V FURTHER CONTRIBUTIONS 
TO THE 
TREATMENT OF LUPUS. 
BY ' 
HENRY G. PIFFARD, M.D., 
PROFESSOR OF DERMATOLOGY UNIVERSITY MEDICAL COLLEGE, NEW YORK, 
SURGEON TO CHARITY HOSPITAL, ETC. 
Read before the Medical Society of the State of New York, February 4, 1879. 
Reprinted from Tiie Medical Record, April 5, 1879. 
NEW YORK: 
TROW’S PRINTING AND BOOKBINDING COMPANY, 
205-213 East 12th Street. 
1879. FURTHER CONTRIBUTIONS 
TO THE 
TREATMENT OF LUPUS. 
[Read before the Medical Society of the State of New York, February 4, 1879.] 
It will be remembered that at the annual meeting of this Society in June, 
1877, the writer had the honor of reading a paper entitled “Certain Points 
Relating to the Nature and Treatment of Lupus.” The matters specially 
dwelt on at that time were the infectious character of the lesion, and the 
necessity for thorough and radical treatment if we wished to stay its ravages. 
Concerning these points I wrote as follows: 
“We see, then, that one important peculiarity of lupus is the extreme 
viability of its cells. Another peculiarity is its gradual extension and involve- 
ment of new regions, by an apparently infective process, similar to, but less in 
degree than that manifested by cancer. In other words, lupus is an affection 
that presents a certain degree of malignity, varying in different cases, and 
always less marked than in true cancer. This infective quality is evidenced by 
the fact that, if a patch be incompletely destroyed, the disease will most 
certainly return. 
“ A consideration of these two points, namely, the extreme viability of the 
cells and their infective quality, gives us a clue to appropriate treatment. The 
indication is clearly to remove the infiltration as soon as possible, and to remove 
it thoroughly; to destroy, not nine-tenths or ninety-nine hundredths of the 
lupous cells, but all of them.” 
The paper from which these extracts'are taken was published in the Medical 
Record, July 21, 1877, and subsequently in the Transactions of this Society 
for that year. 
In the Medical Times and Gazette for August 4, 1877, there appeared an 
article by Mr. Jonathan Hutchinson, of London, entitled, “ On the Mode in 
which Lupus Spreads,” which commences as follows: 
“The mode in which lupus extends itself, and more especially the manner 
in which multiple patches are developed, is well worthy of investigation. 
My impression is that the processes are by cell-infection, and very similar to 
what we observe in cancer.” 
Farther on he says : “ You will see that the correctness or incorrectness of 4 
this theory is of considerable importance—as, indeed, all theories are—in its 
bearing upon practice. If lupus be, as I hold it is, an infective tissue malady 
rather than a blood disease, we have a strong additional reason for vigor in 
the use of those methods of treatment which are likely to eradicate its first 
local manifestations. We apply to it the same rule that we so constantly 
reiterate in reference to cancer. ‘ Stamp out the very first indication of flame, 
in order to prevent the spread of the fire.’ ” 
The remarkable similarity of the views expressed by Mr. Hutchinson, and 
those which I had previously laid before you, strengthens me in the belief that 
they are in the main correct, and that a full appreciation of their importance 
will in the future lead to more thorough and successful treatment of this serious 
affection. Before entering into further details it may be well to indicate just 
what we desire to accomplish in the treatment of lupus. 
In the first place, we seek to replace the lesion by a cicatrix. 
In the second, to prevent a relapse in situ. 
In the third, to prevent the development of the disease elsewhere. 
The fulfilment of the first of these indications is a comparatively easy task, 
and one that may be effected in a number of ways. Without considering all 
the methods proposed, or even those which give fairly good results, I will 
simply recall to your recollection the ones to which I gave the preference 
in my previous paper. 
These are : 1. To excise the lesion, when suitably located ; 2. When this is 
not practicable, to thoroughly scrape out the lupous tissue with the dermal 
curette, and then cauterize the wound with the galvanic or other actual 
cautery. 
One or other of these means will certainly cure the lesion (temporarily at 
least) more quickly and less painfully than any method yet proposed. 
As regards the second indication—to prevent a relapse in situ—it is clear 
that the more thoroughly the operation is performed the greater the probability 
of permanent success. 
In these cases there is but one consideration that should stay the surgeon’s 
hand, and this is the amount of deformity that will result from the operation 
itself. Manifestly it would not be proper to remove half the cheek to cure a 
lupus half an inch in diameter. On the other hand, if not enough of the 
apparently healthy surrounding tissue is removed a relapse is inevitable. The 
problem is to destroy just enough and not too much, a matter that cannot 
always be determined with precision in advance of the operation. In my for- 
mer paper I gave a table of results obtained in the treatment of twenty-five 
lesions by different methods. These were: 
Excision 
Successful. 
G 
Unsuccessful. 
2 
Excision and actual cautery 
1 
0 
Scraping and actual cautery 
4 
0 
Total 
.11 
2 
By other methods 
5 
7 
These results were certainly calculated to inspire me with a good deal of 5 
confidence in the methods advocated, and the cases hereafter to be related will 
show that in their practical application they almost, if not quite, fulfil their 
early promise. I feel loath to recite the cases in detail, and would not do 
so were it not that they proved exceedingly instructive, and will probably 
enable me in the future to obviate some avoidable causes of failure, and may, 
for a like reason, prove profitable to you. The cases referred to in my previous 
paper were numbered from one to ten, and the ones now to be related will 
follow them in the order of occurrence, with the exception of Case IX., which 
belongs to the last series, and was then reported as being still under treatment. 
Case IX.—Frank W., a native of the United States, thirty-six years of age, 
and a seaman by occupation, came under treatment March 22, 1877. His 
disease commenced at the age of thirteen, by the appearance of the lesion near 
the inner end of the left eyebrow, from which it spread until it gradually in- 
vaded the portions shown in the photograph. It is of the erythematous 
variety, and involves the lower half of left side of the forehead, the left side of 
the nose, and the greater part of the left cheek above the angle of the mouth. 
A portion of the original lesion, directly under the eye and on the forehead, 
that is, the parts that look pale in the photograph, have already undergone 
spontaneous retrogressive changes, being smooth, pale, and slightly depressed. 
The remaining portion of the lesion is elevated and red, with a few fine scales, 
and is slowly advancing at its periphery. In the infiltrated portion the patient 
experiences a sensation of heat, worse when he bends down his head. Owing to 
the extent of the lesion I decided to attack it piecemeal, and on day of visit 
(March 22d) scraped out some of the peripheral parts and applied a saturated 
solution of chloride of zinc. 
March 27.—The parts cauterized with zinc do not present the usual appear- 
ances after cauterization, the eschar being softer than usual, partially detached, 
and under it there is an unusual amount of pus. To-day scraped out some of 
the papules, at the exterior and inferior parts of the lesion, and touched the 
holes with the galvano-cautery at a white heat. The design of the present 
operations was first to eradicate the disease at the margins, and thus prevent the 
spread of the affection, and afterward attack the more central and older 
portions. Those parts which had already undergone spontaneous absorption 
and cicatrization required no special attention. 
March 29.—A slight tendency to suppuration has shown itself about the 
parts cauterized. The sloughs caused by the zinc have mostly separated, 
leaving small suppurating ulcers. He says that the parts operated on feel 
more comfortable than those in which the lesion still exists. 
April 1.—To-day, assisted by Dr. H. P. Farnliam, removed by incision an 
elliptical piece from the forehead, extending from the upper part of the lesion 
to the root of the nose, the piece removed being about 15 mm. long by 7 mm. 
wide at its broadest part. Two ligatures were necessary to control hemorrhage. 
The wound was brought together with two silver sutures and dressed with a 
lotion of Calendula. The actual cautery, without scraping, was passed around 
the margin of the entire lesion, except on the forehead. In addition the 
diseased surface within the margin received linear cauterizations. Gave him 
calcium sulphide, gr. -iV ter die, in the hope of controlling the tendency to 
suppuration. 6 
April 5.—There has been a great deal of suppuration and crusting upon 
the parts cauterized, but none at all along the line of incision which had been 
dressed with calendula. Removed one ligature, but did not disturb the other 
dressings. 
The subsequent history of the case through the summer need not be 
detailed other than to state that the patient received two very thorough appli- 
cations of the galvano-cautery to the diseased surface, without previous scrap- 
ing. The great apparent change for the better wrill be seen by examination of 
the accompanying photographs taken June 9, 1877, and November 22d. 
April 1, 1878.—Have not seen the patient for some months, but find him 
again on resuming charge of the Dermatological wards at the Charity Hos- 
pital. On examination find that some portions of the original lesion are 
thoroughly cicatrized and exhibit no tendency to relapse in situ. On the 
other hand the lesion has extended at other points of the periphery, and little 
papules are cropping out like islands beyond the edge of the main lesion. 
The patient’s general condition is more depressed than I have before seen it, 
and the affection exhibits a more evident semi-malignancy than at any previous 
time. 
During the succeeding three and a half months he was subjected to repeated 
partial scrapings and applications of cautery, and at the end of this period was 
discharged, at his own request, in a very much better condition than at any 
previous period. lie felt so much better that be was anxious to seek employ- 
ment out of the Hospital. I do not consider him cured, but expect to en- 
counter him again at some future time. 
Constitutional treatment.—During the early periods of treatment he received 
cod-liver oil without apparent benefit. Phosphorus wTas tried, but even in very 
small doses disagreed and had to be stopped. 
In 1878, arseniateof sodium, chloride of gold and sodium, and hydrocotyle 
asiatica appeared to be useful. (Illustrated with three photographs.) 
Case XI.—Miss A. L., thirty-one years of age, referred to me by Dr. 
Giroux, of Brooklyn (E. D.). The disease commenced when she was seven 
years of age, and occupies a portion of the right cheek, as shown in the photo- 
graph (June 23, 1877). 
July 2,1877.—To-day, assisted by Drs. Giroux and G. II. Fox, scraped out 
the lupous tissue and applied the galvano-cautery to the wound. 
July 18.—Her face is entirely healed and has been for some days, but there 
is a suspicious look to it. The skin is red, and there is a fine desquamation 
over the site of principal lesion. She says it feels the same as before the 
operation. 
August 18.—Scraped out four small papules that have reappeared, and 
applied the cautery. 
January 6, 1879.—Relapsed, as shown in the photograph taken to-day. 
This case was a complete failure, the only one that has yet occurred to me 
after a second operation. (Illustrated by two photographs.) 
Case XII.—Peter H., aged 19, referred to me by Dr. Geo. Bayles, of New 
York. Disease commenced in 1874, and now occupies both sides of lower 
half of nose and a large patch below right eye, which produced decided 
ectropion. 7 
July 3,1877.—To-day, assisted by Drs. Bayles, Fox and Goodwillie, scraped 
out the lupous tissue and applied the galvano-cautery. 
July 4.—He says that the parts feel better than before the operation. 
July 24.—Entirely healed. 
August 15.—Looks well everywhere, except three small papules 1 mm. in 
diameter on left ala, and two hardly perceptible papules that look suspicious. 
There is also a little scaliness under the eye near the nose. 
August 21.—Scraped out the papules referred to and cauterized, but the 
heat was not satisfactory and the burning inefficient. 
May 4, 1878.—Have not seen him since last date until to-day, when I find 
that the disease has relapsed and is nearly as bad as ever. Operated again by 
scraping cautery and chloride of zinc. 
June 21.—It has been healed for some time and is looking well. Takes 
chloride of gold and sodium, and arseniate of sodium, of each gr. rjju ter die. 
(Two photographs.) 
Case XIII.—G. W. G., aged sixty, referred to me by Dr. J. W. S. Gouley. 
Dec. 21, 1877.—In 1862 a lesion appeared on his lip, diagnosticated lupus 
by the late Dr. John Biddle, of Philadelphia. This received two severe ap- 
plications of chloride of zinc at the hands of Dr. Biddle, and has not re- 
turned. Fifteen months ago a similar lesion appeared on right ala nasi, 
diagnosticated by Drs. Bazin and Hardy in 1876 as lupus. It was then treated 
with Vienna paste and healed, but broke out again. In August, 1877, Dr. Lente 
of Saratoga applied a hot iron with good effect, but two other points of 
disease appeared near the old spot about two months ago. To-day, on ex- 
amination, find an ulcerating lupus occupying a portion of the right ala nasi 
1 cm. in diameter. It involves the whole thickness of the skin, and exposes 
the cartilage. It has also crept around this latter and invades the mucous 
membrane to a slight extent. 
Dec. 22.—Assisted by Drs. Gouley and Fox, scraped the ulcer thoroughly 
and applied actual cautery. 
Jan. 13, 1878.—Looking very well, and nearly healed. 
Feb. 2—Entirely healed, and looking well. 
Feb. 16.—No relapse. For the last two months has taken plios. gr. 
two or three times a day. 
Some months later heard from the patient indirectly to the effect that there 
was no relapse of the disease. (Illustrated with diagram.) 
Case XIV.—Maria M., aged thirty-two, referred to me Dec. 30,1877, by Dr. 
O. S. Paine, of New York, for opinion. 
The disease had commenced twelve years before by the appearance of a 
small spot between the eyebrows and spread centrifugally until it occupied 
the position and dimensions shown in the photograph. At present date spon- 
taneous cicatrization has taken place in the older portions, but the peripheral 
portions on the left side of the nose are in part nodulated, in part ulcerated, 
and covered with crusts. Both eyelids of right side near inner canthus are 
occupied by nodules, that of the upper lid being the larger and ulcerated. 
There is also a small nodule near left inner canthus and between it and the 
nose. The diagnosis was lupus vulgaris. An operation was recommended. 
To this the patient would not consent. 8 
May 24, 1878.—Since last date have not seen the patient until two days 
ago, except when she was exhibited one evening at a meeting of the New 
York Dermatological Society by another member. To-day, assisted by Drs. 
Paine, Mulford, and Alexander, I removed a portion of the growth near the 
right eye with the knife, and the other diseased portions by scraping. The 
whole was then cauterized, and finally deliquesced chloride of zinc was ap- 
plied, and the parts dressed with absorbent cotton. 
June 14.—All healed. 
July 21.—Evidences of relapse. 
July 30.—Removed with the knife a relapsed nodule near right eye, and 
applied chloride of zinc to the wound. 
August 21.—All healed, and looking well. Subsequent to this date a small 
ulcer appeared at root of nose, and another one on the nose at lower portion 
of original lesion. These were not operated on, but healed while taking 
medicine. 
January 2, 1879.—A fresh ulcer has appeared at root of nose. Internal 
treatment. 
January 15.—Ulcer healed (illustrated with three photographs). 
Case XV.—May 14, 1878.—Margaret W., aged sixty-six years. Twelve 
months ago a pimple appeared near left external canthus. This enlarged, and 
ulcerated in the centre. At present the lesion is about 15 mm. in diameter, and 
consists of a periphery of small nodules surrounding a central depression, cov- 
ered with small adherent crust. Assisted by Dr. McMaster, excised the entire 
growth with some surrounding tissue. The connective tissue beneath the lesion 
appeared healthy, so no caustic was applied, but the wound closed with suture. 
May 30.—Wound healed, and no trace of disease. 
Nov. 20.—Exhibited at Dermatological Society. No signs of relapse. 
Jan. 14,1879.—No relapse. (Illustrated by diagram and photograph). 
Case XVI.—M. M., female, aged forty, referred tome March 9, 187/, by Dr. 
T. G. Thomas, of New York, gave the following history: The disease com- 
menced four years before by the appearance, on the left side of the forehead, 
of a small papule. This increased in size, but did not ulcerate. At times it 
was covered with a fine scale, and was occasionally painful. Later another 
patcli appeared midway between her right eye and ear, and, like the other, 
gradually increased in size. At present the lesion on the forehead consists in 
part of a depressed scar toward the median line, and a raised infiltration ex- 
tending outwardly; the whole about 12 mm. in length. The other lesion is 
about 2 cm. in diameter, circular, with depressed centre, surrounded by a 
slightly raised infiltrated ring. Besides these the patient had a small lesion 
below left eye, one over right shoulder-blade, and one on right thigh. Or- 
dered phosphorus, gr. -,-iu ter die. 
March 12.—Assisted by Dr. Fox, I scraped the lesions first mentioned, 
and applied the galvano-cautery. The lesion above right shoulder was dealt 
with in the same manner. 
March 17.—Scraped the lesion under left eye, and applied chloride of zinc. 
March 22.—The lesions scraped and cauterized on the 12th inst. entirely 
healed, and looking nicely. 
April 19.—The spot beneath left eye healed, and exhibiting no sign of 9 
relapse; but the other three lesions have all relapsed, so to-day, assisted by 
Dr. H. P. Farnliam, scraped them out very thoroughly and applied galvano- 
cautery. 
June 20.—The lesions have all been healed for some time, but there has been 
a suspicious look about the one on the side of face. Of late, however, it has 
improved in appearance. 
August 7.—No signs of relapse. Since last date she has been taking a 
preparation of gold, which she is to continue. 
Sept. 15.—Has greatly improved in general health. No signs of relapse 
in any of the lesions treated, but a lesion has appeared during the last few 
weeks on lower lip that has a suspicious aspect. Internal treatment. 
Oct. 5.—Possibly slight improvement. Continue internal treatment, 
Nov. 23.—Tlie tubercle on chin has entirely disappeared. 
Dec. 1.—-Appears to be well—placebo. 
Dec. 14.—No evidence of relapse anywhere. Discontinue medicine. 
Jan. 25, 1879.—No relapse. (Two photographs). 
Case XVII.—Matthew M., aged 24, admitted into Charity Hospital Jan. 
24, 1878, came under my care April 1, with verrucous lupus occupying a 
large part of dorsum of left hand, and extending upon the wrist and forearm, 
as shown in the photograph. Disease commenced two years and a half before. 
Internal treatment. 
May 23.—A surface 5.5x4 cm. at distal portion of lesion scraped and 
cauterized. The entire lesion measured 10x6 cm. 
June 24.—The cauterized portion is rapidly healing, having assumed a 
perfectly healthy granulating surface, surrounded by a broad cicatricial band. 
June 27.—The remaining diseased surface scraped and cauterized. 
July 15.—The part last cauterized is more elevated and of a deeper color 
than the rest. 
July 25.—Five small grafts from healthy skin were inserted. 
July 30.—Two of the grafts have taken, the others not. A small place on 
the part first cauterized looks suspiciously like a relapse, and is rescraped and 
cauterized. 
Aug. 31.—Hand entirely healed except a small place about 1 cm. in 
diameter. 
This was subsequently scraped and cauterized by Dr. Habirshaw, house- 
surgeon, and the patient was discharged from the Hospital in September with 
the hand entirely healed. (Illustrated by photograph.) 
Case XVIII.—Mrs. M. G., 60 years of age, referred to me by Dr. F. D. 
Lente, Oct. 31, 1878. Disease commenced between three and four years ago as 
a small pimple in the middle of the forehead. This increased in size and now 
measures 2 cm. in diameter. It has ulcerated at times and is now in part cov- 
ered with a crust. The color of the edge is rather pale and waxy looking, but 
the limiting infiltration is well defined. Advised scraping and cautery. 
Nov. 2.—Assisted by Dr. Beverley Robinson, I scraped out the lesion and 
applied galvano-cautery. 
Dec. 16.—The ulcer left after the fall of the slough has proved, perhaps 
owing to her age. very indolent and slow in healing, but to-day is quite 
healed with firm cicatrix. 10 
Jan. 13,1870.—Site of lesion looking well; no signs of relapse.* 
Internal treatment.—In addition to tlie surgical measures, all of the above 
cases received internal constitutional treatment. In my last paper I referred 
to the unsatisfactory results obtained from internal treatment alone, expressing 
at the time but little confidence in any medication, except perhaps the use of 
phosphorus, at the same time cautioning against its too free or indiscriminate 
use. With the present series of cases I have experimented quite freely with 
a number of additional agents, including gold, bromide of gold, chloride of 
gold and sodium, arsenious acid, bromide of arsenic, phosphorus, liydrocotyle 
asiatica, silicic acid, silicate of calcium and arseniate of calcium. Under the 
use of some of these the patient’s health was benefited and the appearance of 
the lesions improved, but whether they contributed in any way to the preven- 
tion of relapse in situ, I am, of course, unable definitely to determine. 
The present paper has already reached such length that the discussion of 
the third topic—the prevention of the development of the disease in parts 
other lian those first attacked—must be deferred to another occasion. 
Conclusions.—With the facts and evidence before you, each may draw such 
inductions and conclusions as may seem to you warranted. Those at which I 
have myself arrived, simply corroborate the ones expressed by me two years 
ago, and are as follows: When excision is impracticable, scraping followed 
by the actual cautery is the least painful of the radical operations that have 
been proposed, and cicatrization is most rapid. The resulting cicatrix is smooth 
and less disfiguring than that which follows spontaneous involution or the 
potential caustics. The success of the operation will depend on the thorough- 
ness with which it is performed. If a relapse of the lesion occurs it may 
be expected within three months at latest, and if this period passes without 
reurn of the disease in situ, the only fear is its development elsewhere. 
It is from constitutional treatment alone we can here expect success, and as 
I have seen small lesions, undoubtedly lupous in character, disajipear during 
internal treatment, I am not without hope that much may yet be accomplished 
in this direction in the future. 
10 West 35th Street, 
New Yoke. 
♦March 13th.—No relapse.