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]
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 Paré (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] Paré’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 Paré did not describe the spring mechanism.[111] Paré did not recommend the instrument for cupping, but rather for the treatment of gangrene. Several sixteenth- and seventeenth-century surgical texts made reference to Paré’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 Paré 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].)