Actual Heated Cautery

The application of heat by iron cauteries is noted by Hippocrates, principally as a method of counter-irritation against internal diseases, or to dry up ulcers and wet gangrene, to destroy tumours and to treat haemorrhoids; he does not describe heat coagulation of bleeding vessels. Celsus in the 1st century a.d.15 and Archigenes in the 2nd century a.d.16 give early references to the application of heated cauteries to control haemorrhage; this is mentioned again by Paul in the 7th century a.d.17 and by Albucasis in the 10th century.18 Thereafter cautery is the mainstay of controlling severe haemorrhage until Pare revived vessel occlusion by ligature in the 16th century, as discussed in Chapter 5. Even so, red-hot iron cauteries continued to be applied by some surgeons until the late 19 th century.

Iron cauteries from the Roman period are rare survivals, usually corroded and fragmentary, offering little information on the structure of cauteries before the 7th century a.d. when Paul described a variety of forms, each for specific treatment indications, mostly for counter-irritation of internal diseases but also for amputation due to gangrene of the hand and foot, when he advised: "... apply red-hot irons to the vessels to stop the haemorrhage."17 Albucasis illustrated more than a dozen forms of cautery for disease, and for arterial haemorrhage he wrote:

"... put in the fire several olivary cauterie, small and large, and blow them to make them very hot. Then take one, small or large according to the size of the wound and the site of the opening of the artery, and bring the cautery right down on the artery.. ",18

Subsequently olivary-headed cauteries are frequently mentioned (Fig. 10.3a) as a correct shape for sealing the mouths of arteries. Yet, cautery was not infallible, especially for larger arteries. Yonge19 and John Bell20 both observed that if the cautery iron was too hot, the scar stuck to the iron or the scar loosened and dropped off; if the instrument was not hot enough, no adequate scar formed and repeated applications might be needed. In addition, the furnishing of a suitably heated cautery at a critical moment also posed practical problems, a a

Artificials Limbs

Fig. 10.3. a. Selection of cautery heads for fitting into ebony handle; two olivary heads are seen on the right. (From Aubry's Instrument Catalogue, Paris: author, 1900.67) b. Brazier for heating 18th-century style cauteries with fixed wooden handles. Most of the cauteries seen below were for drying up gangrene and ulcers. (From Bell J. The Principles of Surgery, vol 1. Edinburgh: Cadell, 1801:149.20)

Fig. 10.3. a. Selection of cautery heads for fitting into ebony handle; two olivary heads are seen on the right. (From Aubry's Instrument Catalogue, Paris: author, 1900.67) b. Brazier for heating 18th-century style cauteries with fixed wooden handles. Most of the cauteries seen below were for drying up gangrene and ulcers. (From Bell J. The Principles of Surgery, vol 1. Edinburgh: Cadell, 1801:149.20)

especially on a rain-swept battlefield or a ship in severe weather (Fig. 10.3). Bell concluded dismis-sively in 1801:

.. the horrors of the patient, and his ungovernable cries, the hurry of the operator and assistants, the sparkling of the irons, and hissing of the blood against them, must have made terrible scenes, and surgery must in those dark days have been a terrible trade."21

This drama of heat cauterisation, hideous for both patient and surgeon, encouraged the application of potential cautery, that is, the use of styptics, astringents and caustics and, unfortunately, poisonous agents such as arsenic and corrosive sublimate. Combined with local pressure these applications often succeeded initially but, sadly, were often followed by tissue necrosis, infection, ulceration and secondary haemorrhage and even death from poisoning.

Following abandonment of red-hot iron cauteries, the efficacy of thermal haemostasis was not overlooked and, assisted by general anaesthesia, new sources of heat were explored. In 1854, Middledorpf discovered galvanocautery22 and, in 1876, Paquelin devised thermocautery,23 both extremely efficient for small vessel occlusion. In 1907-1908, Doyen introduced an electrocoagulation machine24 and Nagelschmidt coined the term "surgical diathermy" for small vessel coagulation.25 In 1928, Cushing and Bovie devised a diathermy machine offering a choice of coagulating or cutting current.26 Today, at the beginning of the 21st century, coagulation methods continue to evolve utilising electrohaemostatic scalpels, laser beams and ultrasonic energy.

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