THE TREATMENT OF SUPERFICIAL AND INFIL- 
TRATING VARIETIES OF PAVEMENT EPI- 
THELIAL CARCINOMA OF THE EYELIDS 
BY 
ROBERT SATTLER 
CINCINNATI, O. 
[Reprinted from the Archives OF Ophthalmology, Vol. xiv., No. I, 1885.] THE TREATMENT OF SUPERFICIAL AND INFIL- 
TRATING VARIETIES OF PAVEMENT EPI- 
THELIAL CARCINOMA OF THE EYELIDS. 
ROBERT SATTLER, Cincinnati, O. 
THE importance of epithelial neoplasms of the palpe- 
bral area, entitles them to a most careful considera- 
tion, principally on account of their well-known progressive 
and destructive tendencies. Interference of some kind, to 
prevent almost inevitable dangers from resulting deform- 
ity of the lids and defective protection of the globe, is 
imperative in those cases in which the history and local 
alterations of the growth render a successful arrest or 
removal probable. In other more advanced cases, with 
extensive infiltration and destruction of tissue, in which the 
local changes preclude the prospects of a radical disappear- 
ance, at least relief from suffering and perhaps a retardation 
of an otherwise uninterrupted progress can be effected by 
prompt appropriate, measures. 
The comparative frequency of epithelial growths in this 
locality, among persons predisposed by age, heredity, and 
other causes to their occurrence ; the almost uniformly 
insignificant beginning and frequently overlooked progress; 
the well-known latent or non-progressive tendency, com- 
prising often a period of years and followed by a sudden 
a.nd uninterrupted destructive advance, are all well estab- 
lished characteristics which can only receive a passing 
reference. For the same reason the clinical, pathological 
and histological features of the different forms of pavement- 
cell, cylindrical, and glandular cell carcinoma are not referred 
Reprinted from the Archives of Ophthalmology, Vol. xiv., No. i, 1885. 20 
Robert Sattler. 
to, as it is the purpose of this communication to refer to 
the operative treatment of these treacherous neoplasms, and 
to give the results of personal observation and experience 
in the management of the most frequent forms of the dis- 
ease in this locality, i. e., the superficial or lobulated, and 
the infiltrating or tubulated forms of pavement-cell epi- 
thelial carcinoma. 
The methods to effect the removal of these growths are 
many and various, and include the caustics, the knife, 
thermo-, galvano-, and the actual cautery. That all these 
methods, either separately or combined, have in a large pro- 
portion of cases, accomplished the purpose for which they 
were resorted to, must be admitted, but on the other hand 
it must also be conceded that many and perhaps the larger 
proportion of cases have eluded successful treatment by the 
above means, even though they were clearly indicated and 
were resorted to early, promptly, and thoroughly. 
Unsatisfactory observations, the result of a limited per- 
sonal experience, induced me to test more extensively the 
value and merits of the method of scraping, suggested and 
practised by Prof. Volkmann, for the arrest and treatment of. 
lupus nodules and ulcers, but also resorted to by him and 
other German surgeons for the removal of epithelial tumors. 
Among the first cases observed was one of a superficial lobu- 
lated epithelioma of the lower lid, which had defied the use of 
caustics,—zinc, chlor., acid, monochloroacet., arsenic pastes, etc. 
The patient persistently refused excision, which it may be inferred, 
was at once proposed when she was first examined. Impressed 
with the inefficacy of caustic agents and the needless pain their 
application produced, I resorted to the plan of scraping the infil- 
trated area with Volkmann’s steel spoon or scoop, without inform- 
ing my patient of its surgical nature. The scraping was thor- 
oughly done and the result was excellent. Seven years have 
elapsed and no return has been noticed. The neoplasm was situ- 
ated in the lower lid, was oval in shape, and about one and one half 
cm. long and one cm. broad. Its upper edge approached to within 
four mm. of the lid margin,—the outer two thirds of which were 
everted by the traction and weight of the growth,—and it extended 
obliquely toward the centre of the cheek. The patient was forty- 
six years old and in good general health. She had noticed an Carcinoma of the Eyelids. 
21 
“irritable wart,” which was situated in the site of the affected 
area, for eight or nine years, but only within the last fourteen or 
sixteen months had it increased in size, accompanied by a ten- 
dency to ulceration and local stinging and discomfort. The his- 
tological structure of the growth consisted of closely packed 
groups of flat or pavement epithelial cells imbedded in a vascular 
stroma, traversed by cicatricial bands and warts or fringe-like 
projections. 
The cicatrix which followed this radical scraping was smooth 
and superficial. The ectropium which existed before the opera- 
tion, was made to disappear effectually by stretching the scar. 
In the second case, a man, aet. fifty-two, the growth was of 
more than ten years’ standing. It had invaded the outer two 
thirds of the right upper lid and almost the entire border of the 
lower lid. Necrosis of certain parts, indolent ulcerations covered 
with crusts and ectropium, were prominent features of the infil- 
tration. The cutaneous area of the right lower lid, side of the 
nose, malar region, and cheek, had been the seat of destructive 
ulceration, which had transformed this region into a thin, clean, 
shining white surface. At its lower termination, a wall of waxy 
nodular elevations, concealing foci of ulceration was arranged in 
.a sernicircular manner, presenting all the characteristics of both 
the progress and results of a rodent form of ulceration, which had 
started from and was engrafted upon the specific growth. 
Thorough excision, combined with a plastic operation was 
resorted to without delay. No reaction followed, and the imme- 
diate result of the operation was favorable. In four months a 
return in the outer and also the inner portion of the upper lid, 
near its border, was noted. Both points were speedily excised. 
After this operation, without a plastic to cover the defect, only 
about one fifth of cilia-bearing lid border of the upper lid re- 
mained ; the entire border and adjoining region of the lower id 
had been removed. At the same time, the semi-circular wall of 
nodular waxy elevations was attacked and thoroughly scraped and 
excavated. Several attempts followed the first one, and accom- 
plished an arrest of the ulcerative process in this region. In the 
course of five months fresh foci of the neoplasm developed, par- 
ticularly near the inner canthus. The steel scoop was from this 
time exclusively resorted to to combat the destructive tendency 
of the disease, to prevent greater deformity, and to relieve pain. 
Not alone was the removal of the infiltrated portions more easily 
accomplished, but it was also attended with, less pain and reaction 22 
Robert Sattler. 
afterwards, and was followed by a less dense and more elastic 
cicatricial covering. It did not or could not completely arrest the 
disease, but it opposed and modified its progress in a variety of 
ways, and was at the advanced stage of the growth more applica- 
ble and effectual than the knife or caustics. 
A third case also demonstrated to me the advantage of the 
scraping over the use of the knife ; yet I venture to say that in 
this locality the knife would have been the choice of any surgeon 
to effect the removal of the growth. 
A clergyman, aged fifty-six, sought relief from a chronic dacryo- 
cysto blennorrhoea. In treating the tear-sac trouble, I discovered 
a suspicious eroded warty growth in the left posterior auricular 
region. The patient was aware of its presence, and said it had 
existed for years, and that at times it caused him great annoyance. 
Microscopic examination revealed its epithelial nature. Imme- 
diate removal was advised, to which the patient willingly assented. 
The growth was about if cm. long and if cm. broad ; it had in- 
vaded only the skin. It was circumscribed by a deep incision 
and removed, together with a broad border of healthy skin. 
Feeling secure, on account of the liberal excision, that this would 
end the neoplastic formation, I was not a little surprised to find, 
after four months—the disease for years antedating the operation 
having shown no special tendency to advance,—a return in con- 
nection with the cicatrix of the first operation, and also a new in- 
filtration of skin in its vicinity. Immediate excision with most 
liberal attachments of healthy skin was practised. Complete 
union and no reaction followed. After the lapse of eight months, 
not alone were points of infiltration to be discovered in the scars 
of the two former operations, but numerous new points existed in 
addition. The knife was abandoned, the scraping-spoon being 
used in its stead. The ease of manipulation, diminution of pain, 
and absence of reaction impressed me so favorably, and accom- 
plished so completely the disappearance of this troublesome affec- 
tion, that I determined to give it an extensive and systematic 
trial, in all typical and suitable operative cases of epithelioma, in 
dispensary practice. 
From March, 1878, all cases in which operative inter- 
ference was indicated were treated according to this method. 
During this period thirteen cases were observed. Eight 
belonged to the superficial and five to the deep or infil- Carcinoma of the Eyelids. 
23 
trating variety. In nine patients the scraping method was 
exclusively practised ; in three it was combined with ex- 
cision. In some a single scraping sufficed ; in others several 
were necessary to bring about an arrest of progress or an 
effectual disappearance. All were examined microscopically, 
and were found to belong to the superficial lobulated and 
infiltrating or tubulated variety of pavement-cell or flat 
epithelial carcinoma. 
The eight cases belonging to the superficial variety could 
be subdivided, according to their most distinctive altera- 
tions, into cicatricial (2), necrotic (3), warty (2), and rodent 
(1) ; of these, four were situated on the lower lid, one at 
the inner canthus, involving the caruncula lachrymalis 
and semilunar fold, one at the outer canthus, involving also 
the lower lid, and two on the side of the nose, extending 
over the tear-sac region. All these cases were treated by 
the scraping method, and all recovered. Three of this 
number had received previous treatment by excision and 
caustics. 
Five belonging to the infiltrating, presented all the histo- 
logical characteristics of this variety ; these were subdivided 
into the simple tubulated (2), papillomatous (2), and rodent 
(0- 
Four were treated by excision and scraping combined. 
In one case exenteratio orbitae was necessary, and most effec- 
tual work was accomplished by the scraping spoon. 
The tubulated varieties involved the lower lid and bur- 
rowed along the inner wall and floor of the orbit. In both 
cases the disease began in the lower lid ; the first1 was 
excised and thoroughly scraped, and up to the present time, 
a period of several months, developed no activity. 
The second case began in the lower lid, destroyed it en- 
tirely, invaded the upper lid, and pushed its destructive 
course along the inner wall of the orbit and attacked the 
globe. This case had been in the hands of competent sur- 
geons, and also so-called cancer quacks. It would be diffi- 
cult to say what had not been done for this poor woman. 
When she applied for relief there was so much infiltration 
1 This case came to the clinic during my absence, and was treated during its 
entire progress by Dr. S. C. Ayres. 24 
Robert Sattler. 
near the inferior margin of the orbit and on the globe, that, 
to facilitate the operation I excised this mass and carefully- 
detached with a pair of scissors the exuberant tissues ad- 
hering to the globe. After this the knife was not again 
used, and the remaining portions were removed by the aid 
of the scraping spoon, even from the sclera. The scraping 
was repeated in different parts of the growth, at least twelve 
times during a period of almost three years. During this 
time the patient enjoyed comparative freedom from suffer- 
ing, danger from hemorrhage was lessened, enucleation of 
the extensively infiltrated and adherent globe was not 
necessary, and the advance of this malignant neoplasm was 
arrested and markedly modified. Each scraping made to 
arrest some fresh or recent manifestation of the disease was 
attended and followed by the best possible results under 
the hopeless circumstances. Recently, however, either in 
consequence of latent inherent activity of the growth, or 
the result of impaired health, physical exhaustion, or age, 
it has again developed most startling activity. 
The papillomatous variety was treated by exenteratio 
orbitse and thorough scraping of the bony walls. The globe 
and all the tissues of the orbit, including both upper and 
lower lids, were involved in the disastrous process. 
For eight months no return was observed, and the patient 
was improved in every respect; a recent communication 
however, refers to the not unexpected but, certainly delayed 
return of the disease. The second case, the disease being 
not so extensive and with less malignant tendencies, was 
more favorably influenced by the scraping method of treat- 
ment. 
The rodent variety was an unusually extensive and dis- 
astrous illustration of the disease. Interference was not 
deemed indicated or justifiable. All the structures of the 
orbit had succumbed to the destructive process, the soft 
parts over cheek, nose, frontal, temporal, malar, and ante- 
rior auricular region had disappeared, and in addition the 
bony structures were extensively and hopelessly infiltrated. 
As already stated, the scraping method, by the aid of 
sharp steel scoops or spoons, of variable size and shape, was Carcinoma of the Eyelids. 
25 
the method, even in the infiltrating forms, which was relied 
upon to bring about an arrest or a complete disappearance 
of the disease. If it is stated that excision was performed, 
it was only resorted to to render the removal of large areas 
of infiltration more speedy. The attempt, however, to eradi- 
cate, or at least arrest, the disease in those portions which 
were accessible to the influence of the instrument, was made 
by the former method. 
The presence of microscopic foci, notably in the glandular 
structures of the skin or in the connective tissue of the subcu- 
taneous region, or the lymphatics, etc., surrounded by areas 
of perfectly healthy tissue, would, of course, oppose a com- 
plete removal of these concealed and not to be discovered 
hiding-places of the disease, as effectually as the knife or 
caustics. In this locality particularly, although the rule of 
operative art and experience is not to spare tissue, owing 
to the well-known treacherous characteristics of these 
growths, it is a point of paramount importance to save as 
much healthy tissue as possible, and avoid dense scars on 
account of the unsightly deformity and dangers to the globe. 
Therefore, a reckless excision is as unjustifiable as a too 
cautious one. For this reason this method appears to me 
particularly applicable to this locality. It is easy of accom- 
plishment, little or no reaction is to be feared, and the ad- 
jacent healthy or non-infiltrated regions are not removed, 
and the defect after the scraping is not much greater than 
the infiltration before it. 
All the cases referred to, with the exception of one, were 
observed in dispensary practice, and if at first the method 
was not extensively resorted to in private practice, it was 
because the trust and safety in the removal by the aid of the 
knife was too secure in my mind to permit of its being sup- 
planted by a method not extensively practised and arous- 
ing doubt and fear as to its real efficacy. I may add that 
after it had been thoroughly tested, and its advantages es- 
tablished by the observations referred to, and in addition 
corroborated by a number of cases in private practice, it is 
now looked upon as a most valuable and reliable method of 
management ; in many cases, without doubt, far superior to 26 
Robert Sattler. 
excision, caustics, etc., and in others, again, inferior to the lat- 
ter methods. Yet it is applicable in so many cases, that it 
deserves recognition and a trial where other methods have 
failed, or where the knife and caustics are no longer of ad- 
vantage, and also in a large number of cases where it may 
be resorted to in conjunction with them. 
My observations prompt the following suggestions: 
When thoroughly accomplished the scraping method is of 
particular advantage and superior to the knife, and, there- 
fore, should enjoy preference and its principal application 
in the management of the different varieties of superficial 
lobulated pavement epithelial cancer of the lids or adjoining 
regions, for the following reasons : 
a. The defect of tissue after is not greater or deeper than 
the infiltrated area at the time of operation. 
b. Little or no danger from inflammatory reaction. 
c. The formation of a smooth superficial covering of the 
excavated area, which on account of its pliable and elastic 
nature interferes least with the protective function, and 
secures also better adaptation of the altered lid to the 
globe. 
d. The invaluable advantage of being able to observe the 
cicatrized base of the recently affected area, and, therefore, 
discover easily and early any reproduction of the growth. 
e. It is rarely necessary to resort to plastic operations. 
Other advantages are: the ease and readiness of perform- 
ance of the method, less pain during and after the opera- 
tion, avoidance of dense or extensive scars and those dangers 
which attend the healing of the wounds. 
In the deep or infiltrating forms it is of the greatest ad- 
vantage when combined with cautious excision. It can be 
resorted to alone with prospects of success only in a limited 
number of cases of this variety of the disease. 
This method, either alone or combined with excision, has 
the valuable and not to be overestimated advantages : 
a. That it accomplishes the removal of part or parts of the 
growth with the least sacrifice of tissue. 
b. That it is as safe and more easily accomplished in many 
cases. Carcinoma of the Eyelids. 
27 
c. In those cases where excision promises little or nothing 
it should have the preference, because it accomplishes as 
good a result with less pain, hemorrhage, and deformity. 
d. In those cases where excision is clearly indicated, and 
rational promptings for its selection exist, it may be advan- 
tageously combined with it, as it can remove traces or con- 
cealed foci of infiltration which are beyond the scope of the 
knife. g. p. putnam’s sons, printers 
NEW YORK