Part 4

After a period of neglect, cupping enjoyed renewed popularity in the late eighteenth and early nineteenth centuries. In that period a number of professional cuppers practiced in the cities of Europe and America. Both Guy's and Westminster Hospitals in London employed a professional cupper to aid physicians and surgeons. Of these hospital cuppers, at least four, Thomas Mapleson, Samuel Bayfield, George Frederick Knox, and Monson Hills published treatises on the art of cupping, from which we gain the clearest account of cupping procedure.[101] Knox, who succeeded Mapleson as Cupper at Westminster Hospital, was petitioned by 59 medical and surgical students to write his practical and portable text.[102]

_Instruments of the Professional Cupper_

Cupping instruments in the eighteenth and nineteenth centuries were generally simple dome-shaped glass cups provided with thick rims so that the cups would be less painful when applied and removed. Cups were sold in various sizes, ranging from about 45 mm to 75 mm high. Some were made with a smaller diameter and a larger belly for cupping on parts of the body with a limited surface area. For the same reason, cups with an oval rim were recommended. (Figure 11.)

There were several common methods for exhausting cups, of which the simplest and most widely used was that of throwing burning lint or tow (the coarse part of flax, hemp, or jute) inside the glass before applying the glass to the skin of the patient. The professional cuppers vehemently disapproved of this clumsy practice, for the patient could easily be scorched.[103] Various improvements were suggested to avoid burning the patient. Dionis (1708) had recommended placing a small card with lighted candles over the scarifications, and then applying the cup.[104] Other methods included the brief introduction of a wire holding a bit of sponge soaked with alcohol and ignited, or attaching a bit of sponge to the inside of the glass by means of wax and a piece of wood. All such methods were deemed "clumsy expedients" by professional cuppers,[105] who preferred to employ a lamp or torch especially made for cupping. Eighteenth-century surgical texts illustrated brass grease lamps with covers to regulate the flame. Probably less difficult to maneuver was the alcohol lamp first introduced in the 1790s. Alcohol lamps for cupping were made of metal, shaped like teapots, and contained a heavy cotton wick protruding from the spout.[106]

[Illustration: FIGURE 11.--Typical glass cupping cups, late 19th century. (NMHT 152130 [M-4766-68]; SI Photo 61135-C.)]

Although Mapleson (1813) employed an alcohol lamp, the cuppers writing after him preferred the more recently-introduced cupping torch. This consisted of a piece of hollow metal tubing cut obliquely at one end and provided with a metal bulb or ring at the other end. A cotton wick was stuffed as compactly as possible into the tube so that a small piece of wick protruded from the oblique end. The wick was dipped in alcohol, ignited, and inserted briefly into the cup. The torch was more convenient than the older teapot lamp because it was easier to insert into the cup, and was small enough to hold in the hand at the same time as one held the scarificator.[107]

The introduction of the scarificator represented the major change in the art of cupping between antiquity and the nineteenth century. Unlike later attempts at improving cupping technology, the scarificator was almost universally adopted. Previous to its invention, the cupper, following ancient practice, severed the capillaries by making a series of parallel incisions with a lancet, fleam, or other surgical knife.[108] This was a messy, time consuming, and painful procedure. Ambroise Pare (1510?-1590) was the first to employ the word "scarificator" and the first to illustrate a special instrument for scarification in his compendium of surgical instruments.[109] However, a precursor to the scarificator had been suggested by Paulus of Aegina (625-690), who described an instrument constructed of three lancets joined together so that in one application three incisions could be made in the skin. The instrument, recommended for the removal of coagulated blood in the wake of a blow, was considered difficult to use and was not generally adopted.[110] Pare's scarificator had a circular case and eighteen blades attached to three rods projecting from the bottom. A pin projecting from the side may have served to lift the blades and a button on the top to release them although Pare did not describe the spring mechanism.[111] Pare did not recommend the instrument for cupping, but rather for the treatment of gangrene. Several sixteenth- and seventeenth-century surgical texts made reference to Pare's instrument, among them Jacques Delechamps (1569) and Hellkiah Crooke (1631).[112]

It is not known who made the first square scarificator and adapted it to cupping. The instrument was not found in Dionis (1708), but it did appear in Heister (1719) and in Garengeot (1725). Thus it appears that the scarificator was invented between 1708 and 1719. Garengeot disliked cupping in general and he had little good to say of the new mechanical scarificator. "A nasty instrument," he called it, "good only for show."[113] The German surgeon, Lorenz Heister, was more appreciative of the innovation. After describing the older method of making sixteen to twenty small wounds in the skin with a knife, he announced that "The modern surgeons have, for Conveniency for themselves and Ease to the Patient, contrived a Scarificator ... which consists of 16 small Lancet-blades fixed in a cubical Brass Box, with a Steel Spring."[114] Heister noted that while Pare had used the scarificator only for incipient mortification, it was now "used with good success by our Cuppers in many other Diseases, as I myself have frequently seen and experienced."[115]

The earliest scarificators were simple square brass boxes, with cocking and release levers and 16 pointed blades. By 1780, illustrations in surgical works showed that the bottom of the scarificator was detachable. Thus, although the illustrations do not show the screw for regulating the height of the blade cover, provision may already have been made for adjusting the depth of cut of the blades.[116] Square or German-style scarificators continued to be sold in Germany throughout the nineteenth century. The earlier models (late eighteenth, early nineteenth century) were frequently embellished with ornate decoration, and had pointed blades. Some were quite tall. A specimen dated 1747, in the Wellcome Medical Museum collection, is 14.4 cm high and 4.5 cm wide at the base. (Figure 12.)

[Illustration: FIGURE 12.--Lavishly decorated scarificator, 18th century. (Held by the Wellcome Institute of the History of Medicine, London. Photo courtesy of the Wellcome.)]

The later models (mid- to late nineteenth century) were wider and plainer and had arched or crescent shaped blades (which made a cleaner lesion), but the internal mechanism remained the same. Square scarificators all had 16 steel blades that cut in the same direction and were arranged on three rods of five, six, and five blades respectively. At one end of each rod was a gear pinion. The cocking lever, protruding through an aperture at the top of the scarificator, broadened out into a flat plate with as many gear sectors as blade rods. The plate was held against the interior of the scarificator by a heavy support rod running the width of the scarificator, in such a way that the gear sectors of the cocking lever meshed with the pinions on the blade rods. Pulling up on the cocking lever turned the blades 180 degrees. A heavy flat cantilever spring, attached at one end to the bottom of the case, was caught under a protuberance on the cocking lever and bent as the cocking lever was pulled. As the blades were turned, a catch slipped over a tooth on the cocking lever, and held the blades in place. Nineteenth-century octagonal scarificators generally had two catches, the first exposing the blades, and the second rotating them a full 180 degrees. Pressure on the release lever pushed the catch off the tooth on the cocking lever, thereby releasing the lever and allowing the spring to snap the apparatus back to its original position. Releasing the spring brought the blades around so quickly that their movement could not be seen. (Figure 13.)

[Illustration: FIGURE 13.--Interior of square scarificator. (NMHT 152130 [M-4771]; SI photo 76-9111.)]

In the square scarificators, the top and two sides were detachable from the bottom and the other two sides. Turning the wing-tip nut on the top of the scarificator lowered, by means of a yoke, the bottom of the scarificator that was fitted by grooves into the top. By raising and lowering the bottom, one could regulate the length of blade protruding beyond the bottom, and hence the depth of cut.

In the 1790s, the octagonal scarificator that was to become the standard English-American model began to appear in surgical texts. The early octagonal scarificator, as illustrated in Latta (1795) and Bell (1801), had sixteen rounded blades arranged as in the square scarificator, an iron triggering lever similar to that of the square scarificator, a button release on the side, and a flat key on top for regulating depth of cut.[117] Early in the nineteenth century the flat keys were replaced by round screws. Only the bottom or blade cover of the octagonal scarificator was detachable. In some of the octagonal scarificators, the round screw on top ran the height of the scarificator and screwed directly into an internally threaded post inside the blade cover. In other scarificators, the screw raised and lowered a yoke whose two sides were attached by additional screws to side projections of the blade cover.

A notable improvement was made in the early nineteenth century when John Weiss, a London instrument maker, introduced a 12 blade octagonal scarificator whose blades, arranged on two rods or pinions, were made to cut in opposite directions. This advance was mentioned by Mapleson in 1813 and adopted by London professional cuppers thereafter. The advantage of the innovations was that the skin was thereby stretched, and a smoother, more regular cut could be made. Weiss's Improved Scarificator also featured blades that could easily be removed for cleaning and repair. In place of two rows of six blades, one could insert a single row of four blades to adopt the scarificator for cupping on small areas such as the temple.[118] The feature of inserting a pinion with clean and sharp blades permitted the cupper to own only two scarificators. For cleansing the blades the manufacturer supplied a thin piece of wood covered with wash leather or the pith of the elder tree.[119]

Scarificators in which the blade rods turned in opposite directions (called "reversible" scarificators in trade catalogs) were more complicated to manufacture and therefore somewhat more expensive than unidirectional scarificators. The cocking lever meshed directly with only the first blade rod. To make the second blade rod turn in the opposite direction, an extra geared plate (or idler lever) was necessary to act as an intermediary between the cocking lever and the second blade pinion. The cocking lever turned the idler lever, which then turned the second pinion. Two support rods and two cantilever springs were needed in place of the one in unidirectional scarificators.

The brass, octagonal scarificator with 8, 10, and particularly 12 blades became the standard scarificator sold in England and America.[120] Both unidirectional ("plain") and reversible scarificators were offered through trade catalogs. Smaller octagonal scarificators with four to six blades were sold for cupping parts of the body with limited surface area.

_Cupping Procedure_

The art of cupping, it was generally agreed, required a high degree of dexterity that could be maintained only by constant practice. Professional cuppers were concerned with avoiding any appearance of clumsiness, else the patient might come to fear an operation essential to his health. In the hands of an inexperienced physician or surgeon, cupping could be highly painful to the patient, and yet fail to produce the requisite amount of blood. While expert cuppers were usually available in cities, the rural doctor was not trained in the operation. It was to these rural practitioners that the treatises of the professional cuppers were addressed. One cupper, George Frederick Knox, offered in addition personal instruction in cupping procedures. His charge was a guinea for medical students and three guineas for non-medical students for a three month course.[121]

Physicians and surgeons took a renewed interest in cupping in the early nineteenth century. Cupping was no longer regarded as merely a useful substitute for bloodletting. Recent physiological research seemed to prove to the advocates of cupping that the effects of slow withdrawal of blood from the capillaries produced a different effect on the constitution than the quick withdrawal of blood from a vein. Thus, Knox was convinced by the results of this research that, while phlebotomy was indicated in cases of high fever, "particular phlegmasiae" specifically required the intervention of cupping.[122]

The procedure that the experts followed in wet cupping was as follows. First, the cups were immersed in hot water. Bayfield recommended that one glass be used for every four ounces of blood required. Thus, to abstract 18 to 20 ounces, as was common in cupping on the back or abdomen, four or five glasses were needed. The spot chosen for placement of the cups should be free of bone, but also not overly fatty. Cupping over the belly of a muscle was especially recommended. After the spot was fomented with hot water, the torch was dipped in alcohol, lit, and inserted into the cup for about two seconds. Once the torch was removed, the cup was allowed to sink of its own weight into the skin. During the minute that the skin was allowed to tumefy under the cup, the scarificator was warmed in the palm of the hand in preparation for the most difficult part of the operation. It required great skill to manage torch, scarificator, and cups in such a way as to lift the cup, scarify, and recup before the tumefaction had subsided. Monson Hills (1834) described the manipulations involved thus:

The torch is held in and across the palm of the right hand, by the little and ring finger, leaving the thumb, the fore and middle fingers free to hold the scarificator, which may be done by the thumb and fore finger only; the glass is then grasped by the thumb, fore and middle fingers of the left hand, leaving the little and ring fingers free; the edge of the glass is then detached from the skin by the middle finger of the right hand; the scarificator being set, care must be taken not to press upon the button with the thumb too quickly; directly the glass comes off, we apply the scarificator, spring it through the integuments, and then placing it between the free little and ring fingers of the left hand, we apply the torch to the glass, and glass to the skin over the incisions, as before recommended.[123]

Hills recommended practicing on a table, "taking care, of course, that the lancets are not allowed to strike the table."

According to Bayfield, the blades of the scarificator were generally set at 1/4". If cupping behind the ears, they should be set at 1/7", if on the temple at 1/8", and if on the scalp at 1/6". When the cups were two-thirds full, they were removed and reapplied if necessary. This, too, was no easy task. One had to manipulate cup and sponge deftly in order to avoid spillage. Cupping was to be not merely a neat operation, but an elegant one. After cupping, the wound was dabbed with alcohol or dressed, if necessary. Scarificator blades could be used some twenty times. After each use, the scarificator was to be cleaned and greased by springing it through a piece of mutton fat.[124]

A great variety of bodily parts were cupped, just about any part that had sufficient surface area to hold a small cup in place. Knox, for example, gave directions for cupping on the temple, back of the head, behind the ears, throat, back of the neck, extremities, shin, chest, side, abdomen, back and loins, back of the thighs, perineum, sacrum, and on buboes.[125] In reply to those who wondered if cupping hurt, Knox asserted that "those who calculate the pain incurred in cupping by comparison with a cut finger are very much deceived." The scarificator itself produced little pain, he claimed, but he admitted that the pressure of the rims of the glasses could cause a degree of discomfort.[126]

_Nineteenth Century Attempts to Improve Cupping Technology_

The story of nineteenth-century attempts to improve cupping technology is an interesting one, in that a great deal of effort was expended on comparatively short-lived results. For those who were adept at cupping, the cups, torch, and standard scarificator were quite adequate. Innovations were thus aimed at making the operation more available to the less practiced. The new gadgets could not rival the traditional instruments in the hands of an experienced cupper, and, moreover, they were usually much more expensive.

Most of the attempts at innovation centered in eliminating the need for an alcohol lamp or torch to exhaust the cups. As far back as Hero of Alexandria,[127] we find directions for the construction of "a cupping-glass which shall attract without the aid of fire." Hero's device combined mouth suction with a system of valves. Another famous inventor of assorted devices, Santorio Santorii (1561-1636), described a cup that contained a syringe in the early seventeenth century.[128] From the 1780s on, cups with brass syringes began to appear in compendia of instruments. A cup with brass fixings would be screwed onto a brass pump, placed on the skin, and the air within removed by a few strokes of the piston.[129] This sounded better in theory than it worked in practice. Expert cuppers agreed that they thoroughly disliked using the syringe. Mapleson (1813) offered three strong objections to the instrument. First, exhaustion could easily be carried too far, so as to obstruct the flow of blood. Second, the operation become tedious and fatiguing to the bloodletter because of the repeated screwing and unscrewing of syringe and glasses. Third, the valves were liable to malfunction.[130] Twenty-three years later Knox continued to disapprove of the syringe for the very same reasons. Of all the new inventions for cupping, he declared in 1836, "the worst is the syringe, as it makes that a most complicated and bungling operation that which, with common care and attention is one of the most simple in surgery."[131]

Despite rejection by experienced cuppers, manufacturing of an air-tight syringe continued to challenge inventors throughout the nineteenth century. Some attempted to substitute stopcocks for valves, and some to place long flexible tubes between pump and glasses so that the pumping motions would not be communicated to the patient. Pumps were gradually improved, and, although rarely recommended by experts, were sold in great numbers as part of fancy and expensive cupping sets. These sets, with prices as high as fifteen dollars, consisted of a mahogany or leather box with brass latches, lined in plush, and containing compartments for scarificators, a brass pump, and an assortment of glasses provided with metal attachments. Some of the most elegant of the cupping sets were those made by Maison Charriere of Paris. Today the luxury of these cupping sets seems rather incongruous with the bloody purposes for which the instruments were used. Yet, the beauty of the instruments and their containers must have added to the esteem of the physician or surgeon in the mind of the patient.

Syringes were not only useful in cupping but also were employed in a wide variety of medical and surgical operations. Creating an all-purpose syringe that would extract or inject liquids into any part of the body was yet another inventor's dream. Two of the earliest English surgical patents were awarded to two such syringes. John Read (1760-1847), surgical instrument maker for the British Army and the East India Company, patented a pump in 1820 for use in "extracting poison from the stomach, administering clysters, introducing tabacco fumes into the bowels, transfusion of blood, draining off the urine, injecting the bladder, female injection, anatomical injection, administration of food and medicine, cupping, drawing the breasts ... &c."[132] John Weiss, inventor of the improved scarificator, invented his own patent syringe in 1825, which he claimed to be superior to all previous syringes because it employed stopcocks in place of valves, which were subject to leakage and clogging. Cupping was only one of many operations that could be performed with its aid. The Truax Surgical Pump is an example of a late nineteenth-century all-purpose patent pump outfit that included cups among its numerous optional attachments.[133] (Figure 14.)

Those who went a step further in their efforts to improve cupping procedure attempted to combine cup, lancet, and exhausting apparatus all in one instrument. Bayfield described and rejected several such devices in 1823, including perhaps the earliest, that of the Frenchman, Demours. Demours' instrument, first introduced in 1819, consisted of a cupping glass with two protruding tubes, one containing a lancet, and the other an exhausting syringe. The lancet, surrounded by leather to keep air out of the cup, could be supplemented by a cross with four additional blades, if more than one puncture was desired.[134] In 1819, Thomas Machell, a member of the Royal College of Surgeons in London, described a similar apparatus in which the glass cup was separated from the tin body of the apparatus by a flexible tube. The facility and precision of the instrument, claimed Machell, "are incalculably surpassed by the power of its application to any part whatever of the surface, under any circumstances indicating its propriety, and by any person untrained to the manual dexterity of a professed cupper."[135]

Professional cuppers who took pride in their skill naturally avoided such novelties. Bayfield found the complex instruments objectionable because even "the most trifling degree of injury is generally sufficient to render the whole apparatus useless."[136]

The Smithsonian collection contains two patent models of American wet cupping devices. The first is an ingenious cupping set patented by a Philadelphia navy surgeon, Robert J. Dodd, in 1844. It consisted of a metal syringe provided with a plate of lancets that screwed on to a glass tube with a protuberance for collecting blood. The most interesting feature of the apparatus was the provision made for cupping internal parts of the body such as the vagina, throat, or rectum. One could attach to the pump either a curved or a straight tapering glass tube, seven to eight inches long, and corresponding flexible metal lancet rod. The pump could also be adapted for extracting milk from the breasts of women by attaching a metal cap with a hole just large enough to accommodate the nipple.[137] The second patent model is that of W. D. Hooper of Liberty, Virginia, who invented in 1867 an apparatus combining cup, pump, and scarificator. The novel part of the instrument was the tubular blades that were injected into the flesh and then left in place while the blood was being removed, "by which means the punctures are kept from being closed prematurely, as frequently happens with the ordinary device."[138]

It is unlikely that any of these ingenious devices were marketed in quantity. For those skilled in the art of cupping, the torch, cups, and scarificator were more effective. For those not experienced in the art, the new devices were simply too expensive, inconvenient to carry about, and fragile. While doubtless some surgeons bought fancy equipment in order to impress their patients, other surgeons, and the professional cuppers, realized that expensive and unfamiliar gadgets could inspire more dread than awe, especially among rural patients. The cupper Monson Hills advised his readers: