“ DEFICIENT EXCRETION FROM KIDNEYS NOT ORGANICALLY DISEASED, 
AND SOME OF THE DISEASES PECULIAR TO WOMEN,” 
AND DISEASES OF THE SKIN. 
BY 
L. DUNCAN BULKLEY, A.M., M.D., 
PHYSICIAN TO THE NEW YORK SKIN AND CANCER HOSPITAL ; CONSULTING PHYSICIAN 
TO THE NEW YORK HOSPITAL, ETC. 
Read before the 
Medical Society of the State of New York, 
January 27,1897. [Read before the Medical Society of the State of New York, January 27, 1897.] 
“ DEFICIENT EXCRETION FROM KIDNEYS NOT 
ORGANICALLY DISEASED, AND SOME OF 
THE DISEASES PECULIAR TO WOMEN,” 
AND DISEASES OF THE SKIN. 
By L. DUNCAN BULKLEY, A.M., M.D., 
NEW YORK. 
One year ago Dr. James H. Etheridge, of Chicago, by invita- 
tion, made an address before this Society, the title of which was 
the first portion of that above giveu. As there was no discussion, 
except some remarks made by the present writer, it seemed best 
to present the matter again, with the author’s full consent, in the 
hope that the important subject might receive farther consideration 
from the members present, and that it might thus become doubly 
impressed on those likely to meet the cases referred to. 
While the present writer disclaims all special knowledge in re- 
gard to diseases peculiar to women, he feels particularly interested 
in the subject which Dr. Etheridge so ably presented, for several 
reasons. Incidentally he has met with many female patients, 
coming under treatment for various diseases of the skin, who were 
known to have also various uterine disorders of distressing char- 
acter, and many of these patients had previously undergone varied 
and prolonged gynecological treatment, often with unsatisfactory 
results. These uterine disorders he has seen improved and often 
quite recovered from under lines of treatment directed for their 
skin difficulty, which quite coincided with those laid down by Dr. 
Etheridge, and without gynecological treatment. He therefore 
begs to present the subject again as briefly and clearly as possible, 
urging the profession to recognize the principles and employ the 
methods laid down by the distinguished author of the paper alluded 
to. Dr. Etheridge has kindly given permission to use in the freest 
manner possible the material presented by him, which will be done 
as far as necessary to make the matter clear and forceful. 
“ Toxic materials always feuittati bodk. They 2 
L. DUNCAN BULKLEY, 
constitute the waste-products of living beings. From birth to 
death they battle for supremacy. So long as they are plentifully 
excreted, death is postponed. The skin, the pulmonary mucous 
membrane, the bowel, and the kidney constitute the avenues of 
escape for all toxic materials from our bodies. If one of these 
emunctories be crippled, the initiation of death is manifest. . . . 
The physician who busies himself with solving the problem of the 
initial departure from the proper performance of excretion enters 
a new field of labor. It is the most interesting one he can invade 
to-day. . . . Herein he deals with the beginnings of disease.” 
Such are the strong words with which Dr. Etheridge introduces 
his interesting and important study. 
Prominent among the systemic derangements which lead to a 
vitiation of the blood-current and the retention in the system of 
the waste-products of animal life undoubtedly stands imperfect 
kidney excretion; the elements composing the urine are known to 
be poisonous both to the individual forming them and also to ani- 
mals when artificially introduced. Extirpation of both kidneys 
is very quickly followed by death; the gradual retention of these 
normally excreted poisons, by means of imperfect elimination from 
the kidneys, leads, as many have shown, to various forms of dis- 
order and disease in many organs of the body. 
Dr. Etheridge has rendered an inestimable service to the profes- 
sion and to suffering females in earnestly calling attention to the 
fact, which I can confirm most positively, that this insufficient kid- 
ney secretion plays a very important part in the production and 
continuance of many of the diseases peculiar to women. The 
study of this initiative cause of these diseases merits the most 
serious consideration of the profession. 
How far the errors observed in the excretion from the kidneys 
pertain to the action of those organs alone does not belong to our 
present discussion, nor how far the remedies used have for their 
action solely their influence on the kidneys. Undoubtedly the 
liver plays a very important share, as also the digestive organs, 
in rendering the ultimate process of removal of effete products 
imperfect. Suffice for the present that we discover in the kidney 
excretion the evidences of the imperfect removal of the waste and 
poisonous substances, and by means of the improved excretion 
from the kidneys we find the proof of their proper removal and 
consequent good health. DEFICIENT RENAL EXCRETION. 
3 
Recognizing that the proportion of the solids in the normal urine 
bears a certain ratio to the normal body-weight, below a certain 
percentage of which they cannot fall without indicating “ renal 
insufficiency,” Dr. Etheridge has given a table, prepared by an 
expert physiologist, which is here reproduced : 
Table I.—Relation of Body-weight of Healthy Human Beings 
to Total Daily Excretion of Urinary Solids. 
Weight. 
Total urinary 
solids. 
Weight. 
Total urinary 
solids. 
40 pounds . 
. . 392 grains. 
130 pounds . 
. 1028 grains. 
50 
. 479 “ 
140 “ 
. 1078 “ 
60 “ 
. 563 “ 
150 “ 
. 1150 “ 
70 
. 639 “ 
160 
. 1198 “ 
80 “ 
. 716 “ 
170 “ 
. 1237 “ 
90 “ 
. 789 “ 
180 “ . 
. 1260 “ 
100 “ 
. 854 “ 
190 
. 1300 “ 
110 “ 
. 916 “ 
200 “ 
. 1330 “ 
120 “ 
. 974 “ 
As this table was constructed for healthy human beings, and, of 
course, takes into account exercise, Dr. Etheridge does not think 
that practically quite these amounts can be expected in women who 
come for treatment. It is to be remembered also that women always 
excrete less than men, perhaps one-tenth less. He would therefore, 
from experience, fix the limit at 500 grains for a woman weighing 
90 pounds and 1100 grains for one weighing 180 pounds. From 
these data a scale can easily be constructed, as follows, for prac- 
tical daily work : 
Table II.—Relation of Body-weight of Women of Average 
Health to Total Daily Secretion of Urinary Solids. 
Weight. 
Total urinary 
solids. 
Weight. 
Total urinary 
solids. 
90 pounds . 
. . 500 grains. 
135 pounds . 
. 815 grains. 
95 
. 535 “ 
140 “ 
. 850 “ 
100 “ 
. 570 “ 
145 “ 
. 885 “ 
105 “ 
. 605 “ 
150 
. 920 “ 
110 
. 640 •* 
155 
. 955 “ 
115 “ 
. 675 “ 
160 
. 990 “ 
120 “ 
. 710 “ 
165 
. 1025 “ 
125 
. 745 “ 
170 
. 1060 “ 
130 
. 780 “ 
175 “ 
. 1095 “ 
This table is at the rate of just 35 grains additional for each 
five pounds of body-weight, or seven grains to the pound, which 
is near enough for ordinary daily work. For greater accuracy 
there should be still some deduction for age; thus, between forty 
and fifty years deduct 10 per cent.; between fifty and sixty deduct 4 
L. DUNCAN BULKLEY, 
15 per cent.; and between sixty and seventy deduct 20 per cent, 
from the amounts above given. 
It is not a very difficult matter to carry out the plan of learning 
the total daily excretion of solids, if it be rightly arranged; it is 
especially easy in regard to women, as they are more apt to be at 
home and willing to attend to such matters. I have long had it 
done, daily in many instances, and in others at stated intervals. An 
ordinary two-quart mineral-water bottle is used, with a strip of 
paper pasted on the side for the scale. This is graduated by fill- 
ing the bottle from a two-ounce measure and marking off each two 
ounces; the intervening ounce can be divided by the eye. Many 
druggists keep large bottles graduated for this purpose. A glass 
funnel is placed in the mouth of the bottle, by means of which 
all the urine can be poured into it as passed. The index is read 
off, the amount recorded, and the bottle emptied at a fixed hour 
every day, and a sample of the whole is sent to the office, with the 
statement of the total amount passed. 
From the specific gravity of the sample the total amount of 
solids passed in the day is easily estimated by Haines’s modifica- 
tion of Hasser’s method, as given by Hr. Etheridge, which is as 
follows : Multiply the last two figures of the specific gravity of the 
urine by the number of ounces voided in twenty-four hours, and add 
10 per cent, to the product. Thus, if the amount passed in the 
twenty-four hours was 36 ounces and the specific gravity 1021, it 
would be 36 X 21 = 756 -f- 10 per cent. = 831, the number of 
grains of solids in the whole amount; compared with the table it 
can be readily ascertained if this is above or below the normal 
amount for the body-weight of the patieut. 
It will be noticed that this estimate is for the total solids of the 
urine, and not for the urea alone; the estimation of this latter is a 
relatively slow and laborious process, and, while often extremely 
valuable, is really not always necessary; for, under normal condi- 
tions, the urea represents nearly one-half of the solid constituents 
of the urine, and so would be expected to vary with the total solids. 
It is to be remembered that our study is in regard to kidneys not 
organically diseased, and at present no reference is made to albumin 
in the urine. 
But, further, the toxicity of the urine does not depend upon the 
urea alone. Etheridge states that u the coloring-matter and other 
organic substances removed by charcoal filtration contribute at least DEFICIENT RENAL EXCRETION. 
5 
one-half of the toxic power of the urine/’ and he attributes a con- 
siderable proportion to the urinary salts of potassa. 
It will be noticed, however, that very little has been said in 
regard to the actual quantity of the urine passed, representing the 
amount of water in it, or the solubility of its constituents—a point 
hardly alluded to by the writer of the previous paper. The urinary 
water mdty vary so greatly from day to day, according to the amount 
of fluid drank and the activity of the secretion of the skin and respi- 
ratory organs, that it is, in some ways, of less importance than the 
actual solids of the urine, which represent the removal of the waste- 
products of metabolism from the body. But, on the other hand, 
it is often immensely important, and should always be known and 
appreciated; for even if the total amount of solids voided may 
be up to normal, there is still insufficiency of kidney action, and 
consequently ill health, if the proportion of water be not also 
about normal. A smaller amount of water, with higher specific 
gravity, and consequently containing a normal daily amount of 
urinary solids, does not conduce to the good health which a normal 
amount of urine with a lower gravity would indicate. Clinically, 
this matter is often of the very greatest importance, and I could 
illustrate it by dozens of instances did time and space permit. 
Dr. Etheridge gives some very interesting cases illustrating the 
ill effects of renal inadequacy and their relief upon the employ- 
ment of appropriate diuretic treatment, which I will very briefly 
quote before adding my own clinical statements and comments : 
Case I.—Mrs. C., multipara; had general metritis,'with deep, double 
laceration of the cervix, with an obstinate bronchitis, and profuse secre- 
tion. The.severity of the cough increased the pelvic suffering and vesical 
irritability, also the profuse leucorrhcea. Each winter she had been an 
invalid, submitting to very much gynecological treatment, and had sought 
relief in warmer climates, where she was better, as also in summer; but 
with the advent of cold weather the bronchitis returned, aggravating all 
her other troubles. Finally it was found that she was passing only 298 
grains of urinary solids, when 850 grains was her normal amount. Under 
stimulating diuretics, tonics, and a laxative, the urinary solids were increased 
in thirty days to 950 grains; the cough had disappeared, though in mid- 
winter, and she was shortly in better condition than for many years. 
Case II.—Miss G., aged twenty-three years; had menstruated only five 
times in the previous year ; she had backaches and headaches, circumpelvic 
pains, increased by exercise ; an albuminous leucorrhcea, and great nervous- 
ness. The ascending colon was loaded with feces. She should have voided 
850 grains of urinary solids daily, but was passing only 485. Under treat- 6 
L. DUNCAN BULKLEY, 
ment by laxatives and diuretics the urinary solids were increased to over 
1300 grains for a number of days, and regular menstruation returned. 
When, from neglect, there was again insufficiency of the solids in the urine 
the amenorrhoea returned, and a recurrence to diuretics again made her 
monthly sickness appear regularly. 
Case III.—Mrs. B., aged thirty-six years, the mother of three children, 
and the victim of many abortions, complained of pelvic weight, general 
rachialgia, tender spine, pleurodynia in left chest, excessive nervousness, 
and moderate metrorrhagia ; she had a moderate metritis. She weighed 154 
pounds, and should have passed 900 grains of urinary solids daily, but was 
voiding only 480 grains. Her urinary solids were kept above 1000 grains 
daily for many weeks, and with local treatment and tonics she was cured in 
four months. 
My own experience in regard to the value of diuretic treatment 
in many disorders peculiar to women dates back a good many 
years, and has come to me slowly, though very convincingly; but 
I have always hesitated about reporting on the subject, because of 
my want of acquaintance with the actual condition of the pelvic 
organs, except from a report as to those who had previously seen 
the case or cases, aided by the statements of the patient. But as 
I have gone on, year after year, seeing and knowing of the vast 
improvement which occurred in my patients in regard to symp- 
toms pointing to the pelvic orgaus of which they had complained, 
I have become more and more convinced of the reality of what I 
was observing, and more and more confident as to prospective 
benefit when patients complained of uterine or other pelvic de- 
rangements. 
When, therefore, Dr. Etheridge spoke with such positiveness, I 
was pleased, indeed, to find my own experience verified by so dis- 
tinguished an authority, and I felt justified in adding my testimony 
to the same facts, observed from quite a different portion of the 
medical field; for it need hardly be added that my cases came to 
me for the treatment of various diseases of the skin, and not for 
uterine or female troubles. 
The first case, which impressed me perhaps most forcibly of all, 
occurred at least twenty years ago. The name of the patient has 
gone from me, so that I cannot look up the notes of the case, but 
the details are yet very vivid in my mind, for many reasons. 
The patient was a girl of about twenty-three years of age, with one of the 
worst case of indurated acne that I had seen; the cheeks and chin being 
dreadfully disfigured. She gave the history of very great uterine trouble, DEFICIENT RENAL EXCRETION. 
for which she had received an infinity of treatment; for a number of years 
she had profuse menorrhagia with very great pain. Her condition had 
become so bad that an elevator had been put in her home for her use, as 
she never could go upstairs. She drove to my office, and, as this was then 
on the second floor of a basement-house, I saw her the first few times in the 
reception-room on the ground floor. 
For her acne I gave her first alkaline diuretics and laxatives, tonics, etc., 
with a regulated diet, and she responded well to treatment. I remember 
well my surprise when one day she walked upstairs to my office. I shortly 
persuaded her to take a little exercise, walking a block, and gradually more; 
and, to be brief, by the time the treatment for the acne was completed she 
walked a mile to my house, and had abandoned her elevator at home, and the 
symptoms looking toward the uterine function had ceased. She had had no 
gynecological treatment in the meantime, and I do not think that I knew 
what condition existed in the pelvic organs. In treating constitutionally 
the condition I found on the face, the general results followed; and this 
treatment was very decidedly in the line of a relief to insufficient kidney 
and bowel action. 
It is hardly necessary to occupy time in relating individual cases, 
and indeed it is difficult to make selections from the notes of sev- 
eral dozen cases now before me; there are so many which exhibit 
gains in the directions mentioned in a striking degree. It is 
really now of daily occurrence for me to see patients who have 
suffered from many of the diseased conditions peculiar to women 
become freed from them under treatment directed largely along 
the lines advocated by Dr. Etheridge, and given mainly on account 
of skin diseases for which they sought relief. And I may say 
that almost without exception such cases have exhibited insuffi- 
cient kidney action; many of them, of course, being also compli- 
cated with constipation and primary or secondary indigestion. 
In this way I have seen many patients with amenorrhoea, in 
varying degrees, in whom the menses have beeu thus established 
in a regular manner; but, as in Dr. Etheridge’s case, their trouble 
will often return when the treatment is neglected for some time, 
and from one cause or another the insufficient action of the kidneys 
returns. We all know of many instances where the menstrual flow 
has been suddenly checked by chilling of the feet, and it is just 
this same accident which so often deranges kidney action. Irregu- 
larities of the menses, both as to the interval and the duration, have 
constantly been observed by me to disappear as the eliminative 
treatment necessary for the skin disease has gotten under full action. 
Excessive flowing has also been met with from time to time which 
has been regulated by the same line of treatment. 8 
L. DUNCAN BULKLEY, 
Bat it is in dysmenorrhoea that the largest number of most in- 
teresting cases are found, and of these I could give many very 
striking examples. It is not at all uncommon for me to learn from 
a patient that since she had been under treatment the monthly flow 
had become more regular and natural than for years previously. 
Many who have suffered so severely that even opiates were re- 
quired with each monthly sickness to make life endurable, have, 
when under full treatment, absolutely lost all pain and become 
even unconscious as to when the menstrual epoch begins. And 
it has occasionally happened that a mother has brought a second 
daughter to me, not at all for the treatment of any skin disease, 
but solely for the relief of menstrual difficulties, because another 
daughter had found such benefit while under treatment for the skin. 
My experience in a very considerable number of cases has also 
led me to the belief that many of the ills and discomforts com- 
plained of at the period of change of life, and usually more or less 
accredited to this condition, as though dependent upon it, are in 
reality due to faulty elimination, principally of the kidneys. I 
could cite many, many instances where attention to this element 
has resulted in the disappearance of the unpleasant symptoms in 
very brief time, while a neglect of the same would be followed by 
their recurrence, only to again disappear under exactly proper 
treatment. 
I am quite aware that some statements I have made may seem 
exaggerated, and I may seem unwarranted in speaking thus posi- 
tively in regard to matters outside of my chosen specialty. I can 
only assure you that I am speaking of what I have observed and 
know; for surely even the gynecologist cannot know of the suffer- 
ings of patients except from their own statements ; and I can verify 
the facts by many physicians who have seen cases with me. I may 
also say that in the local societies and to friends I have mentioned 
these ideas, and others have seen like good results iu patients where 
this plan of treatment has been put in thorough practice. 
It will be understood, of course, that in the cases referred to 
there has been no local or gynecological treatment employed at the 
time, as I never, in any way, attempt such ; nor have I generally 
known what, if any, local disorder or displacement existed, 
never make examinations in such cases, but send patients to gyne- 
cologists when special treatment is required. 
I do not, however, wish to be misunderstood in regard to the DEFICIENT RENAL EXCRETION. 
9 
matters of which I have spoken. I by no means claim that care 
in regard to deficient urinary secretion will cure all the ills to 
which woman is heir. I most fully appreciate the need of the 
gynecologists, and recognize in the highest degree the splendid 
work which has been accomplished by them in the relief of suffer- 
ing women; but from experience I know that many cases of 
uterine disorders can be relieved and indeed cured by full and 
adequate general medical treatment, including attention to and 
rectification of a faulty urinary secretion, which had too often 
been previously neglected. I cannot do better than to close with 
a quotation of the final part of Dr. Etheridge’s excellent paper : 
“ No intimation is here given that it is the most important 
factor in diseases of women. To set up such a claim would be 
most absurd. The aim of this article is solely to call attention to 
one line of treatment that has been all but universally neglected 
heretofore and to invite observation and original investigations. 
u There is the gravest reason for thinking that a very close rela- 
tion, even that of cause and effect, exists between renal insuffi- 
ciency and pelvic disorders. The developmental phase of the 
renal and generative organs constitutes that reason. Embryologi- 
cally, these two sets of important organs arise from the same 
source. The mesoblast in the ovum gives rise to the muscles, 
bones, circulatory and lymphatic systems, the urinary and genera- 
tive organs. From this fact it becomes an easy matter to infer 
that derangements in one set of the organs can produce, in a reflex 
way, if you please, or at least are very frequently associated with 
derangements of the other. 
“ Since observation shows the numerous cases of coexistence 
between renal insufficiency and neuralgias, mucous membrane dis- 
orders, and serous membrane inflammations, one cannot question 
the possibility of the insufficiency producing or permitting amen- 
orrhoeas, dysmenorrhoeas, leucorrhoeas, and attacks of pelvic peri- 
tonitis. It is strongly emphasized that the position is not assumed 
that all cases of these disorders are produced by renal insufficiency, 
but from the fact that many of them are relieved by including in 
the treatment remedies that increase the urinary solids, the conclu- 
sion cannot be resisted that cause and effect actually exist between 
many of them and the deficiency of urinary ingredients.’’ 10 
DISCUSSION. 
DISCUSSION. 
Dr. H. R. Hopkins, of' Buffalo: I wish to emphasize that which 
the speaker has very well put, that in estimating the urinary conditions 
or complications we are apt to overlook the one important matter which 
we should inquire into. That part of the examination which relates 
to the presence of albumin, or sugar, or casts, is probably the least im- 
portant, for the question of the renal functions of the patient have 
scarcely been touched, since in eclampsia, albuminuria, and a large 
variety of dietetic disturbances there is for a long time a period of 
renal incompetency which is indicated, and indicated invariably, by a 
deficiency in urinary solids, and it is infinitely more important to bring 
out this fact than to determine later the presence of albumin or sugar 
when the time for effective treatment may have been lost. 
Dr. R. W. Wilcox, of New York : It is unfortunate that the profes- 
sion does not appreciate the importance of an estimation of the amount 
of urinary solids. It is now many years since Sir Andrew Clark called 
attention to renal insufficiency, and many years since the more advanced 
French clinicians have been writing upon the subject. Long before 
we find albumin or casts, evidence of renal insufficiency can be deter- 
mined if a careful estimate is made of the quantity of urine and of 
the total solids. 
Dr. Woods Hutchinson, of Buffalo: We have here the edifying 
spectacle of two specialists—a gynecologist and a dermatologist, both 
uniting in testifying that a large and important class of the diseases 
they are called upon to treat are due to disturbances of an organ outside 
the domain of either of them. As an embryologist I am struck with 
the sympathy which is here shown to exist between the different por- 
tions of the great tissue-sheets—the primitive germ-layers. On the 
one hand, we have the epithelium of the skin sympathizing (eczema- 
tously) with its remote cousin or descendant, the secretive epithelium 
of the Malpighian capsules and tubules. On the other hand, we have 
the mesoblastic tissues of the uterus and tubes almost similarly sym- 
pathizing with their kindred, the vascular mesh of the kidneys and 
blood-knots of their glomeruli. “ Blood is thicker than water” even 
in our tissues, and our cells have far longer and more accurate mem- 
ories than we have. 
Dr. A. T. Bristow, of Brooklyn : I have been taught to regard the 
urea as the most important factor in the urine, and any system of 
determining the amount of solids which assumes that the relation be- 
tween this and the amount of urea is constant, is faulty. By the DEFICIENT RENAL EXCRETION. 
11 
method given it would be assumed that in fifty ounces of urine of a 
specific gravity of 1020 there would be a certain number of grains of 
urea, but that by no means follows. I call to mind a very interesting 
case in my practice last winter, in which the specific gravity of the 
urine was fairly constant, but the urea oscillated in the most extraor- 
dinary manner, varying as much as 50 per cent. It seems to me that 
the only positive and accurate way of estimating the urea is the quan- 
titative test, and the easiest test, and one which is fairly accurate, is that 
by displacement of nitrogen. With Doremus’s apparatus this can be 
carried out in five minutes, and the method is almost absolutely accurate. 
Dr. Bulkley : With regard to the objection raised, that the amount 
of the urea was not considered, I may say that I mentioned in one part 
of my paper the fact that it is exceedingly desirable to test for the 
urea. But that requires a certain amount of apparatus and time, and 
the stopping of other work, which many physicians will not do. But 
other ingredients beside urea have been found very poisonous to ani- 
mals. They are in the total solids, and I still hold that to estimate 
the total solids is most necessary.