acid is found in the blood of gouty patients, also in 
blisters raised upon them. It has also been found in the fluid 
contained in the vesicles of eczema. Urate and phosphate of soda 
have been recovered from the contents of pemphigoid bullae in a 
case of psoriasis, and uric acid has also been discovered in the 
scales of psoriasis. Hippuric acid has been demonstrated in the 
scales of ichthyosis. 
4. Urea is a normal ingredient of the sweat, has been recovered 
in notable quantity from the perspiration of a gouty patient in a 
Turkish bath, and has also been found to be excreted in quantity 
on the skin in certain fatal cases of chronic kidney disease. Urate 
of soda has been found crystallized on the skin of eczematous legs, 
in gouty patients. 
5. The rate of secretion of the urine varies greatly with the state 
of the cutaneous surface, cold applications increasing and warm 
diminishing it. Daily bathing increases the total solid constituents 
in the urine, the urea and uric acid being increased. Profuse 
sweating diminishes the quantity, raises the specific gravity, in- 
creases the urates and chlorides. Complete suppression of exhala- 
tion by varnishing the skin causes death from uraemia, with 
albuminuria and the production of triple phosphates in various 
parts of the body. 
6. The urine, during the acute febrile diseases of the skin, 
presents features such as might be expected from the extensive 
damage to its secreting powers occurring in these affections. 
(a) In erysipelas the urea in the urine is increased somewhat, 
the uric acid augmented three fold, the chloride of sodium 
diminished, and albumen not unfrequently appears. 
(b) In measles the urine is rich in uric acid and urates, 
lower products of metamorphosis, albumen and blood, 
are not uncommon. 
(1c) In scarlet fever the urea is not necessarily increased; 
uric acid is almost entirely suppressed at first and large- 
ly in excess at the close of the fever; the chloride of 
sodium is diminished. Sediments of uric acid and ura- 
tes are common and albumen and epithelium and casts 
generally appear. 
(d) In small pox the quantity of urine is diminished and its 
specific gravity not proportionately increased ; uric acid 
is precipitated and the chlorides are diminished. Albu- 
men is sometimes seen. 
7. In the chronic diseases of the skin the urine exhibits alter- 
ations of two kinds : first, those due to assimilative disorder, cor- 
responding to those known to accompany derangement of the liver, 28 
L. D UNCAN B ULKLEI „• 
dyspepsia and alterations due to hereditary disposition, a diathetic 
state closely allied to gout and phthisis ; and, second,, those due to 
interference in the functions of the skin, as in extensive icthyosis 
and xeroderma, or in eczema or psoriasis covering much of the 
body, where the urinary changes may be regarded in a measure as 
secondary to the skin lesion. 
(a) Urticaria is associated with a diminution of the urea 
and the organic salts in the urine and their probable re- 
tention in the system. The quantity of urine is small, 
the specific gravity high, urates and oxalates abound. 
(b) Erythema. Here the urine is persistently acid with either 
an abundant deposit of urates or oxalate of lime. 
(c) Ecze7na patients seldom pass large amounts of urine, 
the tendency is to scanty secretion, almost always un- 
naturally acid, with a specific gravity averaging above 
normal. Free uric acid, the urates and oxalate of lime 
abound, sometimes oxaluria is very persistent. Albu- 
men is rarely seen. The urea and uric acid are often 
below the normal standard, although they may be in ex- 
cess when a large portion of the integument is affected ; 
indican has been found in pathological quantities ; when 
the specific gravity is high it may be due to an increase 
in the sulphates. Chlorides are diminished. 
(d) Psoriasis sometimes alternates with phosphatic urinary 
deposits in gouty subjects. Where the excretory functions 
of the skin are much impaired the urea is above normal. 
The fixed salts are increased. The urine shows gener- 
ally a hyper-acidity with deposits of uric acid, urates and 
oxalate of lime, the contrary being rather the excep- 
tion. The specific gravity is liable to great and unac- 
countable variations. 
(e) Acne. Urinary derangements are very common in acne, 
generally those of dyspepsia, the quantity and the specific 
gravity varying greatly. Generally over acid, the urine 
deposits oxalate of lime, urates and uric acid. It is not 
uncommon to find the phosphates increased. 
(/) Pruritus often gives very abundant uratic deposit, and 
sugar is sometimes present. In the aged, pruritus is of- 
ten accompanied or preceded by diminished secretion 
of urine. The specific gravity may vary greatly. 
(g) Herpes zoster. The chlorides and phosphates are in- 
creased, and the sulphates diminished; oxalate of lime 
present. 
(h) Pemphigus. The sulphates and earthy phosphates are 
increased, chlorides diminished. Urea greatly above 
normal; oxalate of lime occurs. The quantity is small, 
specific gravity high and reaction very acid. 
(i) Purpura. Albumen, blood and casts are sometimes 
found. The earthy phosphates, ammonia and uric acid 
are increased, chloride of sodium diminished. The RELATIONS OF URINE TO SKIN DISEASES. 
29 
urine is scanty, with a low specific gravity and faintly 
acid reaction, giving traces of bile pigment. 
(/) Melano-sarcoma. The urine brown, often of a dark 
copper color, at times depositing urates abundantly. 
The deep color due to pigment particles alone or en- 
closed in epithelial cells. The urine very acid, specific 
gravity about normal and towards the end of life the 
quantity of urine is much diminished. 
(k) Elephantiasis Grcecorum. Albumen is common, and 
the urea is diminished in the urine. 
(/) Addison’s disease. Bronzed-skin disease. Quantity of 
urine small, specific gravity generally low, solid constit- 
uents deficient: albumen sometimes. 
(;m) Ichthyosis. The quantity of urine is large and the spe- 
cific gravity low, but the urea, though giving a small 
percentage, is unaltered in its total daily quantity. In 
one case the quantity of urine was greatly diminished, 
the specific gravity high and urates were deposited. 
(n) Xeroderma. Urine diminished in quantity, varying in 
reaction, alkaline and acid, depositing, when alkaline, a 
large quantity of amorphous phosphates ; or, clear and 
acid with oxalate of lime. 
In order to determine how far this urinary disorder is really 
connected with the disease of the skin, we may refer to such inves- 
tigations as those of Dr. Balman,* who examined the urine of a 
large number of patients with. different chronic diseases. The 
highest proportion of disturbance was found in those with marked 
evidence of scrofula, as enlarged glands, and 74 per cent, of these 
cases gave oxalate of lime in the urine. Skin diseases came next, 
yielding 66 per cent., whereas the highest of other diseases was 
phthisis, in which 47 per cent, of the examinations showed oxalate 
of lime ; rheumatism gave only 12 per cent. 
The urinary alterations which have been recorded may largely 
be classed as those indicating imperfect systemic action, whereby 
excrementitious substances fail of their complete evolution into 
elements ready for excretion. The urea has been notably absent 
in many of the analyses we have quoted, while lower grades of 
metamorphosed tissue have taken its place, albumen, the urates or 
lithates and oxalate of lime, most prominently. In may instances 
the amount of urine has been far below the normal quantity, while 
the specific gravity, which should be high in such a case, is often 
low. Many times, however, we have quoted the specific gravity as 
abnormally high, but here the greater density is due to the inor- 
ganic and earthy salts, as especially exemplified in Todd’s case of 
general eczema, with the analyses by Beale. In the case of 
urticaria it was shown that with the increase of urea and uric acid 
in the urine, under colchicum, the disease disappeared. 
We cannot here enter upon special inquiry as to where this ma 
* London Medical Gazette, Nov. 8, 1850. 30 
L. DUNCAN BULKLEY; 
assimilation and faulty disintegration takes place, other than to 
refer to the very high authority of Dr. Murchison, who has so 
clearly brought it home to the liver, that one is almost tempted to 
accredit that organ with every fault of nutrition. In our mind, 
however, a larger pathological idea prevails, and other organs, per- 
chance the whole system, ofttimes, must bear a share. Recognizing 
fully the glycogenic,and depurative,and calorific functions of this great 
organ, the liver, I still see a cause of mal-assimilation and faulty 
disintegration in the possible derangement of the functions of the 
stomach, skin, kidneys, possibly also of the lesser organs, pancreas, 
etc., a disorder of any one of which, and the throwing of its work 
upon other organs, may cause chronic disease. Thus, much of the 
systemic disturbance resulting in gout or skin disease is traceable 
to primary indigestion, that is, to failure in the stomach to properly 
prepare the ingesta for the action of the other organs. Or, as a 
chilling of the cutaneous surface can produce internal disorder, 
manifested by a deposit of lithates in the urine, so chronic inac- 
tivity of the skin may have the same result; how constantly is the 
skin harsh and dry in the states of albuminuria, glycosuria and 
polyuria, and I have already shown urinary derangements to be 
common in cases where the skin is disabled, as in xeroderma, very 
general eczema or psoriasis, etc., and we know, moreover, that the 
action of the skin is apt to be very imperfect, even in cases of 
localized cutaneous disease. 
We come now to the practical bearing of our study of the rela- 
tions of the urine to diseases of tl\e skin, namely :— 
Therapeutical considerations. First we will take the 
matter of diet, hygiene and exercise. The variations in the urine 
both in connection with normal alimentation and the ingestion of 
injurious food have been very conclusively demonstrated by others, 
and it were well to regard these physiological considerations in 
the treatment of skin diseases. When the urine exhibits deposits 
of uric acid, urates, and oxalate of lime, there is evidence of 
imperfect action of the system, a sub-oxidation, whereby, in place 
of the complete combustion of the food, and the perfect elabora- 
tion of the products of dis-assimilation into urea, carbonic acid, 
water, and other elements fails, and oxalic acid represents, in the 
main, this failure in respect to starchy and saccharine food, and 
uric acid and the urates the same for nitrogenous elements; 
(though it is true that this is not absolutely the fact in every in- 
stance, oxalic acid being also derivable from albuminous com- 
pounds.) These changes in the urine, then, which we have shown 
to be so very common in patients with affections of the skin, show 
the latter to be more connected with assimilative disorder than is 
granted by some, or apt to be thought of by most practitioners. I 
cannot here enter further on the subject of the animal chemistry 
of these changes, but will merely state the practical lessons I have 
learned from them, without even stopping to give credit to the 
sources of my knowledge. 
Over eating is not at all uncommon in skin patients, by this RELATIONS OF URINE TO SKIN DISEASES. 
31 
means undue amounts of alimentary substances are taken into 
the blood and the urinary disorder is but an indication of this, 
an effort of nature to rid the system of unneeded supply; 
nature, as it were, considers it unnecessary, or is unable, to 
fully oxydize this waste matter, and throws it off partially disin- 
tegrated. Or, there may be over eating in one particular direction, 
one patient takes more sugar and starch than is needed, another 
more meat, a proper regulation in this respect conduces to health 
and consequently to recovery from skin diseases. Or, again, the 
amount taken at any one time may be greater than the organs can 
care for, some of the proximate elements enter partially elaborated 
and must pass off in the same manner ; the remedy for this is fre- 
quent and small supplies of proper food, rightly prepared. But 
these urinary abnormalities, though often beneficial provisions of 
nature, cannot continue long without evils attending them, as we 
saw that experimentally the circulation of excrementitious sub- 
stances caused disease. 
Other elements in the production of urinary disorders are also 
such as induce skin disease, thus the use of fermented wines and 
ales often are the cause of both, or want of proper and sufficient air 
and exercise. No one of the elements which tend to good or bad 
health should be overlooked in treating skin diseases. 
When speaking of the relations between the skin and kidney- 
functions, the alterations in the urine attending the use of baths 
was spoken of. This is a point too often neglected in Dermato- 
logical practice. We found that daily bathing augmented the 
total solid constituents of the urine, the urea and uric acid being 
increased, and frequent bathing, especially in baths slightly alka- 
line, and proper subsequent friction to the skin, will do much in 
removing cutaneous disease, both by accelerating the assimilative 
processes and keeping the pores of the skin in a condition to do 
their work. The benefits from visits to the mineral springs of 
Europe are largely due to this fact. Dr. Todd,* when speaking of 
acne, says, “ in many diseases of the skin we have found the 
greatest benefit from sponging sound parts of the skin two or 
three times every morning, with a lotion consisting of two drachms 
of nitro-muriatic acid and two pints of water.” 
Finally, many medicines are of benefit in diseases of the skin by 
virtue of acting in a manner calculated to affect the urinary secre- 
tion. Dr. Easton f reports most satisfactory results from the use of 
acetate of potassa in eczema and psoriasis, given in half drachm 
doses three times a day, an experience which I have long verified, 
and he gives some interesting details of the urinary relations dur- 
ing its administration. The smallest amount of urine voided by 
any of his cases when under its influence was 54 ounces daily, the 
largest 120 ounces, an increase of about 14 ounces as a minimum, 
and 80 ounces as a maximum over that in health. The total solid 
constituents were also increased to 1026 grains daily for a mini- 
* Copland’s Encyclopedia of Pract. Med., 1833, Vol. I. p. 31. 
t Monthly Med. Journ. 1850, p. 422. Braithwaite, Vol. XXI, p. 245. 32 
Z. DUNCAN BULKLEY; 
mum, and 1320 for a maximum, or from 200 to 500 grains of solid 
matter daily above the average of health, and with this in- 
crease the skin affection rapidly improved. The same is shown 
in the case I have quoted of Dr. Mapother, where under the use 
of the citrates of lithia and potassa the total daily solids excreted 
by the urine, as estimated roughly by the specific gravity, increased 
about 200 grains as a minimum and 400 as a maximum, above that 
observed in the same patient before treatment. The use of alkalies 
in treating diseases of the skin is of old date and urged in strong 
terms by those with much experience in these affections. Dendy* 
thinks their efficacy specially during the period of childhood, due to 
their “ improving the quantity and quality of the renal secretion, 
which, in skin diseases, are often so unhealthy.” Colchicum we 
have seen to have this effect in urticaria, and the mineral acids 
in proper cases do the same. 
From what has preceded it will be seen that I cannot subscribe 
to the views entertained by some as to the local nature and treat- 
ment of the many affections of the skin. The German school, in 
which I was myself instructed, has done much to improve local 
cutaneous therapeusis, but it has also done much to discredit the 
dependence of skin lesions upon internal disorders, and thereby 
has, in my opinion, done much harm. It is true that a large 
measure of success may be obtained by the judicious employment 
of local remedies and that therein much of the skill of the special- 
ist is often shown, but it is also quite as true, or even more certain 
that we can afford most permanent and satisfactory relief in 
certain skin diseases by a proper regulation of diet, exercise and 
medication tending to restore and keep the assimilative functions 
in perfect order. 
In the present paper I have desired to direct very serious at- 
tention to the importance of the urine as an element in the study 
and practice of Dermatology. To this end, in addition to quoting 
what I have been able to find on the subject, I have endeavored 
to give an account of the urine as I have actually observed it during 
the course of diseases of the skin, and I can affirm that I have 
received very great assistance at times from these examinations. 
I am well aware of their imperfection, but the desire was to pre- 
sent such methods of investigation as could, and should be made 
by every physician, involving mainly the quantity, acidity, specific 
gravity and gross appearances, together with a simple microscopic 
examination, easily made with the assistance of any good text 
book on the urine. To be of more real value to science, and per- 
haps to practice, the investigations should involve the entire 
quantity of urine voided in the 24 hours, and its total specific 
gravity, as well as that of morning and night urines, and the 
acidity should be tested by saturation with caustic soda. It 
would be further desirable, scientifically, to test the daily excre- 
tion of urea, and quantitive tests of other elements, would greatly 
* Diseases of the skin during infancy and childhood. Phil. 1841, p. 20. RELATIONS OF URINE TO SKIN DISEASES. 
33 
develop the subject. But the simple and practical measures we 
have employed and here reported, yield abundant reward in the 
confidence thereby given of a knowledge of the performance of 
its functions of the most important depurating organs of the 
body—the kidneys. Dr. Philips, in 1840, wrote* “ In lepra and 
psoriasis you will commonly see the kidney endeavoring to per- 
form the function which the skin has abandoned, you will find uric 
acid thrown down in considerable quantity in the urine * * * 
It will be very desirable in the different affections of the skin to 
test the urine, as well as the cutaneous exhalation.” 
In conclusion, I may add that although as yet a sufficient num- 
ber of accurate observations have not been made in the various 
diseases of the skin to enable us to state positively that such and 
such changes belong necessarily to one disease, and such others 
to another, still the indications of urinary derangement in these 
affections are such as to invite further study, and at the same time 
to furnish ofttimes very valuable assistance in the daily treatment 
of diseases of the skin. Archives of Dermatology: 
A QUARTERLY JOURNAL OF SKIN AND VENEREAL DISEASES 
Terms: Three Pollars per —in /Advance. 
L. DUNCAN BULKLEY, A.M., M.D., Editor, 
20 West 25th Street, 
O, P. PUTNAM'S SONS, Publishers, 
308 Fourth Avenue, New York, 
Wear Woctor : 
S€llow me to call your attention to the Archives of Dermatology, now entering upon 
its second year. 
dVo field of study has been left uncultivated, in this country, to a greater extent than that of Shin 
and \Venereal Wiseases, and the uncertainty as to the correct diagnosis in these affections, as'also the 
doubt in regard to the best treatment, which it is so common to find, prove that far too little is hnown 
of these branches generally. 
If he name of the journal, “Archives,” would signify to some an abstruseness suited only for 
specialists, but, on the contrary, the wants of the General Practitioner have been Icept continually in 
mew and its pages prepared largely for him. a large amount of scientific matter has 
been condensed and presented in the last volume■, it has not been done solely for the specialist, but with 
the idea of furnishing to the profession at large a, true basis on vjhich to found a scientific and success= 
ful Tcnowledge of these affection s, while at the same time, as much practical matter as possible has also 
been in troduced. 
With the beginning of the Second Volume, October, 18?5, the Sditor commences a series of 
Clinical Conversations, aiming to illustrate the diagnosis and treatment of the More Common affeo= 
tions of the shin , Whey will be in the main a report of cases treated at the Wemilt Wispensary, and. 
the remarhs made to private classes there, the articles being intended rather for the general practitioner 
than the specialist. Strenuous endeavor will also be made to secure, in the future, more contributions 
of a plain and practical character, adapted to the wants of those engaged in general practice. 
if he of the ffew Worh Wermatological Society contain reports of many interesting 
cases and the discussions upon them, and, it is thought, are of qeneral interest. 
Hour attention is called to the large amount of matter contained in the first volume of the <JArchives, 
and its practical character, there being thirty original articles by tiventij=seven writers, while in the 
u Wigest of Sditerature !) and ufteview n Wepartments, more than 600 articles from other ifournals or 
separate boohs and monographs are noticed. St is believed that the index to the first volume, covering seven pages of closely printed double= 
columns; surpasses in fullness any similar one; and will be of much service, embracing, as it does, the 
literature of the world for the year in the departments of Shin and &Diseases. 
She r9lrchives will appear quarterly, as before} 2 commencing in October, and for the 
present will consist of 96 octavo pages each issue. She departments will remain much the same as 
during the past year; the following gentlemen who hare conducted the digest so ally 
heretofore, still retaining the same. 
Srs. S. 13. 73ronson} <W. S. 73ull; S. P. Soster, deo. 16. Sox; S. S3. 76eyes, deo. Jl. Sdefferts, 16. d. 
Piffard; £4. 71. TZobinson, S. 71. Sturgis; 71. W. Saylor, Tlobt. S. Weir, and S. S3. Weisse, of Sew 
33/orlc j Sirs. Cfa,me/S White and ddw. Wigglesworth, r/r. , of Poston, and Sirs. S6. £4. Sluhring and 
£4. Wan 76a,rlingen; of Philadelphia. 
She Sdrchives of Slermatology is now the only Scientific Journal Published in the English 
Language Devoted Exclusively to Skin and Venereal Diseases, and is of service to every practitioner, 
for these affections form a not inconsiderable share of general practice. 
Jn conclusion you are invited to examine the first volume, and also the following from among 
many favorable 
NOTICES OE THE PRESS. 
“ The Editor has enlisted, as co-workers, many of the specialists in these two branches of medicine in New York, 
Philadelphia and Boston, and there is no reason why it may not be successful.”—Boston Medical and Surgical Journal. 
“ Interesting cases, fresh translations and reviews, with a variety of carefully selected miscellany, make the present 
number a very attractive one.”—New York Medical Journal. 
“ If the conductors can secure a succession of numbers in the future as good in character and material as this first 
specimen one, they will not fail, we think, to meet with success.”—London Lancet. 
“ It at once assumes rank among the leading authoritative Journals of the country, and should be handsomely 
sustained.”—Virginia Medical Journal. 
“ Bids fair to be the standard Journal of the country in the specialty of skin and veneral diseases.”—Atlanta Medical 
and Surgical Journal. 
“ That future numbers will be still better we are confident from our personal knowledge of the ability and qualifications 
of the Editor and his co-workers.”—Detroit Review. 
“ Not merely the specialist, but also the general practitioner, especially those practicing outside of large cities, where 
specialists are few, will find the Journal an invaluable guide in the diagnosis and treatment of the diseases of which it treats/’ 
—Physician and Pharmacist. 
“ It is, in my humble opinion, by far the best Journal of Dermatology which has appeared in any language. The 
articles are not tedious and lentliy * * * * they are for the most part practical.”—McCall Anderson. 
Sour support is earnestly desired in the attempt to maintain a good; scientific and practical 
journal in this very important department; both by contribution to its pages; extending its circulation; 
and by personal subscription . S remain; 
°Very respectfully and faithfully yours, 
L. DUNCAN BULKLEY, M.D. 
PS.—Single copies are one dollar, but for a short time Specimen Sumbers will be mailed\ free of 
postage, on receipt of 50 cents. Archives of Dermatology. 
jHeSuS-fiS-. AY J9. APuincun \s* Aanx} 4tJ? Jflve. # 23d St., Aew York. 
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STown. 
■9da.de. 
Yoa/ <jYcd/teM ARCHIVES OF DERMATOLOGY: 
A QUARTERLY JOURNAL OF 
SKIN AND VENEREAL DISEASES. 
L. Duncan Bulkley, A. M., M. D., Editor. 
The Archives, designed largely for the general practitioner, is now the only 
Scientific Journal published in the English language devoted exclusively to Skin and 
Venereal Diseases. It is supported by an able staff of collaborators and will aim 
to contain, besides original matter, an epitome of all that is valuable in the litera- 
ture of the day bearing on topics represented. 
NOTICES OF THE PRESS. 
The editor has enlisted as co-workers many of the specialists of these two 
branches of medicine in New York, Philadelphia, and Boston, and there is no 
reason why it may not be successful.—Boston Medical and Surgical Journal. 
Interesting cases, fresh translations and reviews, with a variety of carefully- 
selected miscellany, make the present number a very attractive one.—New York 
Medical Journal. 
If the conductors can secure a succession of numbers in the future as good in 
character and material as this first specimen one, they will not fail, we think, to 
meet with success. —London Lancet. 
It at once assumes rank among the leading authoritative journals of the coun- 
try, and should be handsomely sustained.—Virginia Medical Journal. 
Bids fair to be the standard journal of the country in the specialty of skin and 
venereal diseases.—Atlanta Medical and Surgical Journal. 
That future numbers will be still better we are confident from our personal 
knowledge of the ability and qualifications of the editor and his co-workers.— 
Detroit Review. 
Subscription S3 a year, in advance. Single number Si. 
G. P. PUTNAM’S SONS, Publishers, 
308 Fourth Avenue, NEW YORK. 
Volume II. begins October, 1875.