John Marshall's first description of surgical electrocautery
Authors: Manoj Ramachandran, Jeffrey K Aronson
Journal: Journal of the Royal Society of Medicine (2011)

The popularization of the use of surgical electrocautery is often attributed to William T Bovie (1882–1958), who had a doctorate in plant physiology, but whom we might nowadays regard as a biophysicist. Between 1914 and 1927 Bovie discovered that high frequency alternating current in the range 250,000–2,000,000 Hz could be used to incise coagulated tissue and obtain haemostasis, and developed the first commercial electrosurgical device at Harvard University. Harvey Cushing (1869–1939) popularized the device in neurosurgery; he first used it in an operating theatre in 1926 and went on to use it in over 500 neurosurgical operations. It was later adopted by other surgeons.

Before Bovie, electrocautery had been available in other forms. Karl Franz Nagelschmidt, a Berlin physician, coined the term ‘diathermy’ (from Greek words meaning ‘heating through’) in 1909 in the Munchener Medizinische Wochenschrift. Earlier, at a congress in Budapest, Nagelschmidt had demonstrated a prototype diathermy apparatus he had designed. In 1907, at Dresden, he demonstrated the ‘heating through’ of tissues by high-frequency currents, and suggested that they be used in the treatment of diseases of the circulation and joints. In the 1890s, Nikola Tesla (1856–1943) and Jacques-Arsene d'Arsonval (1851–1940) had both studied the medical applications of high-frequency currents and shown them to be safe for use in humans.

However, John Marshall can be credited with an even earlier account of the use of surgical electrocautery in a case of resistant cutaneous fistula in the right cheek of a 25-year-old man following multiple abscesses.

Marshall was born on 11 September 1818 at Ely, Cambridgeshire. His father was William Marshall (1776–1842), a solicitor, and his mother Ann Cropley (c.1793–1861). Marshall studied medicine at University College, London and then became a private assistant to the surgeon Robert Liston. He was also Curator of the anatomy museum there, and later an anatomy demonstrator. He became Full Surgeon and then Professor of Surgery in 1866, beating Joseph Lister to the post. He helped Richard Quain in the production of the 1848 edition of Elements of Anatomy (‘Quain's Anatomy’). He set up in private practice in Mornington Crescent in 1844, where he befriended Ford Madox Brown, the first of a series of artists who were also his patients. That year he became a Member of the Royal College of Surgeons; he became a Fellow of the College in 1849 and its President in 1883. He was also President of the Royal Medical and Chirurgical Society of London in 1882–1884. He retired in 1884 and was President of the General Medical Council at the time of his death in 1891.

Marshall was a competent surgeon and an early advocate of Listerian antisepsis. He published books for general audiences, such as A Description of the Human Body (1860), in which he summarized anatomy and physiology for schoolteachers and pupils; Outlines of Physiology: Human and Comparative (1867); and Anatomy for Artists (1878), based on his keen interest in the arts. He was even elected Professor of Anatomy at the Royal Academy in 1873, being supported by the poet and artist Dante Gabriel Rossetti, who had studied under Ford Madox Brown. Marshall was also an avid microscopist, with an interest in germ theory, and a designer of circular hospital wards. As an advocate of the public health movement, he was one of the first to show that cholera might be spread by means of drinking water (although John Snow is more famously associated with this), and in 1854 issued a report on the outbreak of cholera in Broad Street, St James's. The title of his 1883 Bradshaw lecture, ‘Neurectasy or nervestretching for the relief or cure of pain’, contains the first recorded use of the word ‘neurectasy’.

Richard Quain (1800–1887), who read Marshall's paper to the Society, was Professor of Descriptive Anatomy at University College Hospital, having succeeded Sir Charles Bell, for whom he had acted as Senior Demonstrator in Anatomy. Marshall in turn had acted as Quain's demonstrator and succeeded Quain as Chair of Surgery at University College Hospital in 1866.

Marshall wasted no time in telling his audience the purpose of his paper – to describe the use of the heat of electricity in surgery, and he immediately described at length the case that led him to try it first. A 25-year-old man had a fistula in the right cheek, which had resulted from a series of abscesses. The fistula, discharging foul pus, was one-and-three-quarters inches long and irregular in course, running from just below the Stenonian (i.e. parotid) duct on the inside of the mouth to the skin of the cheek. Numerous efforts had been made to heal the fistula, without success, and Marshall himself tried a variety of treatments. He injected it with a solution of copper sulphate and threaded through it setons of lint, moistened with copper sulphate. He injected other causticsolutions, zinc sulphate, silver nitrate, and iodine. He even tried ‘solid caustic’ (i.e. solid potassium hydroxide).

Cautery had been used surgically since the 16th century, either as so-called actual cautery, the use of hot metal, or potential cautery, the use of caustic chemicals. However, in this case direct access to the inflamed and infected tissue with pre-heated metal was not possible and chemical means had failed. Marshall instead decided to try a novel form of cautery, by heating a platinum wire that he would pass through the whole length of the fistula. He carried out a series of successful experiments in animals before trying it on his patient. He passed a fine platinum wire, one-50th of an inch thick, along the whole length of the tortuous fistula and heated it for 9 seconds by passing a current through it via the copper poles of an electrical battery. The patient felt only sensations of burning in the cheek and pricking in the mouth, but no pain along the fistulous track. The platinum wire, adhering slightly to the tissue, was gently withdrawn. Over the next 2 weeks or so the fistula gradually healed. After 4 days the tissues at both ends began to slough and the sides of the fistula began to approximate, with the extrusion of ‘healthy pus’, whose secretion gradually diminished. [‘Healthy pus’, also called ‘laudable pus’, was a thick, creamy pus that was discharged from wounds and ulcers that were in the process of healing, instead of forming an abscess.] After 11 days the external opening was permanently closed. A week later another sinus opened in the inside of the mouth and was treated similarly, although it required removal of the adjacent wisdom tooth and the use of cautery for 15 seconds.

Marshall's account ended with a statement that he had been using this method in other patients, but preferred to wait before announcing his results. Tantalisingly, in terms that recall the modern method of stating that a new medicine was ‘well tolerated’ in early studies, he reported ‘that no bad consequences have followed in any case, and that, at present, all have been attended with success’.