"Cupping is an art," wrote the London cupper Samuel Bayfield in 1823, "the
value of which every one can appreciate who has had opportunities of being
made acquainted with its curative power by observing its effects on the
person of others, or by realizing them in his own."[87] The curious
operation of taking blood by means of exhausted cups had been part of
Western medicine since the time of Hippocrates, and has been found in many
other cultures as well. It is still practiced in some parts of the world
today.
Since antiquity medical authors have distinguished two forms of cupping,
dry and wet. In dry cupping, no blood was actually removed from the body.
A cup was exhausted of air and applied to the skin, causing the skin to
tumefy. In wet cupping, dry cupping was followed by the forming of several
incisions in the skin and a reapplication of the cups in order to collect
blood. It was possible to scarify parts of the body without
cupping--through the nineteenth-century physicians recommended scarifying
the lips, the nasal passages, the eyes, and the uterus. In order to remove
any sizeable amount of blood, however, it was necessary to apply some sort
of suction to the scarifications, because capillaries, unlike arteries and
veins, do not bleed freely. (Figure 8.)
Cupping was generally regarded as an auxiliary to venesection. The
indications for the operation were about the same as the indications for
phlebotomy, except that there was a tendency to prefer cupping in cases of
localized pain or inflammation, or if the patient was too young, too old,
or too weak to withstand phlebotomy. "If cutting a vein is an instant
danger, or if the mischief is still localised, recourse is to be had
rather to cupping," wrote the encyclopedist Celsus in the first century
A.D.[88]
As noted above, the ancients usually recommended cupping close to the seat
of the disease. However, there were several examples in ancient writings
of cupping a distant part in order to divert blood. The most famous of
these examples was Hippocrates' recommendation of cupping the breasts in
order to relieve excessive menstruation.[89]
As was the case for phlebotomy, the number of ills that were supposedly
relieved by cupping was enormous. Thomas Mapleson, a professional cupper,
gave the following list of "diseases in which cupping is generally
employed with advantage" in 1801:
Apoplexy, angina pectoris, asthma, spitting blood, bruises, cough,
catarrh, consumption, contusion, convulsions, cramps, diseases of the
hip and knee joints, deafness, delirium, dropsy, epilepsy,
erysipelas, eruptions, giddiness, gout, whooping cough,
hydrocephalus, head ache, inflammation of the lungs, intoxication,
lethargy, lunacy, lumbago, measles, numbness of the limbs,
obstructions, ophthalmia, pleurisy, palsy, defective perspiration,
peripneumony, rheumatism, to procure rest, sciatica, shortness of
breath, sore throat, pains of the side and chest.[90]
_Early Cupping Instruments_
Mapleson believed that cupping was first suggested by the ancient practice
of sucking blood from poisoned wounds. In any case, the earliest cupping
instruments were hollowed horns or gourds with a small hole at the top by
which the cupper could suck out the blood from scarifications previously
made by a knife. The Arabs called these small vessels "pumpkins" to
indicate that they were frequently applied to a part of the body in which
the organs contained air or that they were vessels that had to be
evacuated before they could be applied.[91] The use of cattle horns for
cupping purposes seems to have been prevalent in all periods up to the
present. When Prosper Alpinus visited Egypt in the sixteenth century, he
found the Egyptians using horns that were provided with a small valve of
sheepskin to be maintained in place by the cupper's tongue and serving to
prevent the intake of air once the cup was exhausted.[92]
In nineteenth-century America, at least one physician still recommended
horns as superior to glass cups for rural medical practice. A Virginia
physician, Dr. W. A. Gillespie, disturbed by the high cost of cupping
instruments, suggested to his readers in _The Boston Medical and Surgical
Journal_ for 1834 that since glass cups were often broken when carried
from place to place, "an excellent substitute can be made of a small cow
horn, cornicula, which may be scraped or polished until perfectly
diaphanous or transparent."[93]
The Smithsonian collection contains a cow's horn from Madaoua, Niger
Republic (West Africa), used for drawing blood in the 1960s. The director
of the Baptist Mission, who sent the horn, noted that he had often seen
Africans sitting in the market place with such horns on their backs or
their heads. Scarifications were made with a handmade razor.[94]
[Illustration: FIGURE 8.--Scarification without cupping in Egypt in the
16th century. To obtain sufficient blood, 20 to 40 gashes were made in the
legs and the patient was made to stand in a basin of warm water. (From
Prosper Alpinus, _Medicina Aegyptorum_, Leyden, 1719. Photo courtesy of
NLM.)]
In addition to horn cups, the ancients employed bronze cups in which a
vacuum was obtained by inserting a piece of burning flax or linen into the
cup before its application to the skin. Most Greek and Roman cups were
made of metal.[95] Although Galen already preferred glass cups to metal
cups for the simple reason that one could see how much blood was being
evacuated, metal cups were used until modern times. Their main virtue was
that they did not break and thus could be easily transported. For this
reason, metal cups were especially useful to military surgeons. Brass and
pewter cups were common in the eighteenth century, and tin cups were sold
in the late nineteenth century.
Since the latter part of antiquity, cups have been made of glass. The
Smithsonian possesses two Persian opaque glass cups dating from the
twelfth century, called "spouted glasses" because of the spout protruding
from the side of the cup by which the cupper exhausted the air with his
mouth. Similar spouted glasses were illustrated by Prosper Alpinus
(sixteenth century), so designed that the blood would collect in a
reservoir instead of being sucked into the cupper's mouth. Like the horn
cups illustrated by Alpinus, the glass cups were provided with a small
valve made of animal skin. It appears that the sixteenth-century Egyptians
were not familiar with the use of fire for exhausting cups. (Figure 9.)
Cupping and leeching were less frequently practiced in the medieval
period, although general bloodletting retained its popularity.[96] When
the eastern practice of public steam baths was reintroduced into the West
in the late sixteenth and early seventeenth centuries, cupping tended to
be left in the hands of bath attendants (Bagnio men) and ignored by
regular surgeons. Some surgeons, such as Pierre Dionis, who gave a course
of surgery in Paris in the early eighteenth century, saw little value in
the operation. He felt that the ancients had greatly exaggerated the
virtues of the remedy.[97] Another French surgeon, Rene de Garengeot,
argued in 1725 that those who resorted to such outdated remedies as
cupping had studied the philosophical systems of the ancients more than
they had practiced medicine. He accused the admirers of the ancients of
wishing to kill patients "with the pompous apparatus of wet cupping."[98]
(Figure 10.)
[Illustration: FIGURE 9.--Persian spouted cupping glass, 12th century.
(NMHT 224478 [M-8037]; SI photo 73-4215.)]
Nineteenth-century cuppers tended to blame the baths for the low status of
cupping among surgeons. Dionis had described the baths in Germany as great
vaulted halls with benches on two sides, one side for men and the other
for women. Members of both sexes, nude except for a piece of linen around
the waist, sat in the steamy room and were cupped, if they so desired, by
the bath attendants. The customers' vanity was satisfied by making the
scarifications (which left scars) in the form of hearts, love-knots, and
monograms.[99] Mapleson's complaint against the baths in 1813 was typical
of the reaction of the nineteenth-century professional cupper:
The custom which appears to have become prevalent of resorting to
these Bagnios, or Haumaums, to be bathed and cupped, appears to have
superseded the practice of this operation by the regular surgeons.
Falling into the hands of mere hirelings, who practiced without
knowledge, and without any other principle than one merely mercenary,
the operation appears to have fallen into contempt, to have been
neglected by Physicians, because patients had recourse to it without
previous advice, and disparaged by regular Surgeons, because, being
performed by others, it diminished the profits of their
profession.[100]
[Illustration: FIGURE 10.--Cupping in the bath, 16th century. (From a
woodcut held by the Bibliotheque Nationale. Photo courtesy of NLM.)]
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:
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]