THE 
ACTUAL CAUTERY 
AND 
Its Employment in Cutaneous Surgery 
BY HENRY G. PIFFARD, M. I), 
PROFESSOR OF DERMATOLOGY, UNIVERSITY OF NEW YORK, 
SURGEON TO THE CHARITY HOSPITAL, Etc. 
[From the Charleston Medical Journal ajd Review, for January, 1877.] 
CHARLESTON, S. C. 
THE NEWS AND COURIER JOB PRESSES. 
1876. THE ACTUAL CAUTERY, 
AND 
ITS EMPLOYMENT IN CUTANEOUS SURGERY. 
If the employment of a remedial agent, or method of treat- 
ment is attended with much inconvenience or expense, its gener- 
al introduction and adoption is apt to be tardily accomplished, no 
matter how valuable the remedy or method may be. This is 
peculiarly true of the actual cautery. Passing by the time when 
the hot iron was used as a htemostatic, anterior to the introduc- 
tion of the ligature, we find that the actual cautery wTas prin- 
cipally confined to the following applications: First, the destruc- 
tion of small vascular growths, as naevi upon the face, etc.; second, 
of cancerous growths upon the neck of the uterus; and third, as 
a means of counter-irritation over the larger joints when dis- 
eased, and along the spine in certain affections of the cord, etc. 
The practical difficulties in the way of a successful use of hot 
irons were mainly due to the fact that the metal began to cool, 
and to cool rapidly, the instant it was withdrawn from the fire, 
and consequently, if the operator desired to employ the heat at 
a particular temperature, he was obliged to manipulate with a 
rapidity that was inconsistent with proper care. The impor- 
tance of maintaining and using a temperature appropriate to 
the particular operation on hand, must not be overlooked; a fact 
of which the following case affords an illustration: A young gen- 
tleman having suffered for some time from an intense neuralgia, 
and having tried various methods of treatment without relief, con- 
sulted an eminent physician of this city, who recommended that 
an iron heated to whiteness should be applied at a certain point 
in the course of the affected nerve, and sent the patient to a well 
known surgeon to have the operation performed. The latter ap- 
plied the iron, not at a white, but at a dull barely red heat. The 
application was exceedingly painful, afforded very little if any 
relief to the neuralgia, and was followed by an extensive slough, 
and an ulcer, which for weeks had refused to heal. In this latter 
condition he came under my care, having been sent by the physi- 
cian first alluded to. If now, white heat had been employed, the 
probabilities are that the operation wTould have been very much 4 
less painful, the slough would have been smaller, the ulcer would 
have cicatrized immediately, and the scar would possess far less 
of the retractile character which is displayed by cicatrices re- 
sulting from burns at a comparatively low temperature, as 
those from burning clothes or boiling water, the scars from 
which so often produce serious deformity. Now, the temper- 
ature of boiling water cannot exceed 212° F., and that of burn- 
ing clothes may not be much greater, but white-hot iron or pla- 
tinum possesses a temperature above 1000° F.; and experience 
shows that the effects will vary greatly with the degree of heat 
employed, a fact which must always be borne in mind in cautery 
operations. In certain operations a white heat is not desired, as 
a dull heat will better fulfill the special indications. We should 
therefore well consider the temperature best suited to the partic- 
ular case, and should possess the means of maintaining and con- 
trolling it. The difficulty of accomplishing this with the blow- 
pipe or furnace as the source of heat, greatly limits the use of 
the ordinary cautery irons. 
Twenty years ago Middeldorff brought into prominent notice 
another method of generating heat for surgical purposes, 
namely by the aid of electricity.* By this means he obtained 
perfect control of the temperature, but the apparatus was ex- 
pensive and cumbrous. The consequence was that galvano- 
cautery was rarely used, except imperatively demanded, and 
many useful applications of the method were neglected or re- 
placed by less efficient means of treatment. 
During the past year, however, the prominent objections to 
the employment of the actual cautery have been dissipated by 
the invention of three wonderfully efficient and convenient 
galvano-cautery batteries of American construction. I allude to 
the recently patented instruments of Drs. Dawson and Byrne, 
and to the one (not patented) made by the Galvano-Faradic Man- 
ufacturing Company of this city.f In addition, a cheap cautery 
instrument, (not a battery) capable of fulfilling many of the 
requirements of actual cauterization, has been recently invented 
by Dr. Paquelin, of Paris. Dr. Allan McL. Hamilton, of this 
city, has also recently revived and improved an old cautery in- 
strument, the origin of which I am unacquainted with. It will 
do about the same work as the Paquelin cautery, and is cheaper. 
Finally, the solar cautery, a lens four inches in diameter, and 
six inches focus, must not be forgotten. 
With convenient, efficient and cheap instruments, there is no 
longer any excuse for neglecting the actual cautery when indica- 
* Middeldorff did not discover this method, as it had been in use to a 
limited extent before him. He was the first, however, to give it much 
prominence. 
f These three instruments are in every way superior to anything of the sort 
manufactured abroad. They are likewise much cheaper than the less efficient 
instruments of two years ago. 5 
cated; and there is no doubt but that its useful applications will 
rapidly multiply. Having for several years been satisfied of the 
advantages to be derived from the actual cautery in proper cases, 
I have been enabled, since the advent of convenient instruments, 
to employ it somewhat extensively in connection with the 
treatment of certain cutaneous affections; in part, repeating the 
operations of others, and, in part, devising fresh applications of 
the method. The principal affections of the skin in which it has 
been found of service will be mentioned below. 
Rosacea.-In the second stage of this affection we frequently 
find the veins of the nose, more especially those of the alae, 
greatly distended, and more or less varicose. An important 
step in the treatment of this affection is obliteration of these 
enlarged veins. This may be effected in various ways; by di- 
vision of the veins with a suitable cutting instrument; by 
injection of coagulating substances, or by the actual cautery. 
This latter may be accomplished with a platinum wire heated 
by a spirit lamp, or better by means of a small battery. For 
this little operation the two cells of an ordinary induction 
machine will generate sufficient heat, provided a quite fine wire 
is used. The vessel to be operated upon should be just touched 
with the wire heated to whiteness. The result will be oblite- 
ration of the vessel, reduction of a good deal of the congestion 
and infiltration around it, and ultimately a minute punctate scar, 
the size of which will depend upon the care and delicacy with 
which the operation is performed. In the third stage of this 
affection, characterized as it is by great hypertrophy of the parts, 
the actual cautery has been satisfactorily employed by Richet.* 
Tn this case the heated wire should penetrate the whole depth of 
the thickened integument at several points. The result will be 
shrinkage of the parts and lessened deformity. 
Varicose Veins.-I have in several instances secured oblitera- 
tion of enlarged veins of the lower extremity by bringing the 
white hot platinum (heated by electricity) almost in contact 
with the vein. The platinum should not quite touch the skin, 
and should be held in position for a minute or more. The 
immediate result will be a blister upon the surface, and ulti- 
mately obliteration of the lumen of the vessel, and a pigment 
spot, more or less permanent, upon the integument. 
Angioma.-I here refer to the little blood-red vascular ele- 
vations, whose size rarely exceeds that of the head of a match. 
They are frequently, in fact generally, multiple, existing upon 
the face and elsewhere to the number, sometimes, of twenty or 
thirty. A fine wire well heated is the neatest and quickest 
method of disposing of them. 
Ncevus Vascularis.-The purely superficial capillary naevus 
(wine-mark) if quite small, may very properly be treated by the 
* L'Ignipuncture, etc., par Trapenard. Paris, 1873. 6 
galvano-cautery, delicately applied. The solar cautery has also 
given good results in the same. Extensive " wine-marks," how- 
ever, demand other treatment; Squire's scarification method 
being probably the best. If the naevus, instead of being purely 
capillary and superficial, is composed of vessels of some size, and 
is located in the subcutaneous tissues as well as the skin, or if it 
projects above the surface, actual cautery is an effective method 
of treatment, whatever be the size of the lesion. These naevi are 
usually treated by injection, ligature, electro-puncture (electroly- 
sis so-called), caustics ( potasa fusa, etc.,), or actual cautery. If 
cautery is selected, the instrument should be heated to a red heat 
only, introduced and kept in sfiw some little time. If white heat 
were employed there would be considerable danger of hemor- 
rhage. If the instrument is inserted perpendicular to the surface 
of the naevus, a cicatrix corresponding to each puncture will re- 
sult. When, however, the naevus is considerably elevated, the 
best way of operating in my judgment, is to make a small in- 
cision oi' puncture with a scalpel, just through the skin at the 
edge of the naevus, then introduce galvano-cautery wire cold, 
close the battery circuit, and let the wire heat gradually, taking 
care that no more heat is employed than would suffice to redden 
the wire in the open air. When this is attained open the circuit 
and carefully withdraw the wire. By this method of operating 
there will result coagulation of the blood and destruction of the 
vessels to a considerable extent around the wire, and very little 
risk of hemorrhage. The skin outside the naevus should be pro- 
tected at the point of puncture by means of asbestos. In gener- 
al, however, I think electro-puncture (with the positive needle 
only) preferable to cauterization in the treatment of naevus, as 
when properly performed less scarring results. 
Lupus.-In the severer forms of tubercular, ulcerative and ro- 
dent lupus there can be no question that actual cauterization 
(where excision is impracticable) is the most satisfactory method 
of treatment, and is to be altogether preferred to the potential 
caustics. In several of these cases the results have been extreme- 
ly gratifying. There is, however, another form of lupus, called 
by Kaposi, the orbicular variety of erythematous lupus, which 
in an advanced condition is characterized by a ring of infiltrated 
tissue, enclosing a portion of skin, reddened and perhaps thin- 
ned, but not accompanied with ulceration. The tendency of the 
affection is to extend centrifugally, and to result in atrophy of 
the portions of tissue involved. The therapeutic indication is 
to check the extension of the lesion. This may be effected by 
applying a fine white-hot wire along the outer edge of the in- 
filtration, and burning through the whole depth of the skin; the 
resulting circular cicatrix will form a barrier across which the 
lupous infiltration will not extend, and the final result will be 
a white depressed scar corresponding to the whole of the surface 
that has been invaded by the disease. 7 
Epithelioma and Cancroid.-Epithelioma of the lower lip, 
when the lesion is exuberant and forms more or less of a tumor, is 
most conveniently removed by excision; but when the lesion is 
ulcerative and depressed, and without much peripheral infiltra- 
tion, the actual cautery white-hot appears to me preferable. In 
treating cancer and lupus in this way the cauterization must be 
thorough; mere scorching of the parts will not answer. The 
diseased tumor must be destroyed, otherwise the cautery will act 
as a stimulant; and upon the shedding of the very superficial 
slough, morbid action will be renewed, and the patient be in- 
jured rather than benefited by the operation. 
Ulcers.-I have on several occasions beneficially modified 
indolent and ill-conditioned ulcers by cauterization at a white 
head. 
Chancroids.-It is in this affection especially that the actual 
cautery has given me remarkably good results. One good 
white-hot cauterization being sufficient to destroy the virulent 
properties of the sore, and upon fall of the slough to leave behind 
a granulating ulcer with tendency to heal. This method mate- 
rially shortens the time of treatment, as I have elsewhere shown.* 
A. Paquelin's, or Hamilton's cautery, 'will be found very con- 
venient, and in some respects better than the galvano-cautery, 
in the treatment of these lesions. A few experiments satisfied 
me that the indurated chancre is not beneficially influenced by 
the cautery. 
Venereal Warts.-The most effectual treatment of these is to 
snip them off with scissors, and to touch the bleeding bases with 
the red-hot wire. This stops the hemorrhage, and effectually 
prevents the return of the original trouble. 
Pediculated Tumors of the Skin.-Amussat| has several times 
removed pediculated tumors from the skin, by means of the 
galvano-caustic loop or knife. The only object of using the 
cautery in cases of this sort is the avoidance of hemorrhage, 
or of sepsis in a crowded hospital ward, otherwise cold steel 
would be preferable. Personally I have removed but two 
pediculated tumors by cautery. One was a lobulated tumor the 
size of a pigeon's egg, removed from the right labium majus, 
and the other was an enlarged preputium clitoridis, which after 
removal was found to weigh between six and seven ounces.J 
Circumcision and division of the prepuce in the medio-dorsal 
line have occasionally been effected with the cautery loop or 
knife, but not by myself, as I have not yet met with a case in 
which the operation appeared justifiable. I can conceive, how- 
ever, of its being suitable and proper, if circumcision is impera- 
tively demanded in the presence of a sub-preputial chancroid, 
the latter being also thoroughly cauterized at the same time. 
* Archives of Clinical Surgery, November, 1876. 
f Memoires sur la Galvano-Caustique Thermique. Paris, 1876. 
j The case is reported in the American Journal of Obstetrics, August, 1876. 8 
In making delicate applications where but small points only 
are to be touched with the glowing metal, the eyes of the 
operator should be guarded with blue glass spectacles, other- 
wise the intense glare will prevent a distinct view of the point 
to which the application is to be made. In using the solar 
cautery, this is specially important. 
The above are the principal applications of the cautery in 
cutaneous surgery, as yet developed, and the present article 
is intended to be suggestive rather than exhaustive. The in- 
creasing employment of the actual cautery in general medicine, 
surgery, and gynaecology, is due in part to the increased fa- 
cilities for its use, and in part to a growing belief in the truth of 
" Hippocrates's last aphorism," a latin translation of which is here 
appended. " Quae medicamenta non sanant, ea ferrum sanat. 
Quae ferrum non sanat, ea ignis sanat. Quae vero ignis non 
sanat, ea insanabilia reputare oportet. "