Part 5

A person about to be cupped, is often needlessly alarmed by the arrival of his operator, with a capacious box of instruments; and he measures the severity of the pain he is about to undergo, by the seeming multitude of instruments required to inflect it. If, on the contrary, the few implements used are carried in the pocket, and produced when about to be used, unobserved by the patient, this evil is easily avoided.[139]

In seconding Hills' sentiments, W. A. Gillespie, the Virginia country physician mentioned earlier, went a step further. Gillespie felt that the rural physician could dispense with the glass cups, torch, and scarificator and substitute in their place a simple thumb lancet and cow's horn. Not only would these instruments save money, but they would also "excite less dread in the mind of the patient than a formidable display of numerous and complicated instruments."[140]

Some inventors concentrated on more modest improvements in cupping technology, namely, modification of cups and scarificators. One of the simplest improvements was that of Dr. Francis Fox, House Surgeon to the Derbyshire General Dispensary. In 1827, Dr. Fox introduced a new glass cup with a short, curved, wide neck and an oval belly that hung downwards. When applied to the skin, the glass hung in the manner of a leech, and so the glass was called "The Glass Leech." Since the burning tow could be placed in the hanging belly of the glass, away from the skin, it was easier to apply and remove the ordinary cup.[141] Other modifications of the cupping cup included the addition of a stopcock to let the air back in, graduations to measure the blood, and the attachment of a metal bar inside the cup in order to hold the burning sponge or wick away from the body of the patient.[142] (Figure 15.)

[Illustration: FIGURE 14.--Weiss's improved patent cupping apparatus. Illustrated are Weiss's patent syringe applied to cupping and Weiss's improved scarificator. (From John Weiss, _Surgical Instruments_, 2nd edition, London, 1831. SI photo 73-5184.)]

The most significant innovation in cups came with the manufacture of cups of vulcanized rubber in the 1840s. Rubber cups could be easily exhausted without need of a torch, and they were far cheaper and easier to manipulate than cups attached to a pump. Most surgical catalogs in the late nineteenth century offered both all-rubber cups and glass cups to which a rubber bulb was attached. In the late nineteenth century, sets of cups were sometimes sold with rubber rims because the rubber fit more comfortably against the skin and prevented air from entering the cup. Museum collections contain few rubber cups because nineteenth-century rubber tended to deteriorate in time. However, the appearance of these cups in all surgical catalogs indicates that they were widely sold.[143]

[Illustration: FIGURE 15.--Fox's glass leech. Cupping set contains two hanging "glass leeches," a scarificator, a bottle of alcohol, and a torch with a ring handle such as the cupper Knox recommended. (Set held by the Academy of Medicine, Toronto. Photo courtesy of the Academy.)]

Several inventors tried to improve upon the scarificator. The defects of the ordinary scarificator were widely recognized. It was too bulky and heavy, and it cost too much--the most inexpensive scarificator offered by George Tiemann & Co. in 1889 cost $4.50.[144] A strong hand was required to trigger the blades, and when the trigger was released, the force of the spring was so great that the lever moved back with great force and produced a loud, unpleasant click. The force of the lever moving against the case of the scarificator made it impossible to use any but expensive materials (brass and German silver) in making the scarificator casing. Furthermore, the springs were liable to break. Finally, the scarificator was difficult to clean.[145] Late in the century, when sterilization became important, some cuppers went back to the lancet because the scarificator could not be surgically cleansed. The surprising thing is, that despite all the defects, the same scarificator was sold in 1930 as in 1830. Either the claims of the inventors of improved scarificators were unjustified, or cuppers were unwilling to try novel instruments in what was becoming an old-fashioned and increasingly less popular operation. (Figure 16.)

A few British and American surgical supply companies sold special models of scarificator, but always in addition to the common scarificator. The special models were generally higher in price. For example, the Englishman, James Coxeter, announced in 1845 a new scarificator with a rotating lever on the side instead of a cocking lever on the top. The roto-lever, according to Coxeter, could be turned to set the scarificator by a child of six. Furthermore, the scarificator was so constructed that when the spring was released only internal parts moved. There was no lever that snapped back and no resounding click. This special model of scarificator continued to be sold by Coxeter and Son (London) until late in the nineteenth century.[146]

Coxeter did not patent the roto-lever scarificator. In fact, through 1852 there were no British patents on scarificators. In contrast, there were eight French patents on scarificators before 1860.[147] Of these, the most important was the 1841 patent of Joseph-Frederic-Benoit Charriere (1803-1973), a Swiss-born cutler who founded a major surgical supply company in Paris. Charriere's octagonal scarificator substituted two flat coiled springs (like watch springs) for the two cantilever springs normally found in "reversible" scarificators. One end of each coiled spring was attached to the scarificator casing and the other to one of the support rods. As the cocking lever was pulled, the support rods turned and wound the springs more tightly about the rods. According to Charriere, these springs were more efficient and less likely to break than the ordinary springs.[148]

Charriere's company later employed the coiled springs in the making of a circular scarificator. The circular scarificators, associated particularly with French manufacture, were the most elegant of nineteenth-century scarificators and a fitting complement to the Charriere cupping sets.[149] They were generally not sold by British and American surgical supply companies, but a number of them appear to have reached the hands of American physicians.

In America, there were five patents on scarificators, of which the Smithsonian possesses three patent models. The most significant American patent was that of George Tiemann in 1846. Tiemann's scarificator had a flattened base and an ebony handle, which contained a coiled spring. The blades were moved by a rack and pinion mechanism, and triggered by a knob at the end of the handle. The advantages claimed by the inventor were ease in handling, ease in cleaning, and the diagonal cut of the blades that allowed the blood to flow more freely and the wounds to heal more readily. Tiemann & Co. was still selling their patent scarificator as late as 1889 for a price of $7.00.[150] The Smithsonian possesses a marketed version in addition to the patent model.

The two other patent scarificators in the Smithsonian collection were both invented by Frederick M. Leypoldt of Philadelphia. The first, patented in 1847, was similar in external appearance to the common scarificator. The novelty consisted of a new arrangement of the cocking lever and cantilever spring that allowed use of a lighter and cheaper casing. Although the patent model was made of brass, Leypoldt claimed that with his improvements in the internal mechanism, the case could, with safety, be made of tin.[151]

Leypoldt's second patent, issued in 1851, was for a scarificator with a greatly simplified inner mechanism allowing for a substantially smaller and lighter case. The cocking lever was placed horizontally in the casing and engaged the blade rods through a rack and pinion mechanism. According to Leypoldt, this scarificator was more convenient, more portable, cheaper, safer, and more reliable than the common scarificator.[152] Leypoldt probably marketed his scarificators, there being in the Smithsonian collection other bloodletting instruments with his name, but he did not form a major surgical supply company as did George Tiemann.

[Illustration: FIGURE 16.--Advertisement for phlebotomy and cupping instruments. Note the rubber cups. (From George Tiemann & Co., _American Armamentarium Chirurgicum_, New York, 1889. SI photo 76-13542.)]

After 1860, interest in inventing new scarificators declined as wet cupping decreased in popularity. The improved cups and scarificators, while they had achieved a limited success, had still failed to supplant the common octagonal scarificator and the plain glass cup. As interest in wet cupping declined, medical attention shifted to the therapeutic virtues of dry cupping. Dry cupping offered even greater opportunities for inventors, who sought means to bring the effects of the vacuum to more areas of the body for greater lengths of time.

_Dry Cupping_

Dry cupping, in its simplest form, was said to act as a "revulsive" or "derivant." By the nineteenth century these once hotly debated terms had become nearly interchangeable in discussions of cupping. In cupping for revulsive purposes, one cupped on a distant part to relieve excess of blood in the affected part. In applying cupping as a "derivant," one cupped closer to the affected part. In either case, the source of pain was presumed to be somewhere below the skin, and the pain was relieved by bringing blood away from the affected part to the surface of the body. Thus, one nineteenth-century cupper concluded, revulsion was only derivation at a distant point.[153]

If dry cupping was applied for ten minutes or longer so that the capillaries burst, the action of the cups was said to be that of a counter-irritant. According to ancient medical theory, the counter-irritant was a means of relieving an affected part by deliberately setting up a secondary inflammation or a running sore in another part. Counter-irritations were traditionally produced in a number of ways, among them, blisters, cautery, setons, moxa, and dry cupping.[154]

One of the most popular counter-irritation devices commonly associated with cupping instruments in catalogs of surgical goods, was Baunscheidt's _Lebenswecker_, sold by most American surgical supply houses in the second half of the nineteenth century. The _Lebenswecker_, or "Awakener of Life," was the mainstay of the mystical medical system known as _Baunscheidtismus_, after the founder of the device, Carl Baunscheidt of Prussia (1809-1860).[155] The system apparently gained much notoriety in Germany, England, and America, for Baunscheidt's book went through ten German editions and several British and American editions. At least two Americans patented improvements on the _Lebenswecker_.[156] The device was made of ebony, about 250 mm long, and contained a coiled spring attached to a handle. At the other end of the spring was a place about 20 mm in diameter, with about thirty projecting needles. By pushing upon the handle, one sent the needles into the skin. The ability of the instrument to create blisters was enhanced by the application of Baunscheidt's special oil to the irritation (Figure 17).

[Illustration: FIGURE 17.--Venus and Adonis with marks showing where Baunscheidt's _Lebenswecker_ should be applied. (From Carl Baunscheidt, _Baunscheidtismus, by the Inventor of the New Curing Method_, Bonn, 1859(?). Photo courtesy of NLM.)]

Dry cupping stimulated much theoretical debate in the nineteenth century as well as a number of physiological experiments.[157] Although physicians generally agreed that dry cupping had curative value if employed properly, they disagreed widely on when to employ the remedy, and on the manner in which the remedy operated. Did application of cups affect only the surface vessels, or could cupping affect the entire nervous system, and through the nerves, the action of the secretory organs? Were the effects of dry cupping of only a temporary nature, or were they permanent? An interesting series of investigations in Europe and America sought to ascertain the value of dry cupping in checking the absorption of poison. An American, Dr. Casper Wistar Pennock, replying to investigations performed by Martin Barry, an Edinburgh physician residing in Paris, carried out an impressive series of physiological experiments in 1827, in which he administered strychnine and arsenic under the skin of dogs and rabbits and then cupped over the wounds. He concluded that while dry cupping prevented almost certain death from the poisons, once the cups were removed, death would ensue, unless the poisons were surgically removed.[158]

Interest in dry cupping led to attempts to apply the therapeutic effects of the operation to larger areas of the body than could be accommodated by a cup. In France, Victor-Theodore Junod (1809-1881) adapted cupping to entire limbs. Shortly after receiving his degree in medicine in 1833, Junod presented at the Academy of Sciences his apparatus, known thereafter as Junod's boot. Junod believed that actual extraction of blood was a dangerous remedy and that the benefits of bleeding might as easily be obtained by his "derivative method," which withdrew blood from the general circulation but allowed it to be returned at will. Junod's boot and Junod's arm, which sold for as much as $25.00 apiece,[159] were constructed of metal and secured against the limb by a silk, and later a rubber, cap. To the boot was attached a flexible tube, stopcock, pump, and if desired, a manometer for measuring the vacuum produced. In chronic illnesses, Junod recommended that the boot be applied for an hour. So much blood was withdrawn from the circulation by use of the apparatus that the patient might easily faint. To explain how his boot worked, Junod invented a theory that he called "hemospasia," meaning the drawing of blood.[160] This was typical of a number of attempts to introduce sophisticated terminology into discussions of traditional remedies. Junod's arm and boot were widely available through American surgical supply companies. As late as 1915, Heinrich Stern, previously mentioned as a latter-day proponent of bloodletting, had no doubt that application of the boot to the foot would relieve congested states of the abdominal viscera.[161] (Figure 18.)

Americans patented a number of modifications of the arm and boot, and in addition they patented a number of whole body devices called "depurators." Junod had introduced such a device along with his boot--a metal casing in which a patient would be placed leaving only his face showing. The air inside would then be exhausted by means of a gigantic syringe. In America such "depurators" may have been regarded more as quackery than as a legitimate extension of cupping, for despite the fact that Americans patented some twenty of these devices, surgical supply houses did not sell them and little was written about them.

In the last decade of the nineteenth century, Dr. August Bier, professor at the University of Bonn, developed another sophisticated theory supporting the use of blood-suction devices, known as the theory of hyperemia, meaning "excess of blood." According to the doctrine, lesions are always accompanied in nature by hyperemia, "the most widespread of auto-curative agents."[162] If we, therefore, wish to imitate nature, we create an artificial hyperemia. Bier recommended several means of increasing the blood supply of an affected part, including hot-air baths, suction devices such as Junod's boot, and dry cupping. Several American surgical suppliers sold Bier's Hyperemic Cups in the early twentieth century. These were glass cups, of a great variety of shapes and sizes including some with curved rims, each fitted with a rubber tube and bulb for exhausting the air. A major function of these cups was to collect wound secretions from boils or furuncles.[163]

[Illustration: FIGURE 18.--Junod's boot applied to a baby in the cradle. (From Victor Theodore Junod, _A Theoretical and Practical Treatise on Maemespasia_. London, 1879. Photo courtesy of NLM.)]

_Breast Cupping_

Related to cupping by its technology is the practice of drawing milk from the breasts by means of breast pumps. Mothers with underdeveloped or inflamed breasts posed a frequent problem for the nineteenth-century physician, who treated them with either large doses of tartar emetic, a strong purgative, or with cupping.[164] Breast pumps were small glass cups with fluted edges made to accommodate the nipple. While some surgeons, as the American Samuel Gross, recommended using a bottle with a long neck in which the air had been rarified by means of hot water,[165] most breast pumps were exhausted by mechanical means. For reasons of modesty, the pumps were usually designed so that the woman could draw her breasts herself. Perhaps the simplest design of a breast pump was a glass cup having a long spout extending in such a way that the woman could perform suction herself. Such all-glass cups were illustrated in the eighteenth century.[166] A few, reputedly made centuries earlier, are found in the Wellcome Historical Medical Museum. Early in the nineteenth century, breast pumps, just as glass cups for bleeding, were attached to brass syringes, and were often included among the variety of cups in cupping sets provided with syringes. Read's and Weiss's patent syringe as well as Thomas Machell's cupping device were adapted for breast pumping. With the invention of vulcanized rubber, the breast pump was frequently attached to a large rubber bulb. A glass protuberance was often added to pumps exhausted by syringes or rubber bulbs, in order to collect the milk so that it could be fed to the infant. In the 1920s some breast pumps were attached to electric motors.[167] Breast pumps have continued to be employed up to the present day. Of all instruments employing the principle of the cupping device, breast pumps were the most frequently patented. From 1834 to 1975, more than 60 breast pumps were patented, the majority in the period from 1860 to 1920.[168]

_The Decline of Cupping_

Cupping died out in America in the early twentieth century, but its disappearance was gradual and scarcely noticed. Some of the most complex of cupping devices were invented in a period when most physicians regarded cupping as ineffectual. Patents for cupping devices continued to be issued as late as 1916 when Joel A. Maxam of Idaho Springs, Colorado, patented a motorized pump, which by means of various sizes of cups, could subject a part of the patient's body to either a prolonged suction or a prolonged compression.[169] One of America's last advocates of bloodletting, Heinrich Stern, writing in 1915, also advocated the use of an electrical suction pump to evacuate cups. With an electric motor, he declared, one could prolong hyperemia for 15, 30, or more minutes.

Stern also invented a theory to account for the therapeutic effects of his inventions, namely, the theory of phlebostasis. Instead of pumping air out of a device, Stern pumped air into a device, for the same purpose of removing a portion of blood from the general circulation. His "phlebostate," manufactured by Kny-Scheerer of New York, was quite similar to a sphygmomanometer. It consisted of a set of cuffs that fit about the thighs, rubber tubes, a manometer, and a suction bulb or an electric force pump. For stubborn cases, such as migraine headaches, Stern recommended using the cuffs for 30 minutes or more. To facilitate the application of the cuffs, Stern invented a "phlebostasis chair," one of the most complex "cupping" devices ever made. Like an electric chair, the phlebostasis chair was supplied with cuffs for both arms and legs. Air was pumped into the cuffs by means of an electric motor. According to Stern, compression of the upper segment of both arms withheld 300 cc of blood from circulation, while compression of the thighs withheld as much as 600 cc.[170]

In addition to these sophisticated devices, simple cupping, especially dry cupping, continued well into the 1930s. Although cupping was no longer generally recommended by physicians, most surgical companies advertised cups, scarificators, and cupping sets in the 1920s and even the 1930s. The last bastions of cupping in the United States were the immigrant sections of large cities. In the lower East Side of New York, in particular, cupping was still flourishing in the 1920s. By then cupping was no longer performed by the physician, but had been relegated back to the lowly barber, who advertised in his shop window, "Cups for Colds."[171]

Leeching

_Leeches_

The word "leech" derives from the Anglo-Saxon _loece_, "to heal." Thus, the Anglo-Saxon physician was called a "leech" and his textbook of therapeutic methods a "leechdom." The animal itself was already known to the ancients under its Latin name _hirudino_. It appears, however, that the introduction of leeches into Western medicine came somewhat later than that of phlebotomy or cupping, for Hippocrates made no mention of them. The earliest references to the use of leeches in medicine are found in Nicander of Colophon (2nd century B.C.) and in Themison (1st century B.C.). Thereafter they were mentioned by most Greek, Roman, and Arabic medical writers.[172]

The leech is a fresh-water parasitic invertebrate belonging to the Phylum Annelida. On one end of its worm-like body is a large sucker by which the animal fastens itself to the ground, and at the other end is a smaller sucker, in the middle of which is a chitinous mouth that makes a triangular puncture. As items of _materia medica_, leeches were described in dispensatories, or compilations of medicaments, and sold by apothecaries, both to physicians and directly to patients. The species most commonly used for bleeding was _Hirudo medicinalis_, indigenous to the streams and swamps of Central and Northern Europe, and known in commerce as the Swedish or German leech. It was 50-75 mm long, with a dull olive green back and four yellow longitudinal lines, the central two broken with black. Somewhat less popular was the Hungarian leech, indigenous to Southern Europe. In addition, there was an American species of leech, _Hirudo decora_, which was gathered principally from the lower Delaware River, but, since it drew much less blood than the Swedish leech, it was regarded as greatly inferior.[173] Most American physicians imported their leeches. In the late nineteenth century, one could buy Swedish leeches for $5.00 per hundred.[174]

Leeches were gathered in the spring of the year either by means of a pole net, or, more primitively, by wading into the water and allowing the leeches to fasten themselves onto the legs. Sometimes horses and cattle were driven into the water to serve as bait for the leeches.[175] (Figure 19.)

[Illustration: FIGURE 19.--Lithograph published in London in 1814 showing three women gathering leeches by a stream. (NMHT 320033.08; SI photo 76-7741.)]

Leeching, like other forms of bloodletting, enjoyed a revival in the early nineteenth century, particularly in France, where the doctrines of heroic medicine preached by Broussais[176] led to an increase of leech usage from about 3 million in 1824 to 41.5 million in 1833.[177] Leechers, although not as high in status as professional cuppers, practiced in many large cities, and numerous tracts were written on the care and breeding of leeches. "Leech farms" were unable to increase the leech supply to meet the rising demand, and most leechers complained of the scarcity and great expense of the little animals.[178]

Leeching and cupping each had their advocates. The major advantage of the leech over the cup was that the leech could be employed on almost any part of the anatomy, including around the eyes, in the mouth, the anus, and the vagina. In fact, leeching the internal membranes enjoyed quite a vogue in the early nineteenth century. Leeches were applied to the larynx and the trachea for bronchitis and laryngitis and for relieving the cough of phthisis. For inflammations of the conjunctiva (the membrane lining the eyelids) they were applied to the nasal membrances of the adjacent nostril, and for inflammations of the ear they were applied to the meatus of the ear and behind the ear. The French popularized the practice of leeching the anus to treat inflammations of the mucous membranes of the bowel. To prevent leeches from getting lost in the body cavities, Jonathan Osborne, a British physician, recommended in 1833 that a thread should be passed through the leech's tail. In addition, he invented a device, which he called a "polytome," specifically for introducing leeches into the rectum.[179] In the mid-nineteenth century, special leech tubes were widely sold for applying leeches to internal membranes.[180]