THE TREATMENT 
OF THE 
SCROFULIDES 
(LUPUS.) 
BY 
HENRI G. PIFFARD, A.M., M.D. 
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MACMILLAN & CO., LONDON, 
And 21 Astor Place, New York. THE TREATMENT 
OF THE 
SCROFULIDES (LUPUS). 
BY HENRY G. PIFFARD, M. D., 
Professor of Dermatology, University of the City of Nezv York, Surgeon 
to the Charity Hospital, etc. 
Believing that Lupus is essentially a scrofulous affec- 
tion, I have adopted the nomenclature and classifiaction 
of Hardy, who arranges the different varieties as follows : 
Erythematous Scrofulide. 
Corneous “ 
Pustular “ 
Tubercular “ 
Phlegmonous “ 
For a graphic description of the clinical features of these 
affections, the reader is referred to Hardy’s original me- 
moir,1 or to the writer’s translation of the same.2 Their 
histology I have recently considered elsewhere,3 and shall 
devote the present paper to the question of their treatment. 
The intractable nature of these affections, and the dis- 
1 Le9ons sur la Scrofule et les Scrofulides, etc., Paris, 1864. 
2 New York Medical Gazette, Dec. 5 th, 1868, et seq. 
3 New York Medical Journal, August, 1875. 2 
TREATMENT OE THE SCROFULIDES. 
figurements which they frequently produce, invest this 
portion of their history with an intense practical interest, 
and lead me to present somewhat at length, the views of 
those who are able to speak advisedly upon the subject. 
The internal treatment should be that which is advisable 
in scrofula generally, and need not be considered in detail. 
Arsenic, though praised by some, has not appeared to me 
to influence the course of the disease in the slightest degree. 
Repeated and prolonged trials of both Fowler’s and Don- 
ovan’s solution (liq. hydrarg. et arsen. iodidi) have always 
caused me to regret the time lost in using them. The 
most appropriate internal treatment, however, is rarely, if 
ever, capable of removing the existing lesion, its sole office 
being, by bringing the general system into a more normal 
condition, to facilitate the action of external applications, 
and to diminish the chances of relapse, and it is to the 
external treatment, that we must mainly look for the cure 
of the affection. 
If we remember that the natural tendency of these af- 
fections is to extend indefinitely, and almost invariably to 
leave cicatrices, the indications for treatment are perfectly 
plain; namely, to check the spread of the eruption, and to 
cure the existing lesion with the least possible scarring. 
The details of treatment will vary with the particular 
variety under notice, and will be considered in the order in 
which they have been given. 
Treatment of the Erythematous and Corneous Scrof- 
ulides (Lupus Erythematosus).—Kaposi recommends fre- 
quent frictions with the spts. saponatus kalinus,T and states 
1 R 
Saponis viridis, lb. ij. 
Alcohol, lb. j. 
M. Let it stand for twenty-four hours, filter and add spts. lavendulae, oz. ij. TREATMENT OF THE SCROFULIDES. 
3 
that he has thus caused the lesion to disappear with leaving 
the slightest trace. I have had the same happy result fol- 
low the use of glacial acetic acid applied hi- or tri-weekly. 
Both of these applications act superficially and without 
producing an eschar, and seem to effect their purpose by 
causing absorption. I have likewise had excellent results 
follow repeated and energetic frictions with the follow- 
ing: 
R 
Saponis viridis, oz. viij. 
Gflycerini. 
Olei cadini. aa. oz. ij. 
01. rosarum. q.s. 
M. 
These preparations should be used in preference to 
stronger caustics, which, destroying tissue, would neces- 
sarily be followed by a cicatrix. The only objection to 
this treatment is the length of time required. In a few 
more fortunate instances a cure may result in a few weeks 
from twenty or thirty of the frictions, or applications of 
the acid, but commonly their use must be prolonged for 
several months. These means are admirably adapted to 
recent patches, and may result, as observed by Kaposi and 
myself, in perfect cure. If, however, the eruption has al- 
ready existed for some time, and portions of it, especially 
the central and older parts, begin to exhibit atrophic 
changes, it will be vain to hope for recovery without cica- 
trix. Under these circumstances the centre of the lesion 
may be left to take care of itself, and attention be confined 
to the periphery, that is, to the advancing border. If the 
preparations spoken of do not appear to act with sufficient 
vigor, the pure sapo viridis may be substituted for them, 4 
TREATMENT OF THE SCROEULIDES. 
applied daily with friction, or spread upon a piece of linen, 
and left in contact with the parts for several hours. If the 
green soap cannot be readily obtained, a solution of caustic 
potassa, 25 per cent., to 50 per cent, may be used instead, 
applied once a week or at more distant intervals according 
to the effect produced. The acetic acid and sol. of potash 
are usually applied with a camel’s-hair brush or a glass rod. 
Both of these methods, however, are objectionable, as they 
are apt to deliver an excess of the fluid, which runs over 
and injures healthy parts. A much better way is to employ 
a small hard-rubber probe around the end of which a little 
cotton-wool has been wrapped. Stronger caustics than 
these mentioned are rarely required, unless speedy destruc- 
tion of the lesion is necessary; in which case potassa cum 
calce or chloride of zinc may be employed. When the 
lesion is small and its early extinction desired, I prefer re- 
moving it (cegroto volente) by excision. 
Dubini,1 and more recently Yolkmann,2 prefer to remove 
the infiltration by means of hundreds of fine punctiform 
scarifications. These are made with a small sharp-pointed 
knife to the depth of two millimetres. The punctured spots 
should be covered with lint well pressed on, to stop the 
bleeding, and left attached until it falls spontaneously. 
The operation should be repeated in from two to four 
weeks, from three to eight operations being usually suf- 
ficient. Yolkmann says that no scarring results from the 
treatment. I have had no personal experience with this 
method in the erythematous scrofulide, but have used a 
modification of it in the next variety. 
Treatment of the Pustular Scrofulide.—The local 
1 Rapporto annuale dei Malati Cutanei dell’ ospedale magg., Milano, 1865. 
2 Ueber den Lupus und seine Behandlung, Leipzig, 1870. TREATMENT OF THE SCROFULIDES. 
5 
treatment of this variety is quite simple. As scarring is 
inevitable, we may attack the lesion with some vigor. If 
it be in an early stage, without much ulceration, I have 
had good results from linear scarifications, followed by 
green soap. When, however, there was considerable ulcer- 
ation, it was formerly my custom to make a few superficial 
cauterizations with the liq. hydrarg. nitratis, followed by 
the application of a mercurial ointment (usually the proto- 
iodide, ten grains to the ounce). Neligan1 and Weisse2 
have used with advantage the acetate of zinc. In this way 
the ulceration may sometimes be coaxed to heal, but the 
process is tedious, and the resulting cicatrix often unstable. 
Latterly, I am inclined to prefer more rapid and energetic 
measures, such as thorough cauterization with the chloride 
of zinc. The chloride exposed to the air until it has suf- 
ficiently deliquesced, is applied to the ulcer in a thin layer 
by means of a platinum spatula. It is then covered with 
a piece of lint cut to fit the part, and the whole left to 
itself until the eschar falls, which may not occur for a 
week or ten days. Upon removal of the crust healthy 
granulations will usually be apparent (and sometimes com- 
plete cicatrization), but if not the cauterization must be 
Fig. 30. 
repeated. In case the floor of the original is covered with 
large, uneven, and papillomatous granulations (verrucous 
formJ, it is best to remove them by thorough scraping with 
the “sharp spoon” (Fig. 30), an instrument specially rec- 
ommended in this connection by Volkmann. It is also 
' A Practical Treatise on Diseases of the Skin, Am. Ed. Phila., i860. 
2 Am. Jour, of Syph. and Derm., vol. I. p. 316. 6 
TREATMENT OF THE SCROFULIDES. 
well to give the edges a good scraping with the spoon. 
The morbid tissue yields more readily than the healthy, 
and a considerable portion of the disease may be thus re- 
moved mechanically. When a somewhat level surface has 
been obtained, apply the zinc in the manner described, 
and, after the fall of the crust, repeat the operation if nec- 
essary. 
Treatment of the Tubercular Scrofulide without 
Ulceration, or with Superficial Ulceration.—If ulcer- 
ation has not yet occurred, we have several methods of 
treatment from which to choose. The indications are to 
check the spread of the lesion, and to do so with the least 
scarring. Excision may he practiced, and is to he pre- 
ferred if the lesion is limited and there is sufficient exten- 
sibility of the surrounding skin to permit of coaptation 
of the edges of the wound, so that we may hope for a 
linear cicatrix. If the lesion is small and quite superficial, 
it may be readily removed with the skin-grafting scissors 
(Fig. 22). Excision to be effectual must be thorough, 
both as to depth and extent. As the morbid deposit in 
this variety, rarely extends beneath the subcutaneous tis- 
sue, and usually ceases at the lower part of the corium, no 
difficulty will be experienced in this direction; but the 
infiltration is apt to extend laterally for some distance be- 
yond the points at which the disease is evident, and conse- 
quently the incisions should be made at least two or three 
millimetres beyond the apparent limit of the lesion : other- 
wise a speedy return of the trouble may be anticipated. 
If the situation of the disease or the condition of the parts 
renders excision undesirable, the tubercles may be de- 
stroyed with nitrate of silver. This method is largely 
practiced in Vienna, and consists in boring into the diseased TREATMENT OF THE SCROFULIDES. 
7 
tissue with a sharpened point of fused nitrate. The points 
of silver prepared by Squibb, to which he adds a little 
chloride, to make them harder, are admirably adapted to 
this purpose. Many of the tubercles, or rather papules, 
are quite small, and boring into them with the ordinary 
caustic points inflicts unnecessary pain and injury upon the 
adjacent healthy tissues. To obviate this, I have for several 
years used a probe made of irido-platinum,1 of the form 
and size shown in Fig. 31. The point of the needle is 
Fig. 31. 
dipped in fused nitrate (Squibb’s is better for this purpose 
than the pure), a thin layer of which immediately congeals 
around it. ' As soon as it is cold, a second or a third dip- 
ping will increase the deposit of silver sufficiently. With 
these needles quite small punctures may be made, and are 
less painful than those made with the ordinary silver stick. 
Instead of nitrate of silver, nitrate of zinc may be em- 
ployed. It is used in exactly the same manner as the silver 
but is a much more energetic caustic. If the irido-platinum 
needles are not at hand, ordinary straight surgeon’s needles 
may be used, but are not so convenient and are soon 
destroyed. Actual or galvano-cautery may be employed, 
but possess no advantages over simpler measures, except 
the opportunity they afford for display. 
Lastly, the disease may be destroyed by means of ar- 
senical paste. IIebra speaks of this method so enthu- 
siastically that I shall give his description in full. The 
formula employed is : 
1 Pure platinum needles would be too soft and flexible. 8 
TREATMENT OE THE SCROFULIDES. 
E 
Acidi arseniosi, gr. xx. 
Cinnabaris, dr. j. 
Ungt. rosse, oz. j. 
M. 
The paste should be thinly spread upon linen, which is cut 
in narrow strips and accurately applied to the affected part. 
It is then covered with lint and held firmly in place with 
adhesive plaster. It is left in position for twenty-four 
hours, when a fresh application is made without previous 
washing. At the end of another twenty-four hours it 
is again applied. During the first day the parts to which 
the application has been made, present very little altera- 
tion and are not very painful. At the end of the second 
day of treatment, however, the pain increases, and when 
the plaster is removed, the tubercles are found to have 
a grayish color and macerated aspect. After the third 
application the pain becomes still more severe, and the 
integument surrounding the lupus patch becomes the seat 
of considerable oedema. On removing the plaster at the 
end of the third day, all the tubercles, both large and small, 
are found reduced to the condition of a brownish-black 
eschar, and covered with a thin pus. The eschars corre- 
spond to each tubercle, and are sharply defined by the 
intervening healthy skin. The pain ceases quickly and 
completely, and the oedema disappears in two or three days. 
The great advantage of this arsenical paste consists in its 
not injuring or even excoriating the healthy skin, while the 
morbid tissue is safely and thoroughly destroyed. 
The little sloughs, which are as numerous as the pre- 
existing tubercles, are loosened by suppuration, and re- 
moved in five or six days, leaving small holes separated TREATMENT OF THE SCROFULIDES. 
9 
from each other by islets of healthy skin. Cicatrization is 
rapid, and the resulting scar not very noticeable. 
Sometimes two applications are sufficient; or again, if 
the tubercles are large and covered with thick epidermis, 
two or more courses may be necessary. Arsenical poison- 
ing has not occurred in any of the hundreds of cases 
treated by Hebra in this manner. 
If the tubercles have already ulcerated, they may some- 
times be coaxed to heal, as already stated, by stimulating 
applications of acetate of zinc and the like ; but it is better 
to excise, subject to the restrictions above noticed. If ex- 
cision is contra-indicated, the ulcer and its margin may be 
well scraped with the sharp spoon, and then cauterized 
with the chloride of zinc, or a mixture of equal parts 
of caustic lime and caustic potash made into a paste with 
absolute alcohol. The fall of the slough will usually reveal 
a healthy ulcer with a tendency to heal. I much prefer 
caustics, to the simply stimulating applications, as the latter 
have in my hands more frequently produced an effect op- 
posite to the one desired. 
In the hypertrophic form, excision when convenient, or 
destruction by the actual or galvano-cautery or by electro- 
lytic needles, seems to be the most reliable method; but 
never having had this variety under treatment, I cannot 
speak from personal experience. 
Treatment of the Tubercular Scrofulide with deep 
Ulceration.—This form demands the most prompt and 
energetic treatment. In the previous varieties it was at 
most a question of disfigurement, but in this it is a ques- 
tion of life and death, for if the destructive processes are 
not checked, a fatal result is by no means rare. In this 
condition there is but one method to be relied upon, and IO 
TREATMENT OF THE SCROFULIDES. 
this is excision followed by cauterization. In recent cases 
this presents no difficulty; but when the disease has al- 
ready advanced to a considerable extent, and the bones 
have commenced to suffer, the indications are not so easy 
of fulfillment. These cases were formerly regarded as in- 
curable, and active measures were not recommended. Mr. 
Moore, however, in his admirable monograph upon rodent 
cancer1 as he terms the affection, has demonstrated the 
possibility of curing cases characterized by a very extensive 
destruction of deep tissues, cases which would usually be 
regarded as hopeless. His plan consists in removing the 
diseased parts as thoroughly as possible with the knife, and 
afterwards applying a layer of deliquesced chloride of zinc. 
The wound is then packed with cotton-wool, which is left 
in position till thrown off by suppuration and the formation 
of healthy granulations. Plastic operations may then be 
employed to remedy the deformity. 
Treatment of the Phlegmonous Scrofulide.—In the 
early stages and before suppuration has occurred, the nod- 
ules may sometimes be caused to disappear by the employ- 
ment of frequent frictions with the ungt. iodi, or ungt. potassi 
iodidi; but if they have already softened and contain pus, 
this should be removed by a fine puncture and suction with a 
hypodermic syringe, with the subsequent instillation of a 
drop or two of iodine. This is much better than the free 
incision recommended by some, and is also better than 
leaving the lesion to take its own course, as in the latter 
case considerable scarring is inevitable. If the abscess has 
already opened and an ulcer formed, it should be freely 
stimulated, and perhaps cauterized with some of the agents 
already mentioned. 
1 “ Rodent Cancer,” London, 1867. TREATMENT OF THE SCROFULIDES. 
Lupus in its several varieties is far from being the in- 
tractable disease it was formerly considered, and, when 
properly managed, is in the majority of cases perfectly 
curable. It is only a question of time, patience, and the 
judicious selection of remedial agents adapted to the par- 
ticular case under consideration. 
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AN ELEMENTARY TREATISE 
UPON 
Diseases of the Skin: 
BY 
HENRY G. PIFFARD, A.M., M.D., 
Professor of Dermatology, Medical Department of the University of the City of New 
York ; Surgeon to the Charity Hospital (Venereal and Cutaneous Divisions); 
and to the New York Dispensary for Diseases of the Skin, etc., etc. 
ILLUSTRATED WITH ENGRAVINGS AND PHOTO-MIOROGRAPHS. 
MACMILLAN & CO., 
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