Bloodletting Instruments in the National Museum of History and Technology Part 4

The earliest scarificators were simple square bra.s.s boxes, with c.o.c.king and release levers and 16 pointed blades. By 1780, ill.u.s.trations in surgical works showed that the bottom of the scarificator was detachable.

Thus, although the ill.u.s.trations 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.)

[Ill.u.s.tration: FIGURE 12.--Lavishly decorated scarificator, 18th century.

(Held by the Wellcome Inst.i.tute 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 c.o.c.king 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 c.o.c.king lever meshed with the pinions on the blade rods. Pulling up on the c.o.c.king 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 c.o.c.king lever and bent as the c.o.c.king lever was pulled. As the blades were turned, a catch slipped over a tooth on the c.o.c.king 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 c.o.c.king 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.)

[Ill.u.s.tration: 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 ill.u.s.trated 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 b.u.t.ton 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 c.o.c.king 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 c.o.c.king lever and the second blade pinion. The c.o.c.king 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 bra.s.s, 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 pract.i.tioners 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 subst.i.tute 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 const.i.tution 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 gla.s.s 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 gla.s.ses 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 gla.s.s 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 gla.s.s 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 b.u.t.ton with the thumb too quickly; directly the gla.s.s 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 gla.s.s, and gla.s.s 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 a.s.serted 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 gla.s.ses 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-gla.s.s which shall attract without the aid of fire." Hero's device combined mouth suction with a system of valves. Another famous inventor of a.s.sorted devices, Santorio Santorii (1561-1636), described a cup that contained a syringe in the early seventeenth century.[128] From the 1780s on, cups with bra.s.s syringes began to appear in compendia of instruments.

A cup with bra.s.s fixings would be screwed onto a bra.s.s 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 s.c.r.e.w.i.n.g and uns.c.r.e.w.i.n.g of syringe and gla.s.ses. 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 subst.i.tute stopc.o.c.ks for valves, and some to place long flexible tubes between pump and gla.s.ses 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 bra.s.s latches, lined in plush, and containing compartments for scarificators, a bra.s.s pump, and an a.s.sortment of gla.s.ses 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 b.l.o.o.d.y 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 b.r.e.a.s.t.s ... &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 stopc.o.c.ks 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 gla.s.s 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 Mach.e.l.l, a member of the Royal College of Surgeons in London, described a similar apparatus in which the gla.s.s cup was separated from the tin body of the apparatus by a flexible tube. The facility and precision of the instrument, claimed Mach.e.l.l, "are incalculably surpa.s.sed by the power of its application to any part whatever of the surface, under any circ.u.mstances 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 gla.s.s 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 v.a.g.i.n.a, throat, or r.e.c.t.u.m. One could attach to the pump either a curved or a straight tapering gla.s.s tube, seven to eight inches long, and corresponding flexible metal lancet rod. The pump could also be adapted for extracting milk from the b.r.e.a.s.t.s 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 quant.i.ty. 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 mult.i.tude 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, un.o.bserved 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 gla.s.s cups, torch, and scarificator and subst.i.tute 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 gla.s.s cup with a short, curved, wide neck and an oval belly that hung downwards.

When applied to the skin, the gla.s.s hung in the manner of a leech, and so the gla.s.s was called "The Gla.s.s Leech." Since the burning tow could be placed in the hanging belly of the gla.s.s, 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 stopc.o.c.k 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.)

[Ill.u.s.tration: FIGURE 14.--Weiss's improved patent cupping apparatus.

Ill.u.s.trated 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 gla.s.s 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]

[Ill.u.s.tration: FIGURE 15.--Fox's gla.s.s leech. Cupping set contains two hanging "gla.s.s 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 (bra.s.s 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 c.o.xeter, announced in 1845 a new scarificator with a rotating lever on the side instead of a c.o.c.king lever on the top. The roto-lever, according to c.o.xeter, 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 c.o.xeter and Son (London) until late in the nineteenth century.[146]

c.o.xeter 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 subst.i.tuted 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 c.o.c.king 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, a.s.sociated 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.